Suggested strategies
Despite all negative factors, we the health professionals need to unite our efforts in finding out the solutions for ever increasing oro-dental problems as well as tobacco related diseases and disorders. The World No Tobacco Day 2005 is being celebrated with theme “Health Professionals against Tobacco” for this year. The World Health Organization not only prompt you to leave tobacco habits but also urges you to get involved and play a prominent role in Tobacco control. We all can work at International, National, Regional, Local and society level to fight against tobacco.
As far as oro-dental problems are concerned, we need to formulate Common Risk Factor Approach with reference to various problems. The messages on Oral Health can be integrated in other programmes like Diabetes prevention, Cardio-vascular Diseases and Obesity prevention programmes. Conversely, oral health professionals can integrate counseling and messages on other non-communicable diseases in their community based intervention. This kind of approach is specially useful for our country since we have limited resources and finances for the health sector.
7.1 Common Risk Factor Approach
World Health Assembly 2000 been perceived and reported that Non-communicable Diseases are going to be major threat to health system and in future it is estimated that by the year 2020, it will be a major cause of death in all countries. The prevention of Non Communicable Diseases (NCD’s) does require efforts to control all the determinants of health including, dietary, environmental, behavioural and social factors. A core group of modifiable risk factors are common to many chronic diseases and injuries. Instructions for prevention of four most common NCD’s – Cardio-vascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases – share common risk factors with Oral Diseases. Most of them are preventable risk factors and are related to the lifestyle. For example dietary habits are significant for development of NCD’s and influence development of dental caries. Community prevention programmes can integrate messages on prevention of many problems together thereby reducing the cost of implementation and ease of operation at the grass root level.
The changes in diet, eating behaviour and lifestyle of people across the globe in the recent times have caused significant increase in chronic non communicable diseases like diabetes mellitus, cardiovascular disease, obesity and oral diseases. These NCD’s are causing disability and sometimes premature death in developing as well as developed countries. In order to achieve the best results in preventing these chronic diseases, the strategies and policies that are applied must use common risk factor approach. The adoption of a common risk factor approach to chronic disease prevention is a major development in the thinking behind an integrated health policy. The main benefit of using Common Risk Factor Approach (CRFA) is that it does not only focus on improving the health conditions for the whole populations as well as the high risk groups. The CRFA will be definitely more beneficial for country like ours where the resources are limited.
Following instructions can be considered as common for prevention of many diseases as well as oral health problems:
1. Promoting the intake of fruits and vegetables.
Apart from being rich sources of carbohydrate, dietary fibre, antioxidants and a variety of phytonutrients, fruit and vegetables are also rich sources of potassium. Daily intake of fresh fruits and vegetables (green leafy and cruciferous vegetables and legumes etc.) in an adequate quantity (400-500gm/day) is recommended to reduce the risk of coronary heart disease, stroke and high blood pressure. The fruits and vegetables have not only dietary but also detergent effects on tooth cleaning.
2. A high dietary intake of non-starch polysaccharides (NSP)/ dietary fibre.
Foods high in NSP (i.e. wholegrain cereals, legumes) are known to reduce plasma total and LDL cholesterol, thus lowering the risk of coronary heart disease. High intake of NSP promotes weight loss. Studies have shown that high intakes of NSP result in reduced blood glucose and insulin levels in people with type 2 diabetes and impaired glucose tolerance. Also, these wholegrain foods require more mastication thereby stimulating increased salivary flow. The recommended intake of total dietary fibre is >25 gm/day.
3. Lesser consumption of energy-dense, micronutrient-poor foods.
This group of food tends to be processed food, that is high in fat and/or sugars (e.g. packaged snacks, fried foods).These foods are low in nutritional value, high in fats and require complex metabolism. Thus, promote weight gain, are a threat to the cardiovascular health, and because of their sticky nature, have a deleterious effect on teeth.
4. Restrict the intake of sugar-sweetened beverages.
Because of the reduced gastric distension and faster transit times, the energy contained in fluids is less detected by the body and subsequent food intake is poorly adjusted to account for the energy taken in through beverages. Thus, it is known to cause unhealthy weight gain. A study has estimated that each additional can or glass of sugars-sweetened drink that children consume everyday increases their risk of becoming obese by 60%. The strong correlation between both the amount and frequency of sugar consumption and dental caries development has been proved by several investigators. Consumption of acidic beverages like, soft drinks, artificial fruit juices and vinegar significantly lower the pH of oral fluids. This causes the progressive irreversible loss of enamel by chemical etching – dental erosion. Therefore, their consumption should be limited to minimum.
