CONCEPT REPORT OF THE RURAL DENTAL CENTER ( RDC ) PROJECT FOR INDIA AND THE DEVELOPING COUNTRIES:

CONTENTS:

1. PREFACE 2. BACKGROUND

A. EPIDEMIOLOGY OF ORAL DISEASE: 1. WORLDWIDE 2. INDIA

B. POLICY BASIS FOR THE WHO ORAL HEALTH PROGRAMME:1. Oral Health is integral and Essential to general health.2. Oral Health is a determinant factor for quality of life.3. Oral Health – General Health4. Proper Oral Health care reduces premature mortality5. Oral Disease and its impact Worldwide.

C. DETERMINANTS:1. DIET & NUTRITION2. FLUORIDE EXPOSURE3. KNOWLEDGE & HYGIENE HABITS4. ACCESS TO CARE5. SUBSTANCE USE

D.BURDEN OF ORAL DISEASE:

E. EFFORTS TO MITIGATE DISEASE BURDEN:1. CURRENT EFFORTS

F. BARRIERS TO DISEASE MITIGATE EFFORTS:

G. ORAL HEALTH INTERVENTION AND IMPLEMENTATION:

a. Primary Intervention:1. Oral Health Education2. Fluoride Rinse

b. Secondary Prevention: 1. Screening 2. School Screening

c. Tertiary Prevention:

1. Dental Care Provider2. Equipment

H.COMPREHENSIVENESS OF INTERVENTION:

I. TRANSDISCIPLINARITY OF INTERVENTION:

J. THE POLICY FRAMEWORK FOR THE WHO ORAL HEALTH PROGRAMME:

K. CHALLENGES IN ORAL HEALTH PROGRAMMING:

L. RECOMMENDATIONS FOR THE FUTURE:

M.CONCLUSION:

N.REFERENCES:

PREFACE:

Dental diseases are a significant public health burden in India, with dental caries affecting 60 to 65 % and periodontal diseases affecting an estimated 50 to 90 % of the general population, depending on age, with research suggesting that higher rates of dental diseases occur in Rural areas.

The consequences of widespread poor oral health can be seen on the personal, population, and health systems level, as caries and periodontal disease deteriorate individual health and well being, decrease economic productivity, and act as significant risk factors for other systemic health ailments.

Oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world. The greatest burden of oral diseases is on disadvantaged and socially marginalized populations.

Dental diseases in rural India are primarily due to socio-cultural factors, such as inadequate or improper use of fluoride products and a lack of knowledge about oral health and hygiene, and systemic infrastructure deficiencies that prevent proper screening and dental care of oral diseases, especially in rural areas. Through a three tiered intervention, this plan aims to comprehensively and cost-effectively address these determinants.

The primary intervention level is a school- based oral health promotion program with two components: an oral hygiene education campaign and a program to provide fluoridated mouth rinse.

The secondary strategy of this intervention plan is to develop a non-invasive screening instrument and implement a comprehensive screening protocol for dental diseases.

The tertiary component of this intervention is designed to increase access to professional dental care through the installation of dental equipment, the development of partnerships with dentists in nearby urban areas to provide care in the short-term, and increasing access in the long-term by the opening up of Rural Dental Centers. BACKGROUND:

The World Health Organization defines oral health as a “state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”.

Of all these, Dental caries are the most common non-communicable disease in the world (Beaglehole, et al., 2009); periodontal disease and dental caries are the two dominant disease burdens in oral health (Petersen & Ogawa, 2005). Both can be attributed to the formation of plaque, a sticky biofilm that adheres to teeth and is comprised mostly of four components: (1) bacteria in the oral cavity used to convert food into acids, (2) acid, (3) food debris, and (4) saliva (Bratthall, Petersen,

Stjernsward, & Brown, 2006). If dental plaque is not removed thoroughly and frequently, the acid created by the bacteria begins to cause localized dissolution of the tooth’s hard tissues such as enamel, dentin, and cementum, which results in tooth damage. As this process occurs over time, Dental carries will form (Bratthall, et al., 2006).

Additionally, if dental plaque is not removed, the biofilm will also mineralize into tartar – also known as calculus – which, along with plaque, acts as an irritant on the gums. This irritation results in gingivitis, an inflammation or infection of the gums. If left untreated, gingivitis ultimately causes periodontal disease, which occurs when the infection spreads to the ligaments and bone that supports the teeth (Rosenberg, 2010). Both dental caries and periodontal disease can cause reduced quality of life and diminished function as a result of the pain and suffering associated with oral conditions (Petersen, 2003).

The need to address these oral health concerns is especially evident in India, because Dental caries affect 60 to 65 percent of the general population (Kaur, et al., 2010). Additionally, Periodontal disease is estimated to occur in 50 to 90 percent of the population in India, depending on age (Agarwal, Khatri, Singh, Gupta, Marya, & Kumar, 2010; Kaur, 2009).

While these statistics reveal a deficiency in dental care for all of India, it can be posited that Oral Health in Rural villages is in more dire conditions than urban areas because rural areas in India are more susceptible to

dental caries and periodontal disease, in part because rural villages have lower access to preventative and restorative dental care (Goldman, Yee, Holmgren, & Benzian, 2008).

Thus, this intervention plans through the opening up of Rural Dental Centers in the villages to increasing awareness of the importance of Good Oral Habits and improving access to Dental Services in Rural India.

A. EPIDEMIOLOGY OF ORAL DISEASE:

Beyond prevalence, oral health status is often characterized with the DMFT index, which sums the number of Decayed, Missing, and Filled Teeth within a person’s mouth (Hussain & Chockalingam, 2009).

1.WORLDWIDE:

In 1979, the World Health Organization initiated a global strategy called Health for All by 2000; the oral health component, developed in conjunction with the World Dental Federation (FDI), identified six major goals to be achieved by 2000 (Petersen, Bourgeois, Bratthall, & Ogawa, 2005; Petersen, 2003):

1. A prevalence of dental caries less than 50% in children ages 5-6 years2. Twelve-year-old children should have, on average, no more than 3 DMFT

3. By age 18, 85% of children should have all their teeth4. A 50% reduction in edentulousness among adults aged 33-44, compared to 1982 level5. A 25% reduction in edentulousness among adults aged 65 and older, compared to 1982 level6. The establishment of a database system for monitoring changes in oral healthThe WHO has considered dental caries and periodontal disease to be two of the most important global health burdens because of the high worldwide prevalence of both conditions (Petersen, 2003). Dental caries are widespread, affecting 60-90% of school-age children and the majority of adults (Petersen, 2003; Petersen, Bourgeois, Ogawa, Estupinan-Day, & Ndiaye, 2005). Industrialized nations have a high prevalence of dental caries and periodontal disease; however, the prevalence in developing nations is increasing, most likely due in part to the growing consumption of sugars and low exposure to fluoride (Petersen, et al., 2005).Periodontal disease is highly prevalent among adults in all regions of the world (Petersen, et al., 2005). Gingivitis is also common, with symptoms present in the majority of children and adolescents worldwide (Petersen, et al., 2005). Severe periodontal disease is present in 10-15% of adults (Petersen & Ogawa, 2005); when periodontal disease becomes severe, it often results in tooth loss (Petersen, 2003).

