Teeth
According to the document “Oral Health in Pakistan – A Situation Analysis” released by WHO and the Government of Pakistan following a survey, it has now been established beyond doubt that dental diseases are the most common cause of human suffering. The socio-economic impact of these diseases on the suffering individuals and their communities are high enough for the WHO to include Oral Health as one of the indicators for a healthy individual.
Dental Caries (cavities), Periodontitis (Gum Disease) & Oral Cancer are the most common diseases to affect the mouth. They rank amongst the commonest of health problems to afflict mankind, usually become symptomatic, and therefore detectable, when reasonably advanced. The good news is that all three of these can be prevented by taking a few simple measures.
Oral diseases, particularly caries and periodontal disease, burden people in Pakistan excessively. Although, oral diseases are preventable, inadequate application of preventive measures and inappropriate establishment of oral health care delivery systems has led to the ineffective control of these problems.
Periodontal Disease
In general, with respect to the levels of oral disease, the commonest disease is gingivitis and periodontal disease. Periodontal disease is a chronic infection caused by bacteria that accumulate in plaque. It is becoming increasingly evident that such infection can influence systemic health in many ways. Studies in animals and humans have linked oral infection in mothers to pre-term low birth-weight (PLBW) babies. Prospective studies have found an association between periodontal disease and heart disease. These infections have also been linked to stroke, aspiration pneumonia in the elderly and those with chronic respiratory disease.
The prevalence of periodontal disease is upwards of 80% in many populations yet its severity and effect on the longevity of the dentition is also moderate.
The Community Periodontal Index (CPI) reflects the oral hygiene care and the periodontal status of the populations. From the CPI scores of the survey it is evident that periodontal health of the nation is very poor with only 28% of the 12 year olds having healthy gums and more than 93% of the 65 year olds have some gum or periodontal disease. These results indicate that periodontal disease including inflammation of gums and calculus is endemic in Pakistan. Level of gingival and periodontal disease is higher in the rural population of the country.
The survey also showed that almost 1% of the 35-44 year olds and 20% of persons aged 65 years or above were edentulous (no teeth). Of the edentulous senior citizens more than one third had no dentures, while in the 35-44 year old group 35% required replacement of missing teeth and only 5% were wearing them.
Dental Caries
The survey reports that dental caries (tooth decay), essentially a bacterial infection, is the single most common chronic childhood disease in the country – 5 times more common than asthma and 7 times more common than hay fever. Almost 50% of 12 and 15-year-old children have two teeth affected. On the positive side more than 50% of the children between the ages of 12-15 years are caries free and on the negative side 97% of all carious lesions in these age groups are untreated. For the 35-44 year old group 50% of lesions are untreated while in more than 90% of cases the treatment offered in extraction. The data also shows that caries is very strongly age related and the average number of affected teeth goes up to almost 18 teeth per individual over the age of 65.
The Pakistan Dental Association has validated the findings of the survey and reinforces that the burden of oral problems is extensive and may be particularly severe in vulnerable populations like the rural poor. The public health capacity for addressing oral health is dilute and not integrated with other public health programs. The public health infrastructure for oral health is insufficient to address the needs of disadvantaged groups, and the integration of oral and general health programs is lacking. Resources are limited in terms of personnel, equipment, and facilities available to support oral health programs.
There is also a lack of available trained public health practitioners knowledgeable about oral health. A national public health plan for oral health does not exist.
The oral disease burdens are aggravated by poverty, poor living conditions, ignorance concerning health education, and lack of government funding and policy to train and provide sufficient oral health care workers in public settings. The current situation with large numbers of untreated cases of oral diseases, the inequality in delivery systems and the virtual non-existence of an adequate community oriented prevention calls for action.
Despite increasing national attention and emphasis on primary health care, there has been little impetus to define or specify the content of primary oral health care. When primary health care (PHC) was developed and implemented in Pakistan, oral health was not included. The present consequences are the marked disparities in the distribution of oral health care. Oral health care is virtually non-existent in rural areas of the country where more than 70% of the population live.
In general, Oral health has had low priority in the health activities of Pakistan, which has resulted in large unmet needs of the population and over 90% of all oral diseases remain untreated. From young adults to the 50 year olds, the lack of perception of dental needs or ‘absence of toothache’ appears to be the most frequent reason for delays in seeking treatment. The majority of patients present teeth at an advanced stage of decay which is usually beyond repair.
An undesirable consequence of these delays is that more than 90% of all treatment given in the public dental clinics is tooth extractions. Moreover, preventive services (examination, scaling and prophylaxis) form less than 3 % of services at the public dental clinics and are testimony to the abysmal lack of oral health education, preventive practices and the lack of dental health promotional programs in the country.
According to the Executive Summary of the document by Dr. Ayyaz Ali Khan, who was the National Coordinator for Oral Health when the survey was conducted. The survey examined almost nine thousand individuals to determine the burden of oral disease in Pakistan and was conducted in 21 districts of the country; 9 in Punjab, 6 in Sind and 3 each in NWFP and Balochistan. The survey was conducted in Lahore, Faisalabad, Multan, Okara, Bahawalpur, Rahimyar Khan, Dera Ghazi Khan, Kasur and Murree districts of Punjab; Hyderabad, Karachi, Mirpur Khas, Sukkur, Thatta and Larkana districts of Sind; Peshawar, Abottabad and Swat districts of the North West Frontier Province; and Quetta, Naseerabad and Sibi districts of Balochistan.
A total of 22 teams were constituted, one for each District. Each team consisted of one examiner, one recorder and one assistant. There were seven team leaders, Dr. Shamta Sufia (National & Punjab), Dr. Ayyaz Ali Khan (Punjab) & Dr. Mohammad Safdar (Punjab), Dr. Abdul Haleem & Dr. Mohammad Khalil (Sind); Dr. Qiamuddin (NWFP) and Dr. Mujib Baloch (Balochistan). Each team leader looked after three districts and ensured that the survey was conducted in accordance to set rules.
Based on the findings of the Situation Analysis of Oral Health Sector of Pakistan a two day workshop was held in December 2003 to formulate recommendations for a National Oral Health Policy. This Workshop was designed for Provincial Directors of Dental Services, Head of Dental Institutions, office bearers of Pakistan Dental Association and senior most District Dental Officers. Thirty eight participants, representing all the four provinces attended the Workshop.
It was agreed that Pakistan, being a developing country, cannot resort to high technology and sophisticated dentistry to achieve coverage for its whole population. The most cost effective means of controlling and preventing oral diseases has to be used. It was agreed that the primary health care approach with its basic philosophy of self-reliance and community participation will contribute substantially to the improvement of oral health of Pakistanis. The recommendations of this workshop along with a proposed plan of action have been included in this report.
There are opportunities for all health professions, individuals, and communities to work together to improve health. More needs to be done to improve oral health in Pakistan.
The report should serve to strengthen the translation of proven health promotion and disease prevention approaches into policy development, health care practice, and personal lifestyle behaviors. A framework for action that integrates oral health into overall health is critical if gains are to be envisaged in the oral health sector of Pakistan.