Oral health inequality in India: Perspectives and solutions
doi:10.1038/nindia.2017.29 Published online 20 March 2017
• Oral health promotion through prevention.
• Establishment of a firm National Oral Health Policy and separate budget allocation for oral health.
• More funding for dental research by Government of India.
• Reduction of taxes on oral hygiene products and dental materials to make it more affordable to the public and the dentist.
• Integration of oral health promotion and preventive services with general healthcare system.
According to a 2012 World Health Organization fact sheet on oral health, “Oral health is essential to general health and quality of life. It is a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing1.”
Of the 291 conditions studied between 1990 and 2010 in the Global Burden of Disease Study, it was found that oral diseases were highly prevalent affecting 3.9 billion people worldwide2. Untreated caries in permanent teeth was the most prevalent condition (affecting 35% of population), whereas severe periodontitis, untreated caries in deciduous teeth, severe tooth loss were the 6th, 10th and 36th most prevalent conditions, respectively, affecting, 11%, 9% and 2% of the global population, respectively2.
According to FDI World Dental Federation, oral cancer is among the 10 most common cancers globally, and is more prevalent in South Asia, due to increasing tobacco and alcohol consumption3. FDI World Dental Federation also estimates that seven out of ten Indian children have untreated dental caries, while approximately 100 Indian babies with clefts are born every day and the majority of them do not survive3.
According to the National Oral Health Survey of India (2002-03), the prevalence of periodontal diseases was 57.0%, 67.7%, 89.6% and 79.9% in the age groups 12, 15, 35-44 and 65-74 years, respectively4. The age standardized incidence of oral cancer in India is 12.6 per 100,000 population5. In the age range of 65-74 years, 19% in India are toothless5.
Barriers to oral health care in India
There are several barriers to oral healthcare in India, identified by Singh et al6 as: (i) a lack of acknowledgement of the importance of oral health among the population, which perceives it as independent from and secondary to general health; (ii) no access for many to an oral health provider due to geographic distance; (iii) dental treatment is unaffordable for many; and (iv) quality of dental treatment is varied.
In India, the dental health workforce to population ratio is low7. There is an unequal distribution of dentists nationally, with most located in urban rich locations. There is also inequity in the number and distribution of dentists between the states, with Karnataka, Maharashtra, and Tamil Nadu over-supplied by dentists and Jharkhand, Rajasthan, and Uttaranchal having great shortages.
Singh et al.6 suggested various measures to address oral care inequality in India. For dental institutions: (i) setting up dental clinics in villages, schools, aged-care homes and orphanages; (ii) satellite centres to provide oral healthcare services to the people in remote and underprivileged areas; (iii) mobile vans to reach remote villages; (iv) using interns for oral health awareness and preventive programmes; and (v) training of health workers at public health centres along with school teachers to provide oral health education. For professional bodies in India: (i) the Dental Council of India could introduce competency-based, community-oriented training in internship; and (ii) the Indian Dental Association, local NGOs and corporations could work towards investing a nominated amount in oral health. Singh et al. also suggest that the Indian government (i) utilize the services of new dental graduates for rural areas; (ii) establish of dental clinics at public health centre level; (iii) develop a firm national oral health policy and separate budget allocation for oral health; (iv) fund research into cheaper and good quality materials to be used in practice; (v) reduce taxes on toothpastes and dental materials to make them more affordable to the public and the dentist; (vi) support local manufacturing of dental products to provide employment and to reduce costs of these products; and (vii) integrate oral health into general health so that it becomes more acceptable to the community.
Oral health policies
In a one-off Indian Oral Health Survey, it was found that Indian dentists perceived the current state of oral health in India as ‘somewhat bad’. They identified the key challenges for the next five years as: periodontal diseases, dental caries, oral health awareness and the increasing rates of oral cancer8. Dentists also felt a need to review and change the current state of dental education in India8. In another article, Jawdekar9 suggested that the existing machinery of successful government health campaigns such as the ‘Pulse Polio’ and the ‘Mid-Day-Meals Scheme’ could be used for oral health promotion for children.
In 1995, an Oral Health Policy10 was accepted as part of a National Health Policy during the Fourth Conference of Central Council of Health & Family Welfare with nationwide goals such as: (i) oral health for all; (ii) to bring down the incidence of dental caries to less than 30% by 2012; (iii) to reduce the number of fluorosis cases in all age groups to less than 4% by 2012; (iv) to reduce high prevalence of periodontal diseases in 15+ age group to lower prevalence i.e. less than 35% by 2012; (v) at the age of 18 years, 85% should retain all their teeth; (vi) to achieve 50% reduction in toothlessness between the age of 35-44 years; (vii) to achieve 25% reduction in edentulousness at the age of 65 years and above; (viii) to bring down level of malocclusion and dento-facial deformities in the age group of 9-14 years to less than 25% by 2012; and (ix) to reduce the number of new cases of oral cancers and precancerous lesions to less than 0.02% by 2012.