2. INDIA:

In India, dental caries directly affect around 60% of the population (Shah, 2005; Kaur, et al., 2010). The prevalence of dental caries is positively correlated with age (Agarwal, et al., 2010). A 2004 survey found that the prevalence of dental caries in children aged five years was 50%; 52.5% in 12 year-olds; 61.4% in 15 year-olds; 79.2% in 35-44 year-olds; and 84.7% in 65-74 year-olds (Bali, Mathur, Talwar, & Chanana, 2004). The World Dental Federation estimates that 83% of children aged 6-19 years have dental caries (FDI World Dental Federation, 2011). The majority of 12 and 15 year-olds had a DMFT value between 1-3, while the majority of older adults (65-74 years) had a DMFT value between 25-32 (Bali, et al., 2004). In 12 year-olds, the average DMFT value was 1.7 (Bali, et al., 2004). The same 2004 survey by Bali, et al. found no gender difference in the prevalence of dental caries, but there was a higher prevalence of dental caries in rural populations as compared to urban.Periodontal disease affects the majority of Indians and follows a similar trend as dental caries, where the prevalence increases as age increases. In 12 year-olds, the prevalence was 55.4%, increasing to 89.2% of 35-44 year olds (Bali, et al., 2004). The prevalence in the 65-74 age range was slightly lower (79.4%), most likely due to the high prevalence of missing teeth in this age range (Bali, et al., 2004). Periodontal disease is equally prevalent across genders, with somewhat higher revalence in rural areas (Bali, et al., 2004).

B. POLICY BASIS FOR THE WHO ORAL HEALTH PROGRAMME:

1. Oral health is integral and essential to general health:

Oral health means more than good teeth; it is integral to general health and essential for well-being. It implies being free of chronic oro-facial pain, oral and pharyngeal (throat) cancer, oral tissue lesions, birth defects such as cleft lip and palate, and other diseases and disorders that affect the oral, dental and craniofacial tissues, collectively known as the craniofacial complex.

2. Oral health is a determinant factor for quality of life :

The craniofacial complex allows us to speak, smile, kiss, touch, smell, taste, chew, swallow, and to cry out in pain. It provides protection against microbial infections and environmental threats. Oral diseases restrict activities in school, at work and at home causing millions of school and work hours to be lost each year the world over. Moreover, the psychosocial impact of these diseases often significantly diminishes quality of life.

3. Oral health - General health:

Oral health is integral to general health. Periodontal disease, for example, is associated with general health conditions such as cardiovascular disease and diabetes. Those with complex health conditions are at greater risk of oral diseases.

The strong correlation between several oral diseases and noncommunicable chronic diseases ( NCDs ) is primarily a result of the

common risk factors. Many general disease conditions also have oral manifestations that increase the risk of oral disease which, in turn, is a risk factor for a number of general health conditions.

Some general health diseases manifest in the mouth, and oral lesions may be the first signs of other life threatening diseases such as HIV/AIDS.

Poor oral health can have a profound effect on the quality of life. The experience of pain, endurance of dental abscesses, problems with eating and chewing, embarrassment about the shape of teeth or about missing, discoloured or damaged teeth can adversely affect people’s daily lives and well-being.

General health risk factors such as excessive alcohol intake, smoking or other tobacco use and poor dietary practices also affect oral health.

4. Proper oral health care reduces premature mortality:

Early detection of disease is in most cases crucial to saving lives. A thorough oral examination can detect signs of nutritional deficiencies as well as a number of general diseases including microbial infections, immune disorders, injuries, and oral cancer. The craniofacial tissues also provide an understanding of organs and systems in less accessible parts of the body.

5. Oral Disease and its Impact Worldwide:

Despite great achievements in the oral health of populations globally, problems still remain in many communities around the world - particularly among underprivileged groups in developed and developing countries. Dental caries and periodontal diseases have historically been considered the most important global oral health burdens. At present,

the distribution and severity of oral diseases vary in different parts of the world and within the same country or region. The significant role of socio-behavioural and environmental factors in oral disease and health is demonstrated in a large number of epidemiological surveys.

Dental caries is still a major oral health problem in most industrialized countries, affecting 60-90% of schoolchildren and the vast majority of adults. It is also a most prevalent oral disease in several Asian and Latin American countries, while it appears to be less common and less severe in most African countries. Currently, the disease level is high in the Americas but relatively low in Africa. In light of changing living conditions, however, it is expected that the incidence of dental caries will increase in many developing countries in Africa, particularly as a result of a growing consumption of sugars and inadequate exposure to fluorides.

In many developing countries, access to oral health services is limited and teeth are often left untreated or are extracted because of pain or discomfort. Throughout the world, losing teeth is still seen by many people as a natural consequence of ageing. While in some industrialized countries there has been a positive trend of reduction in tooth loss among adults in recent years, the proportion of edentulous adults aged 65 years and older is still high in some countries.

While oral and pharyngeal cancers are both preventable, they remain a major challenge to oral health programmes. The prevalence of oral cancer is particularly high among men, the eighth most common cancer worldwide (Incidence rates for oral cancer vary in men from 1-10 cases per 100 000 inhabitants in many countries. In south-central Asia, cancer of the oral cavity ranks amongst the three most common types of

cancer. In Asia, the age standardized incidence rate of oral cancer per 100 000 population ranges from 0.7 in China to 4.6 in Thailand and 12.6 in India. The high incidence rates relate directly to risk behaviours such as smoking, use of smokeless tobacco (e.g. betel nut or miang chewing) and alcohol consumption.

C. DETERMINANTS:

a.Diet & Nutrition:

A common global trend in population-level oral health is a link between the prevalence of dental diseases and economic improvement in developing countries. Increased rates of gingivitis, dental carries, and periodontal disease traditionally follow rising economic development because, as economies expand in developing countries, the populations within these countries have access to a wider variety of food as a result of increased income and trade. Thus, as countries become wealthier, there is more exposure to, and an increased preference for, a “westernized” diet that is high in carbohydrates and refined sugars (Goldman, et al., 2008). This change in dietary patterns influences oral health because chronic dental diseases are strongly related to diets rich in saturated fatty acids and non-milk extrinsic sugars (Petersen & Ogawa, 2005).