5. Promoting breastfeeding.
In line with the positive health effects of breastfeeding, prevention of childhood obesity is one. Studies have proved breastfeeding as a protective factor against weight gain. Also, association of breastfeeding with low levels of dental caries has been shown by various epidemiological studies. Breastfeeding has the advantage that it does not necessitate the use of a feeder bottle, which has been associated with early childhood caries. A breastfed infant will also receive milk of a controlled composition to which additional free sugars have not been added. The risk for several chronic diseases of childhood and adolescence eg. Type 1 diabetes have also been associated with infant feeding on breast milk substitutes and short term breastfeeding.
6. Culture of eating out should be discouraged.
Heavy marketing of fast-food outlets, energy dense foods needs to be checked. The energy, total fat, saturated fat, cholesterol and sodium content of foods prepared outside home is significantly higher than that of home prepared food. Young children are often the target group for the advertising of these products because they have a significant influence on the foods bought by parents. People who tend to eat in restaurants have a higher BMI (Body Mass Index) than those who tend to eat at home. Measures need to be taken to limit the exposure of young children to these fast food options. Access and exposure to healthier, nutrient-rich diets, fruits and vegetables in home is important for the development of preferences for these foods. A reduction in eating out will also help in reducing the sticky food and soft drinks thereby helping in keeping oral health better.
Alcohol consumption is found to be associated with high blood pressure, thus, increasing the risk of cardiovascular diseases, stroke and other complications of hypertension. The reasons alcohol is responsible for causing weight gain are, that it is a significant source of calories, and drinking may stimulate eating. Alcohol promotes the uptake of blood glucose into liver glycogen causing a drop in blood glucose. Many alcoholic drinks contain sugar, particularly mixed drinks. The symptoms of drunkenness and hypoglycemia are similar thus alcohol may mask the effects of a hypoglycemia. Between 80 and 95 percent of alcoholics smoke cigarettes, this synergistic action of alcohol and tobacco is known to cause far more damage to various body systems than what is caused by them individually.
The glycaemic index reflects the ability of foods to raise the blood sugar. The problem with blood sugar is that in the short term it gives one a short boost of physical and mental energy. However, a high blood sugar is very damaging to arteries and therefore the body works hard to keep the blood sugar within tight limits. The glycaemic index of foods is partly dictated by their carbohydrate content, and partly dependent on food preparation. It is advisable to eat more quantities of food with lower glycaemic index eg. meat, poultry, fish, cheese, nuts, salads, green vegetables, soya etc. Foods like sugar, syrup, honey, jam, marmalade, sweets, chocolates, bread, pasta, pastry, biscuits have a high glycaemic index, so should be taken in minimum quantities. The reduction in food with high glycaemic index will also reduce sugar exposure to the oral cavity.
Tobacco is a great global problem affecting all segments of the population. Tobacco consumers are 2-3 times more likely to develop heart disease and paralysis than non-smokers, as tobacco is known to suddenly raise the blood pressure and reduces the blood flow to heart. Recent studies have shown association of tobacco consumption with increased risk of diabetes. Various case control studies have shown the direct relationship between tobacco abuse (both smoking and smokeless form) and Oral cancers.
Proper tooth brushing and flossing, getting regular dental check-ups for timely intervention of any oral disease should be advocated to avoid any chronicity. Development of periodontal disease, if remains unchecked can lead to hoards of systemic complications including cardiovascular diseases, diabetes, stroke, oral cancers and various oral opportunistic infections.
7.2 Oral Health Promotion through Schools
Time and again it has been proven that schools can provide an ideal platform for the promotion of oral health. Children spend considerable period of their lifetime in the school right from their childhood to adolescence. This period has a special importance in their growing age as they are particularly receptive during this phase. They can be nurtured well for there general and oral health and the saying “catch them young” can very well be implemented. Equally important is the reinforcement of message on health which can be implemented and executed through the school years of the children. The proper guidance can help in the development of correct beliefs and attitudes regarding oral health. The schools can provide a supportive environment for promoting oral health and they can also be extremely helpful in spreading the right message to the local community. The school personnel and school children can pass the oral health promotion messages to their family members, which can be beneficial in health promotion activities.
