As part of visiting Pakistan to view sponsored free cataract
and cleft palate operations, I had the opportunity to visit , examine and
assess the oral health of around 12000 children in 18 schools in parts of
northern Pakistan around the city of Gurjurat.
The schools varied from free Government schools, part
private schools and totally private schools both in the city of Gurjurat and in
the surrounding very rural areas in that district.
The pattern of my visit was an arranged address to the whole
school with a simple short message and demonstration on tooth brushing and diet
advice, followed by examination of a number of children either directly in
front of the assembly using the portable dental chair as designed by Dentaid
with attached led examination light or in a previously set up side room.
Those examined had a dmf( decayed missing filled) count and those with more serious evidence of
decay counselled further. Numbers examined in each school varied from 30 to 90
children. 81% of the children examined had poor oral hygiene and the need for
improved tooth brushing technique was repeated. 39% of children examined whose
ages arranged from 5 to 9 years old have carious affected teeth. ( dmf counts
from 3 to 8) In about 15 % of cases there was evidence of
severe carious lesions (with dmf counts from 9 to 20). I also examined a number
of adults and teachers who all showed untreated caries, many with totally
collapsed first permanent molars for which extraction is the only treatment
option. Because the decay was in most cases involving the whole of the crowns
of the teeth, there was little food trapping and any infection present was able
to drain through the open cavities. Patients did complain that they did have
pain sometimes on eating and in a few cases evidence of a sinus discharge from
the apex of the decayed tooth was present.
A determined effort was made in all 18 schools to engage all
the teachers into the realisation that the high level of caries in the primary
teeth of most of the small children was being caused mainly by a bad pattern of
frequent sugar consumption both in drinks and food. The devastation of the
primary dentition in a great many children reminded me of the ‘baby feeder’
syndrome and gross caries I used to see in small children shortly after
qualifying and practicing in Walsall in 1970. The routine serial extraction of first
molars was commonplace. A barrier to seeking dental care is the cost which
would be beyond the resources of a large proportion of the population. They is
the risk that such patients will seek treatment from totally unqualified
individuals for in reality not much less cost in money terms but an enormous
cost for the patient in health terms with the risk of cross infection from
inadequately autoclaved instruments, so transmitting hepatitis and other viral
infections.
A few decades on, with improved diet patterns, better tooth
brushing and of course both fluoride in the water supply and toothpaste has
resulted in the midlands of a total transformation in the caries rate amongst
children.
However as has been highlighted by WHO and others, there is
a large increase in caries amongst young children in developing poorer
communities now getting virtually unrestricted access to sweetened foods and
drinks .
There was strong evidence that the exposure of the primary
dentition to a corrosive mix of sugar and low ph drinks was present during the
eruption of this dentition resulting in the
loss of enamel over the whole surface of the exposed crowns and giving
the dreadful blackened appearance of the remains of the primary dentition.
The aim of this exercise in entering primary schools, giving
direct simple advice on the importance of tooth cleaning and a reasonable
pattern of sugar consumption will be continued by their teachers on a daily or
at least on a weekly basis and will begin to start a change in behaviour of the
children and so their parents. This must be sustained by future visits with a
reinforcement of the message.. perhaps by volunteer dental students and further
dentists who can speak Urdu and so have a better chance of training more
teachers and other key personnel to repeat the message. As with all health
advice this needs to be simple, clear ,realistic and repeated frequently and
the dental message tied in with linked health advice on healthy eating and
lifestyles. In dental care ,there is also of course a place for simple
interventions, fissure sealing first molars for those children at most risk,
glass ionemer restorations on early food trapping cavities; active supervised
fluoride toothpaste application of very small amounts ( after check on levels
of any local fluoride content)
I was very well received by the many schools I visited and
impressed by the obvious concern expressed by their teachers who did not often
realise the extent of the caries problem. I also thank a local dentist who
accompanied me to most of the schools and was able to translate our oral health
care message. The easily portable dental
chair makes it easy to check comfortably many children and lends a more
professional approach to oral health assessments. There is a real opportunity
to follow up this initial brief visit with a longer term sustainable oral
health campaign linked also into treatment and care for adult patients with
their high incidence of periodontal problems and awareness of danger of
practices that will increase the risk of developing oral cancer.
Ian Robertson October 2012.