India has demonstrated a marked increase in sugar consumption in recent years, as per capita consumption was 13.8 kilograms in 1991, 16.5 kilograms in 2000, and

19.6 kilograms in 2005 (World Health Organization, 2011). This shows that an increasing consumption low nutritional value foods, or “junk” foods, and refined sugars in the form of chocolates and other sticky sugar-rich foods, especially in younger generations, may be contributing to an increase in dental caries and periodontal diseases (Kaur, et al., 2010; Khan, Jain, & Shrivastav, 2008).

Diet and nutrition affects oral health in many ways. Dental diseases related to diet include dental caries, developmental defects of enamel, dental erosion and periodontal disease.

b. Fluoride Exposure:

While an increase in the consumption of refined sugars has contributed to the prevalence of dental diseases in India, this determinant alone is an insufficient explanation because research evidence has demonstrated that proper oral hygiene practices with fluoride-supplemented products can mitigate the detrimental oral health effects of sugar consumption.

Therefore, the cariogenic potential of diets high in sugar emerges mostly in areas where fluoride supplementation is inadequate or improperly used (Goldman, et al., 2008). Sodium fluoride is available in a number of supplemental forms including fluoridated drinking water, fluoridated salt, fluoridated milk, fluoridated varnish, and fluoridated toothpaste (Petersen & Lennon, 2004).

However, research has indicated that, in the rural villages, fluoridated toothpaste is the only product readily available, and the beneficial effects of using fluoridated toothpaste for oral health are optimized if brushing is performed twice a day, using proper brushing technique, because this maintains a consistent low concentration of fluoride in the oral cavity (Marinho, Higgins, Logan, & Sheiham, 2009).Howerver field research has observed that the vast majority of rural villagers surveyed only cleaned their teeth once a day. Thus, it is evident that a lack of use and improper use of fluoridated toothpaste both contribute to the high level of dental diseases observed in the villages and the rest of rural India.

Fluoride is being widely used on a global scale, with much benefit. More than 500 million people worldwide use fluoridated toothpaste, about 210 million people benefit from fluoridated water, some 40 million people from fluoridated salt, while other forms of fluoride applications (clinical topical fluorides, mouthrinses, tablets/drops) are administered to about 60 million people. However, populations in many developing countries do not have access to fluorides for prevention of dental caries for practical or economic reasons. One of WHO’s policies is to support the widespread use of affordable fluoridated toothpaste in developing countries. This is particularly important in light of the changing diet and nutrition status in these countries. Recent local studies have shown that affordable fluoridated toothpaste is effective in caries prevention and should be made

available for use by health authorities in developing countries.

c.Knowledge & Hygiene Habits:

Effective oral hygiene practices have been well established in developed countries. However, oral hygiene practices in India indicate that there is still a lack of knowledge about proper oral hygiene. This is demonstrated by a 57% usage rate of toothbrushes and only 40% use of fluoridated toothpaste in the rural areas, with higher rates of usage reported in urban areas (Bali, Aswath, et al., 2004). This implies that toothbrush and fluoridated toothpaste usage in rural areas is considerably lower.

Additionally, as noted earlier, it has been observed to be common practice in rural villages to only brush once a day, rather than the widely-recommended twice a day brushing patterns utilized in developed countries. Field observations have also indicated a lack of oral health education in primary and secondary schools in the villages, and a general lack of oral health knowledge within the community.

These observations support academic claims that mass awareness of oral health practices is very low in India, especially in rural communities which tend to place a low importance on oral hygiene (Kaur, 2009).

There also seems to be a general lack of awareness about oral health in general among residents living in the rural

areas. The majority of residents (55%) were aware of neither factors that could cause oral health problems nor any preventative measures that could be taken to prevent oral health issues (Bali, Aswath, et al., 2004).

d.Access to Care:

In rural India, the dentist to population ratio can be as high as one dentist for every 250,000 residents, while the ratio is estimated at one dentist to every 10,000 in urban areas (Tandon, 2004). At the same time, 72.2% of the population in India resides in rural areas (Saravanan, et al., 2008). In comparison, the Henry J. Kaiser Family Foundation estimates there to be one dentist per every 1,250 residents in the United States (2009).

There has been an increase in the number of dental colleges in India over the last 50 years to over 150 dental colleges which graduated over 26,000 dentists in 2002 (Tandon, 2004). Additionally, only 2% of dental specialists are trained in community dentistry, the specialization that one would typically practice in rural areas (Tandon, 2004).

The low number of dentists in rural areas, a distribution perpetuated by the current landscape of professional oral health training, is a significant barrier to access for rural village residents.

India in the last financial budget ( 2015-2016) spent just 4.2% of its GDP on Healthcare, of which Public Health spending was a mere 1.2%. Suprisingly, no government

funds were specifically designated for oral health care. This lack of financing is reflected in the oral health infrastructure of government health centers.

The most accessible and principal healthcare provision facilities for Rural India, Primary Health Centers (PHC), do not provide Dental Services, and only 20-25% of Community Health Centers, the point of secondary healthcare for Rural villages within the Indian healthcare system, provide Dental Care (Agarwal, et al., 2010; Tandon, 2004).

e.Substance Use:

Tobacco is generally accepted to be a harmful substance; its use has been correlated to numerous diseases, including coronary heart disease, respiratory diseases, diabetes, ulcers, and many forms of cancer, including oral, lung, kidney and pancreas (Petersen & Ogawa, 2005).

Additionally, it has significant effects on the oral health of users. Tobacco use is associated with heightened periodontal breakdown, poorer standards of oral health and subsequent premature tooth loss (Petersen, et al., 2005). In periodontal disease, smoking has been identified as major risk factor and, among United States adults, is potentially responsible for more than 50% of periodontal disease cases (Tomar & Asma, 2000).

Smoking is the most significant modifiable risk factor for periodontal disease (Johnson & Guthmiller, 2007). Chewing tobacco is also a significant risk factor correlated with gingival inflammation and periodontal disease (Winn, 2001). Both the use of chewing tobacco and smoking cigarettes are risk factors in the development of caries (Tomar & Winn, 1999; Campus, Cagetti, Senna, Blasi, Mascolo, Demarchi & Strohmenger, 2011). Chewing tobacco is especially significant, as its contents include a high proportion of sugar (Winn, 2001).