There have been calls for a firmer and more resolute national oral health policy in India. Kothia et al11. have summarized the need for National Oral Health Policy as: (i) for oral health promotion through prevention; (ii) to decrease the burden of oral diseases; (iii) to eradicate taboos, myths or misconceptions; (iv) to narrow the rural-urban gap in oral healthcare; (v) to organize a data recording system; (vi) for quality dental education; and (vii) definite budget allocation for oral health as seen in developed countries.
Nodal agency for national oral healthcare programme in India
The Centre for Dental Education and Research (CDER), All India Institute of Medical Sciences (AIIMS), New Delhi, India has been declared a nodal agency for the national oral healthcare programme. The primary activities10 undertaken by CDER, AIIMS include: (i) formulation of implementation strategies; (ii) development of module for training of trainers (TOT); (iii) development of modules for training of health workers and school teachers in Oral health; and (iv) development of Information, Education and Communication (IEC) materials, in Hindi and English such as: a film on oral health entitled Kripaya Muskuraiye, training manuals for health workers and school teachers, oral health ready reference sheet for health workers and posters for community awareness.
A website (http://www.nohpindia.com) for National Oral Healthcare Program was also created by CDER, AIIMS in 2015 to collect information about this programme and generate activity. The Indian government had initiated the National Oral Health Program through CDER, AIIMS to provide integrated, comprehensive oral healthcare in existing facilities with various objectives: (i) to change the causes of poor oral health; (ii) to reduce morbidity from oral diseases; (iii) to integrate oral health promotion and preventive services with general healthcare system; and (iv) to encourage promotion of Public Private Partnerships (PPP) model for achieving better oral health.
In order to achieve these objectives, the federal government is assisting state governments to initiate provision of dental care along with other health programmes at various levels of the primary healthcare system. Funding has been made available through the State Project Implementation Plans (PIPs) for establishment of a dental unit (at district level or below). In line with this, orientation training was organized for the State Nodal Officers of the National Oral Health Program by the National Institute of Health and Family Welfare, New Delhi, India, in collaboration with CDER, AIIMS, New Delhi, India with support of the Ministry of Health and Family Welfare (MOHFW), Government of India, in February 2016 and again in January 2017.
Activist and humanitarian Martin Luther King Jr. told the Medical Committee for Human Rights in 1966: ‘Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.’ This remark is apt for the status of oral healthcare in a country with such a vast population and cultural diversity as India. Oral diseases are highly prevalent and affect general health and there is an urgent need to combat them.
1Professor & Chief, Centre for Dental Education and Research, All India Institute for Medical Sciences, New Delhi, India (email@example.com); 2Assistant Professor, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India (firstname.lastname@example.org).
1. World Health Organization: Oral health. Available at http://www.who.int/mediacentre/factsheets/fs318/en/index.html. Accessed on 28.02.2016
2. Marcenes, W. et al. Global burden of Oral conditions in 1990-2010: A systematic Analysis. J. Dent. Res. 92, 592-597 (2013)
3. The Challenge of Oral Disease – A call for global action. The Oral Health Atlas. 2nd ed. Geneva: FDI World Dental Federation (2015)
4. Bali, R. K. et al. National Oral Health Survey and Fluoride Mapping 2002-03. Dental Council of India (2004)
5. Petersen P. E. et al. The global burden of oral diseases and risks to oral health. Bull. World Health Organization 83, 661-669 (2005)
6. Singh, S. et al. Oral health inequality and barriers to oral healthcare in India. Eur. J. Dent. Ther. Res. 4, 242-245 (2015)
7. Halappa, M. et al. SWOT analysis of dental health workforce in India: A dental alarm. J. Clin. Diagn. Res. 8, ZE03-5 (2014)
8. Kakde, S. et al. Oral health inequalities: a call for action to improve oral health in India. Int. Dent. J. 63, 324-328 (2013)
9. Jawdekar, A. M. A proposed model for infant and child oral health promotion in India. Int. J. Dent. 2013:685049 (2013)
10. Nanda Kishor, K. M. Public health implications of oral health – inequity in India. J. Adv. Dent. Res. 1, 1-9 (2010)11. Kothia, N. R. et al. Assessment of the status of National Oral Health Policy in India. Int. J. Health Policy Manag. 4, 575-581 (2015)