Finally, tobacco use is highly correlated with the presence of oral cancer, with 95% of oral cancers directly related to tobacco use (Winn, 2001; Shah, 2005). The use of tobacco has a clear impact on a person’s oral health status.

Tobacco use is a major preventable cause of premature death and of several general diseases. In addition, cigarette, pipe, cigar and bidi smoking, betel quid chewing (pan), guhtka use and other traditional forms of tobacco have several effects in the mouth. Tobacco is a risk factor for oral cancer, oral cancer recurrence, adult periodontal diseases and congenital defects such as cleft lip and palate in children.

Tobacco suppresses the immune system's response to oral infection, compromises healing following oral surgery and accidental wounding, promotes periodontal degeneration in diabetics and adversely affects the cardiovascular system.

D.BURDEN OF ORAL DISEASE:

As described, dental diseases are very prevalent in India, and this high prevalence has led to a substantial burden on individuals, communities, and the healthcare system. On a personal level, dental caries and periodontal diseases have a significant negative influence on the quality of life in both children and adults due to deteriorations in an individual’s general health and development (Goldman, et al., 2008).

At the youngest ages, the discomfort and difficulties in ingesting food due to untreated dental caries can result in a failure to gain weight and impair cognitive development (Goldman, et al., 2008). By crippling the functionality of the oral cavity, dental diseases, combined with limited food variety and accessibility in rural villages, also causes malnutrition in adults, as severe pain due to untreated caries and periodontal disease incapacitates an adult’s ability to chew coarse food (Shah, 2005; Bali, et al., 2004).

Given the extent of the problem, oral diseases are major public health problems. Their impact on individuals and communities, as a result of pain and suffering, impairment of function and reduced quality of life, is considerable. The four most prominent NCDs - cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases share common risk factors with oral diseases.

The widespread nature of dental diseases in rural India means that the detrimental effects of caries and periodontal disease within the individual will also have a negative impact on the functioning of a population. Evidence of this can be found in a study conducted by the National Council on Macroeconomics and Health (NCMH) in India. Within this study, the NCMH identified oral diseases as one of seventeen priority health conditions they considered to be serious public health problems.

Oral diseases were identified as one of these priority health conditions because, in late stages, dental caries and periodontal diseases cause severe pain and are expensive to treat (National Council on Macroeconomics and Health, 2005). This translates into a loss of man-hours which has a significant negative impact on economic productivity (Shah, 2005 & Goldman, et al., 2008). Finally, in terms of disability-adjusted life years (DALYs) lost, oral diseases represented 0.5% of India’s total disease burden – with 1,247,000 total DALYs lost in 1998 – and this number was projected to increase by 25% in the decade following the study (Peters, Yzbeck, Ramana, Sharma, Pritchett, & Wagstaff, 2001).

As noted earlier, there is insufficient infrastructure for providing dental care in rural India. Nonetheless, the treatment of dental diseases is traditionally very costly worldwide, representing the fourth most expensive set of diseases to treat in industrialized countries with advanced oral health systems that offer curative services to patients (Petersen, Bourgeois, Ogawa, Estupinan-Day, & Ndiaye, 2005).

In developing countries such as India, there has been very little investment in oral healthcare and resources are primarily allocated only to emergency care and pain relief. However, if advanced systems of curative care were in place in India, the costs of treating dental caries in children alone would exceed the total annual healthcare budget allocated for child health (Petersen, Bourgeois, Ogawa, Day, & Ndiaye, 2005).

In addition to the direct burden oral diseases would place on a health infrastructure, if a comprehensive one were in place, Dental caries and Periodontal disease also place additional burdens on traditional medical healthcare systems. This is because, if left untreated, the chronic inflammation and inflammatory mediators associated with dental diseases are a significant risk factor for several systemic diseases. These include the,

1. Birth of pre-term low-birth weight babies,

2. Coronary artery diseases, and

3. Diabetes mellitus (Agarwal, et al., 2010).

The impact of untreated dental diseases on maternal and child health is especially disconcerting, as pregnant women suffering from periodontal disease are seven times more likely to give birth to a pre-term low-weight baby, even when controlling for other factors (Center for Global Development, 2007).

E. EFFORTS TO MITIGATE DISEASE BURDEN:

Current Efforts:

Nationally, the Indian Government has been making steps over the last 20 years to begin addressing the oral health of its population. In 1995, an Oral Health Policy was accepted as part of a National Health Policy during the Fourth Conference of Central Council of Health & Family Welfare (Kishor, 2010). Contained within this policy were a set of nationwide goals similar to the goals World Health Organization crafted in 1979 (Lal, Paul, Pankaj, Vikas, & Vashisht, 2004):

Oral Health for all by 2010 To reduce the prevalence of oral and dental disease to less than 40%, down from the current 90% prevalenceFor children ages 6-12, reduce the average DMFT to less than 2, down from a current approximate average of 4To reduce the high prevalence of periodontal disease to a lower prevalence85% of children age 18 should retain all of their teethTo reduce the prevalence of edentulousness in adults ages 35-44 years by 50%To reduce the prevalence of edentulousness in adults ages 65-74 years by 25%To reduce the prevalence of malocclusion and dento-facial deformities by 50% of the present level+To reduce the incidence of oral cancers and precancerous lesions from the existing levels.

For the new millennium, new oral health goals are urgently needed not only to strengthen dental caries control and prevention activities, but also to address other significant components of the oral disease burden such as periodontal health conditions, oral mucosal lesions, oral pre-cancer and cancer, craniofacial trauma, pain, and oral health-related quality of life. Such global goals for oral health will assist regions, countries and local health care planners to develop preventive programmes that are targeted at populations and high risk groups, and to further improve the quality of oral health systems.

In order to reach these goals,, the National Oral Health Care Programme was established in 1998, targeted at providing oral health care through primary prevention and strengthening existing oral health care set up (Kishor, 2010). The strategies contained within the Programme primarily focus on prevention such as education and screening, as well as proposed mobile oral clinics and a nationwide oral health surveillance system (Kishor, 2010; Pandve, 2009).

The focus on primary and secondary prevention stems from an acknowledgement that there is a lack of basic oral health care facilities nationwide (Srivastava, 2009). Since the acceptance of this policy, the government has been working to determine how to implement these strategies; pilot programs have been focused in North-Eastern states (Pandve, 2009). Given the expensive nature of treating oral and dental conditions, the government has chosen to focus on developing primary prevention strategies, with the belief that it will be more impactful with few resources (Srivastava, 2009).

Among non-governmental organizations, dental screening camps are a popular method to address oral health. These screening camps traditionally offer dental screening with a referral for dental services, occasionally coupled with oral hygiene education.

F. BARRIERS TO DISEASE MITIGATION EFFORTS:

Currently, all existing efforts address one portion of the continuum of care – primary, secondary, or tertiary – without confronting the entire continuum. As previously discussed, there are significant barriers to accessing dental services in India, which mainly include the following: a. high cost for services, b. long travel to reach a dentist, .c. extremely low dentist to population ratio.

Because of these barriers, screening programs alone are not comprehensive enough to have any significant impact on the prevalence of oral health in India. Identifying cases of poor oral health without providing any follow-up care, or providing a referral for a treatment that is both far away and expensive, simply raises the prevalence of disease, as more cases will be identified through screening. Additionally, it is unethical to identify a disease in a person when treatment is not accessible (Shickle & Chadwick, 1994). For these reasons, screening alone simply cannot begin to address oral health in India.

Oral health has been an area of focus for government officials in India for almost fifteen years. However, in that time, much of the work that has been accomplished has been formative research, with pilot programs as the bulk of programming that has been implemented (Pandve, 2009). While pilot programs are a necessary part of program development, the pilots have been concentrated in the North-Eastern states of India; residents of those states may have benefited from the programs, but as no nation-wide programs have been implemented, no nation-wide effects have been documented (Kishor, 2010).

Additionally, the focus of the government has been on preventative care, which, while a crucial portion of oral health care, is simply not enough to impact the general oral health of a population when access to curative treatment is so challenging. In order to have a significant impact on oral health, a comprehensive plan is necessary, in which primary, secondary and tertiary prevention and care are integrated into a multi-faceted intervention.

G.ORAL HEALTH INTERVENTION AND IMPLEMENTATION:

It has been established that rural India is experiencing wide-spread challenges in oral health. It can be further said that these challenges

exist at every level of the healthcare infrastructure, from a lack of dissemination about preventative oral health education to severely restricted access to curative dental treatments.

Accordingly, this intervention is designed to comprehensively address these challenges, through the implementation of an intervention that delivers primary, secondary, and tertiary level prevention.

The primary prevention strategy is a school-based oral health promotion program, including behavioral oral hygiene education and the provision of fluoride-supplemented oral health products.

The implementation of a comprehensive screening program is the secondary prevention strategy, and improving access to professional curative dental care is the health intervention proposed as tertiary prevention strategy.

1. PRIMARY PREVENTION:

a.Oral Health Education:

The primary component of this intervention is a school-based oral health promotion program. A school-based intervention was selected because, in rural areas of developing countries such as India, a considerable number of children and their parents lack knowledge about the causes of oral diseases and methods available

to prevent them. Additionally, schools provide an effective platform for disseminating and reinforcing this information throughout the school years, which are the life-stages where lifelong beliefs, attitudes, and skills are developed (Kwan, Petersen, Pine, & Borutta, 2005). Schools in India are an ideal platform for oral health promotion programs because India possesses one fifth of the world’s children and the majority of young children in India are in primary school, with a 91% male and an 88% female enrollment rate (Joshua, 2009; United Nations Children’s Fund, 2011). School-based health promotion programs have the additional benefit of also improving the health of school staff, families, and community members through exposure to information and behavioral skills (Kwan et al., 2005).

This school-based oral health promotion program will include:

(1)an oral health education component with two lessons covering (i) the etiology of caries and periodontal diseases and (ii) proper oral hygiene behaviors; and

(2)supervised provision of a biweekly fluoridated mouth rinse.

The two lessons will be conducted via multimedia presentations, such as video recordings or audio visual aids for a greater impact on the children and the teachers.

b.Fluoride Rinse:

Fluoride supplementation was chosen as a component of this oral health promotion program because it has been well-established through research that fluoride is the most effective method of dental caries prevention, especially when a low level of fluoride is constantly maintained in the oral cavity, and fluoride therapies have successfully been the cornerstone of caries-preventative strategies for the past five decades, even more so in areas where sugar consumption is high or increasing (Petersen & Lennon, 2004).

The use of fluoride supplementation as a mechanism of preventative oral health is also widely considered to be more cost-effective than providing curative treatments after dental diseases have manifested (Marinho et al., 2009). The anti-caries effects of fluoride are considered to result mostly from the action of fluoride on the tooth/plaque interface, where it promotes the remineralization of early caries lesions and reduces tooth enamel solubility to corrosive acids (Marinho et al., 2009).

The components of this oral health promotion program will be operationalized through two activities: oral health education and a regular fluoride rinse.

2.SECONDARY PREVENTION:

Secondary prevention occurs when a disease is present, but illness is not yet being experienced by the individual. This level of prevention is particularly important in oral health, as dental caries and periodontal disease are often initially asymptomatic and continue to have minimal symptoms until progressing to the point at which the disease is severe and the symptoms have a significant impact on quality of life (Goldman, et al., 2008; Petersen, 2003). Given this progression, a screening program – to identify dental caries and periodontal disease – is a necessary component of this intervention. The screening portion of this intervention plan will be integrated at every level of care.

i. Screening:

The goal of the oral cavity screening is to be comprehensive, not only in the oral conditions screened, but also in its penetration of the population.

ii. School Screening:

In addition to the Oral Health Screening Protocol being implemented population-wide, screening will also occur at the schools. This screening will occur once at the beginning of each semester. Ideally, screening should occur on the same day as the first fluoride rinse and oral health education video, for greater impact. This screening should first utilize the non-invasive oral health screening instrument, with immediate follow-up comprehensive screening occurring that same day at the school.

This secondary prevention portion of this intervention aims to ensure screening of an entire population, recognizing that oral disease is not specific in the demographic that it affects.

3.TERTIARY PREVENTION:

Access to dental care is a significant determinant in the poor oral health status of rural populations in India. This was demonstrated through the experiences of those in villages, as the absence of a dentist in the village and the long travel time associated with seeking the services of a dentist in Cities both affect the ability of village residents to access proper dental care. The tertiary component of this intervention is aimed at increasing access by minimizing the barriers to care. This component is necessary to create a continuum of care; additionally, with the secondary prevention intervention proposed, it is ethically necessary to increase access to care when implementing a screening program in order to provide both follow-up and care for individuals with oral conditions identified by the screening.

This strategy will be operationalized through two activities:

(1)ensuring the presence of a trained dental professional in the Rural Dental Centers, on a permanent basis, and

(2) equipping each Rural Dental Center with the dental equipment necessary to perform basic preventative and curative dental treatments.

a.Dental Care Provider:

As previously discussed, populations living in rural areas in India have very little access to dental care providers, with a trip to the dentist taking an entire day. In order to minimize this barrier, this intervention aims to recruit Dental Professionals willing to serve in the Rural Dental Centers on a permanent basis.

b.Equipment:

In order for any dental care to occur at the Rural Dental Center, it is necessary to procure and install dental equipment in each Rural Dental Center. Therefore, even for the visiting dentists, it is necessary to have dental equipment in the RDC. At the very least, a dental chair and basic scaling tools will be required.

H. COMPREHENSIVENESS OF INTERVENTION:

As the determinants of dental diseases relevant to rural areas were considered, five major determinants were identified . These included:

(1) changes in diet and nutrition that have marked an increase in sugar consumption in India. (2) a shortage of fluoride exposure, either due to non-usage of fluorinated products or inadequate usage patterns. (3) a lack of general knowledge about proper oral hygiene habits. (4) barriers in access to professional dental care in rural areas. and (5) the prevalence of tobacco use .

Thus, this intervention plan is designed to effectively mediate the primary determinants of oral health – a shortage of fluoride exposure, lack of knowledge about oral hygiene, and barriers of access to dental care.

I. TRANSDISCIPLINARITY OF INTERVENTION:

Traditionally, in developed countries with an existing oral healthcare infrastructure in place, the goal of improving and maintaining oral health is primarily considered to be the job of a distinct set of professions including oral hygienists, dentists, and orthodontists, and treatment is typically provided on an individual level. However, considering the resources, facilities, and training necessary to provide enough dental professionals to make this model of treatment effective, it is evident that, due to the dearth of resources in developing geographic areas such as rural India, this traditional approach has not been, and will not be, an effective model for improving oral health.

Transdisciplinarity is a distinct approach to oral health issues that is currently not being employed in India. Current efforts have been rooted in single sectors, mostly relying on dental health care providers to implement and staff programs. This is ineffective in a country in which oral health workforce is already significantly understaffed and unequipped to treat the population.

J. THE POLICY FRAMEWORK FOR THE WHO ORAL HEALTH PROGRAMME:

Health systems, including oral health systems, have roles to play. Systems are becoming more complex and people’s expectations of health care are rising dramatically. In many countries, the role of the state is changing rapidly, and the private sector and civil society are emerging as important players. In developing countries in particular, a growing number of development organizations, private foundations and nongovernmental organizations (NGOs) are becoming active in the health sector.

WHO's goals are to build healthy populations and communities and to combat ill-health. Four strategic directions provide the broad framework for focusing WHO's technical work which also have implications for the Oral Health Programme.

1. Reducing the burden of oral disease and disability, especially in poor and marginalized populations.

2. Promoting healthy lifestyles and reducing risk factors to oral health that arise from environmental, economic, social and behavioural causes.

3. Developing oral health systems that equitably improve oral health outcomes, respond to people's legitimate demands, and are financially fair.

4. Framing policies in oral health, based on integration of oral health into national and community health programmes, and promoting oral health as an effective dimension for development policy of society.

K. CHALLENGES IN ORAL HEALTH PROGRAMMING:

Although this intervention plan was designed to address the prevalence and burden of dental diseases in the rural areas in India – several challenges to fully meeting this goal exist. As noted earlier, there is a relatively pervasive dearth of knowledge about the causes of dental diseases, the detrimental effects of letting dental diseases go untreated, and proper oral hygiene habits in rural areas.

This is problematic for any oral health intervention because correcting a population-wide knowledge deficit requires a very extensive behavioral health campaign.

Another challenge to comprehensively addressing dental diseases in rural India is the insufficient number of dental professionals. An ideal system of professional dental care would encompass preventative care, such as bi-yearly check-ups; dental cleanings and plaque and tarter scrapings by oral hygienists on a regular basis; and also the full range of dental and orthodontic curative services.

L. RECOMMENDATIONS FOR THE FUTURE:

Though there are several current challenges to addressing dental diseases in villages, these limitations also shine light on possible future efforts that could more comprehensively address oral health in rural areas. In the area of oral health education, if the simple, two lesson curriculum utilized in schools is demonstrated to be effective, Rural Dental Centers could begin to offer bi-weekly or monthly oral health education sessions for the general public utilizing the same learning materials.

a. Because fluoridated toothpaste is a highly effective means of caries control, every effort must be made to develop affordable fluoridated toothpastes for use in developing countries. The use of fluoride toothpastes being a public health measure, it would be in the interest of countries to exempt them from the duties and taxation applied to cosmetics.

b. Salt fluoridation as a means of population-wide fluoride supplementation should be considered. This method of salt fluoridation could be easily implemented across the rural hinterland in India as a low economic cost to the Governments especially targetting the rural people in prevention of caries.

Pursuing a fluoride supplementation program of this type is being recommended because it has been demonstrated to be cost effective and beneficial. An example of this is the salt fluoridation program that occurred in Jamaica in the early 1980’s. By 1995, the index of caries severity in this country had fallen by more than 80% in children and the salt fluoridation only cost 6 cents per person (Center for Global Development, 2007).

M.CONCLUSION:

Unhealthy dietary habits, smoking and other tobacco use, alcohol consumption and stress are some of the common risk factors for many NCDs, including oral health. While there has been encouraging improvement in oral health in many countries over the past few decades, much work remains to be done. With many challenges ahead, it is important to build on our achievements, and on strategies that work.

Some countries should reorient their existing investments in health, to reflect the varying needs of a diverse population. Healthy public policies are fundamental to improving access, promoting equity and creating supportive environments.

Public accountability for health can be a driving force for change, a vital element in the advancement of healthy public policies. In order to build effective partnerships for health development and to form healthy alliances, global, national and local commitment is critical.

N.REFERENCES:

1. Adair, S. (1998). The role of fluoride mouthrinses in 3. the control of dental carries: a brief review. Pediatric Dentistry, 20(2), 101-104.

2. Agarwal, V., Khatri, M., Singh, G., Gupta, G., Marya, 4. C., & Kumar, V. (2010). Prevalence of periodontal diseases in India. Journal of Oral Health & Community Dentistry, 4, 7-16.

3. Bali, R.K. Mathur, V.B., Talwar, P.P., & Chanana, 5. H.B. (2004). National oral health survey & fluoride mapping, 2002-2003, India. Dental Council of India.

4. Bali, R.K., Aswath Narayanan, M.B., Mathur, V.B., 6. Talwar, P.P., & Chanana, H.B. (2004). National oral health survey & fluoride mapping, 2002-2003, Tamil Nadu. Dental Council of India.

5. Beaglehole, R., Benzian, H., Crail, J., & Mackay, 7. J. (2009). The oral health atlas. FDI World Dental Federation. Retrieved from: http://www.oralhealthatlas.org/uniflip/index.html

6. Borrell, L.N. (2009). 8. Alcohol consumption was adversely associated with dental caries but not periodontal disease in a Swedish study. Journal of Evidence Based Dental Practice, 9(1), 40-41.

7. Bratthall, D., Petersen, P., Stjernaward, J., & Brown, 9. L. (2006). Oral and craniofacial diseases and disorders. In D. Jamison, J. Breman, A. Measham, G. Alleyne, M. Claeson, D. Evans, P. Jha, A. Mills, P. Musgrove (2nd ed.), Disease control priorities in developing countries (pp. 723-736). The World Bank: Washington, DC: The World Bank.

8. Campus, G., Cagetti, M.G., Senna, A., Blasi, G., 10. Mascolo, A., Demarchi, P., & Strohmenger, L. (2011). Does smoking increase risk for caries? A cross-sectional study in an Italian military academy. Caries Research, 45(1), 40-46. doi: 10.1159/000322852

9. Center for Global Development. (2007). Case 18: 11. preventing dental caries in Jamaica. In Millions Saved: Proven Successes in Global Health. Retrieved from: http://www.cgdev.org/section/initiatives/_active/millionssaved/

10. Chockalingam, R., Tripathy, D., Mukherjee, S., 12. & Longanathan, G. (2009). Validation study of community health workers assessment of oral hygiene in Karambayam, Tamil Nadu. ICTPH. Retrieved from: http://www.ictph.org.in

11. Collins, D. (2003). Pretesting survey instruments: 13. an overview of cognitive methods. Quality of Life Research, 12(3), 229-238. Retrieved from: http://www.jstor.org/stable/4038871

12. Darmstadt, G.L., Baqui, A.H., Choi, Y., Bari, S., 14. Rahman, S.M., Mannan, I., …Arifeen, S.E. (2009). Validation of community health workers’ assessment of neonatal illness in rural Bangladesh. Bulletin of the World Health Organization, 87(1). doi: 10.1590/S0042-96862009000100009

13. FDI World Dental Federation. (2011). DataMirror. 15. Accessed 20 June 2011. Retrieved from: http://www.fdiworldental.org/content/datamirror

14. Goldman, A.S., Yee, R., Holmgren, C.J., & 16. Benzian, H. (2008). Global affordability of fluoride toothpaste. Globalization and Health, 4(7), 1-8. doi: 10.1186/1744-8603-4-7

15. Hussain, F.A., & Chockalingam, R. (2009). 17. Prevalence study of oral hygiene and dental health. ICTPH. Retrieved from: http://www.ictph.org.in

16. Johar, Z. (2010). ICTPH Health Systems Approach. 19. IKP Centers for Technologies in Public Health, IKP Trust.

17. Johar, Z., Chockalingam, R., Lakshmann, S., Das, 20. S., Rajanna, D., & Costica, L. (2011). Population based individual screening protocol for rural Indian populations. ICTPH. Retrieved from: http://www.ictph.org.in

18. Johnson, G.K., & Guthmiller, J.M. (2007). The impact 21. of cigarette smoking on periodontal disease and treatment. Periodontology 2000, 44(1), 178-194. doi: 10.1111/j.1600-0757.2007.00212.x

19. Joshua, A. (2009, November 21). UNICEF hails 22. India’s measures for children’s rights. The Hindu. Retrieved from: http://www.thehindu.com/news/national/article52600.ece

20. Kaur, J23. . (2009). Dental education and oral health problems in India. Indian Journal of Dental Education, 2(4), 167-171.

21. Kaur, R., Kataria, H., Kumar, S., & Kaur, G. (2010). 24. Caries experience among females aged 16-21 in Punjab, India and its relationship with lifestyle and salivary HSP70 levels. European Journal of Dentistry, 4, 308-313

22. Khan, A., Jain, S., & Shrivastav, A. (2008). Prevalence 25. of dental caries among the population of Gwalior, India in relation of different associated factors. European Journal of Dentistry, 2, 81-85.

23. Kishor, N. (2010). Public health implications of oral 26. health – inequity in India. Journal of Advanced Dental Research, 2(1), 1-10. Retrieved from: http://www.ispcd.org

24. Kwan, S., Petersen, P.E., Pine, C., & Borutta, A. 27. (2005). Health-promoting schools: an opportunity for oral health promotion. Bulletin of the World Health Organization, 83(9), 677-685.

25. Lal, S., Paul, D., Pankaj, Vikas, & Vashisht, B.M. 28. (2004). National oral health program (NOHCP) implementation strategies. Indian Journal of Community Medicine, 29(1), 3-10. Retrieved from: http://www.ijcm.org.in

26. Levin, K., Jones, C., Wight, C., Valentine, C., 29. Topping, G., & Naysmith, R. (2009). Fluoride rinsing and dental health inequalities in 11-year old children: an evaluation of a supervised school-based fluoride rinsing programme in Edinburgh. Community Dentistry and Oral Epidemiology, 37, 19-26.

27. Marinho, V., Higgins, J., Logan, S., & Sheiham, A. 30. (2009). Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD002278. DOI: 10.1002/14651858, CD002278.

28. Mathew, B., Sankaranarayanan, R., Sunikumar, K.B., 31. Kuruvila, B., Pisani, P., & Krishnan Nair, M. (1997). Reproducibility and validity of oral visual inspection by trained health workers in the detection or oral precancer and cancer. British Journal of Cancer, 76(3), 390-394.

29. MedlinePlus, (2010a). Dental cavities. U.S. National 32. Library of Medicine, National Institutes of Health. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm. Accessed on 10 July 2011.

30. MedlinePlus, (2010b). Gingivitis. U.S. National 33. Library of Medicine, National Institutes of Health. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/001056.htm. Accessed on 10 July 2011.

31. National Association of Social Workers. (2008). Code 34. of Ethics. Retrieved from: http://www.socialworkers.org/pubs/code/code.asp

32. National Council on Macroeconomics and Health. 35. (2005). Disease burden in India: Estimations and causal analysis. In NMCH Background Papers – Burden of Disease in India (p.1-6). New Delhi, India. Retrieved from: http://www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Oral_and_dental_diseases.pdf

33. Pandve, H.T. (2009). Recent advances in oral health 36. care in India. Indian Journal of Dental Research, 20(1), 129-130. Retrieved from: http://www.ijdr.in/text.asp?2009/20/1/129/49054

34. Peters, D., Yazbeck, A., Ramana, G., Sharma, R., 37. Pritchett, L., & Wagstaff, A. (2001). Raising the sights: Better health systems for India’s poor. Washington, DC: The World Bank.

35. Petersen, P.E. (2003). The world oral health report 38. 2003. Oral Health Programme, World Health Organization. Retrieved from: http://www.whoindia.org/LinkFiles/NMH_Resources_The_World_Oral_Health_Report_2003.pdf

36. Petersen, P.E., & Lennon, M. (2004). Effective use of 39. fluorides for the prevention of dental caries in the 21st century: the WHO approach. Community Dentistry and Oral Epidemiology, 32, 319-321.

37. Petersen, P.E., & Ogawa, H. (2005). Strengthening 40. the prevention of periodontal disease: the WHO approach. Journal of Periodontal Research, 76(12), 2187-2193.

38. Petersen, P.E., Bourgeois, D., Bratthall, D., & Ogawa, 41. H. (2005). Oral health information systems – towards measuring progress in oral health promotion and disease prevention. Bulletin of the World Health Organization, 83(9), 686-693. doi: 10.1590/S0042-96862005000900014

39. Petersen, P.E., Bourgeois, D., Ogawa, H., Estupinan-42. Day, S., & Ndiaye, C. (2005). The global burden of oral disease and risks to oral health. Bulletin of the World Health Organization, 83(9), 661-669.

40. Pierce, K.M, Rozier, R.G., & Vann, W.F. (2002). 43. Accuracy of pediatric primary care providers’ screening and referral for early childhood caries. Pediatrics, 109(5), E82. doi: 10.1542/peds.109.5.e82

41. Prakash, P., Jokovic, A., & Locker, D. (2006). 44. Development and Validation of a pediatric dental screening instrument. Health Measurement and Epidemiology Report, 22. Retrieved from: http://www.utoronto.ca/dentistry/facultyresearch/dri.html

42. Ramachandran, K., Rajan, B.P., & Shanmugam, S. 45. (1973). Epidemiological studies of dental disorders in Tamil Nadu populations. Journal of the Indian Dental Association, 45(4), 65-70.

43. Rosenberg, J. (2010). Dental cavities. U.S. National 46. Institutes of Health. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm

44. Saravanan, S., Kalyani, V., Vijayarani, M.P., Jayajodi, 47. P., Felix, J.W.A., Arunmozhi, P., Sampath Kumar, P. (2008). Caries prevalence and treatment

needs of rural school children in Chidambaram Taluk, Tamil Nadu, South India. Indian Journal of Dental Research, 19(3), 186-190.

45. Satterfield, J.M., Spring, B., Brownson, R.C., Mullen, 48. E.J., Newhouse, R.P., Walker, B.B., & Whitlock, E.P. (2009). Toward a transdisciplinary model of evidence-based practice. Milbank Quarterly, 87(2), 368-390. doi: 10.1111/j.1468-0009.2009.00561.x.

46. Shah, N. (2005). Oral and dental diseases: causes, 49. prevention and treatment strategies. In NMCH Background Papers – Burden of Disease in India (p.275-298). New Delhi, India. Retrieved from: http://www.whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_Bg_P2_Oral_and_dental_diseases.pdf

47. Sharda, A.J. & Shetty, S. (2009). Relationship of 50. periodontal status and dental caries status with oral health knowledge, attitude and behavior among professional students in India. International Journal of Oral Science, 1(4), 196-206. doi: 10.4248/IJOS09061

48. Shickle, D., & Chadwick, R. (1994). The ethics of 51. screening: is ‘screeningitis’ an incurable disease?. Journal of Medical Ethics, 20, 12-18. doi: 10.1136/jme.20.1.12

49. Smyth, E., Caamaño, F., & Fernández-Riveiro, P. 52. (2007). Oral health knowledge, attitudes and practice in 12-year-old schoolchildren. Medicina Oral, Patología Oral y Cirugía Bucal, 12(8), E614-E620. Retrieved from: http://scielo.isciii.es/pdf/medicorpa/v12n8/16.pdf

50. Srivastava, R.K. (2006). Report: working group on 53. communicable and non-communicable diseases. Ministry of Health & Family Welfare. India.

51. Tandon, S. (2004). Challenges to the oral health 55. workforce in India. Journal of Dental Education, 68(7 Supplement), 28-33.

52. Tewari, A., Gauba, K., & Goyal, A. (1991). Evaluation 56. of existing status of knowledge, practice and attitude towards oral health of rural communities of Karyana – India. Journal of India Society of Pedodontics and Preventive Dentistry, 9(1), 21-30.

53. Tewari, A., Gauba, K., & Goyal, A. (1992). Evaluation 57. of KAP of oral hygiene measures following oral health education through existing health and educational infrastructure. Journal of Indian Society of Pedodontics and Preventive Dentistry, 10(1), 7-17.

54. The Henry J. Kaiser Family Foundation. (2009). 58. Dentists per 1,000 population, 2009. Statehealthfacts.org. Accessed 20 June 2011. Retrieved from: http://www.statehealthfacts.org/comparemaptable.jsp?ind=691&cat=8

55. Tomar, S.L., & Asma, S. (2000). Smoking-attributable 61. periodontal disease in the United States: findings from the NHANES III. Journal of Periodontology, 71(5), 743-751.

56. Tomar, S.L., & Winn, D.M. (1999). Chewing tobacco 62. and dental caries among U.S. men. The

Journal of the American Dental Association, 130(11), 1601-1610. Retrieved from: http://www.jada.ada.org

57. United Nations Children’s Fund. (2011). The state of 63. the world’s children 2011. New York, NY.

58. Winn, D.M. (2001). Tobacco use and oral disease. 64. Journal of Dental Education, 65(4), 306-312. Retrieved from: http://www.jdentaled.org

59. World Health Organization. (2011). India sugar 65. consumption [data set]. Retrieved from: http://www.mah.se/CAPP/Country-Oral-Health-Profiles/SEARO/ India/Information-Relevant-to-Oral-Health-and-Care/Sugar-Consumption/

60. Youth for Seva. (2010, June 12). Dental screening by 66. smile child of YFS. Retrieved from: http://youthforseva.org/news/dental-screening-by-smile-child-of-yfs/

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Compiled by: Dated: 25/02/2016Dr. Amit Saini BDS