Dental health education at the level of school teachers can help in reducing the prevalence of oro-dental health problems of school children. School teachers, the nation builders, can definitely play an important role by educating the children and spreading the message of better dental health practices and preventive measures.
It is very important to target oral health education to the children since the lifestyle and hygiene practices once established at an early age can go a long way in spending rest of the life in a healthy way. They should be empowered to take control of their own health early in their lives and encouraged to develop positive attitude towards preventive measures. Based on this background, attempt may be made to develop accessible and sustainable module for prevention of oro-dental problems among school children using existing educational infrastructure. Moreover, the Common Risk Factor Approach (CRFA) can be especially useful in school set-up. Health educational programmes implemented through schools have an additional advantage of imparting primordial and primary preventive instructions to all the children of all socio-economic status.
7.3 Oral Health Promotion for Geriatric Population
Oral health is an important aspect of overall health and well being of elderly people. To promote oral health care awareness amongst the elderly, education programs should be conducted at the community level, in different local languages. Health care services should be strengthened in rural and semi-urban areas with adoption of community based preventive approach. Mobile dental clinics and dental camps should be organized in inaccessible areas for the elderly to provide oral health care and education at their doorstep. Health insurance schemes should include oral health care services to provide maximum benefits to elderly population. The undergraduate curricula should be revised to include geriatric component in all subjects and clinical training. Introduction of the postgraduate degree course in Geriatric Dentistry should be done in India at the earliest.
7.4 Role of Oral Health Professionals in Tobacco Control
Although tobacco is a deadly serious issue, the flavor of activities that are needed to prevent its spread does not have to be heavy and serious. Tobacco use is enhanced by making it look appealing, attractive, casual and fun. The preventive effort can not allow itself to appear serious, heavy, boring and uninspiring. But for efforts to be sustained some amount of underlying seriousness is necessary. The World Health Organization considers tobacco the single most important cause of preventable death worldwide but there is widespread apathy about doing something to curtail its spread. Any effort to reduce its spread is often dismissed as being a needless preoccupation with a trivial problem. In implementing tobacco control, we need to decide whom we will work with, to reach the people that we wish eventually to reach. Health professionals have crucial role to play in creating a tobacco free environment.
There are several ethical, moral, and practical reasons why oral health professionals should strengthen their contributions to tobacco-cessation programmes, for example:
Therefore oral health teams and oral health organizations should be directly, appropriately and routinely involved in influencing patients and the public at large to help in tobacco control. Moreover, oral cancer prevention should be an integral part of national oral health programmes, based on careful planning, monitoring and evaluation, and partnership-building.
Oral health professionals have a prominent role in tobacco control. They can play an important role at an (a) individual level (b) at the local/society level and (c) at the national level.
(a) At the individual level they can educate the people they come across with ,on the harmful effects of tobacco consumption.
· They should use every opportunity to incorporate cessation counseling into their practices. These counseling should be stimulating and non-judgmental.
· They should get involved with local tobacco control group or organization.
· They can propose that questions on tobacco use be included in medical history for all patients as a part of monitoring signs.
· Implement curriculum changes in health professional schools to enhance knowledge and skills in intervention in tobacco prevention, smoking cessation and efforts to reduce exposure to second hand smoke.
(b) At the society level or local health level:
Local health professional organizations can be formed which apart from encouraging cessation work with patients would ensure their members take individual action in other ways in the community.
· Explore the benefits of visiting schools to discuss the impact of tobacco and industry tactics with students, staff and parents.
· Organize campaigns to establish tobacco free and smoke free schools, hospitals, restaurants and other public places.
· Persuade government to ban tobacco advertising.
· Invite politicians to meetings where the harsh realities of tobacco use are being explained and policy solutions discussed and ensure favourable coverage of events.
· Support litigations by testifying as experts witnesses about proof of tobacco as a cause of disease
· Actively participate in World No Tobacco Day every 31 May.
Organizations could be formed. These organizations should work to raise awareness among their individual members about tobacco
· They could share new scientific research findings new developments in cessation and new policy developments.
· They should highlight scientific evidence of harmful effect of tobacco use through the media.
· They can carry out surveys on tobacco consumption habits and attitude towards tobacco consumptions.
· Actively participate in World No Tobacco Day every 31 May.
Preventing people from tobacco consumption is one of the major challenges that one faces. Any prevention programme should cover at least 3 aspects
(i) Keep people specifically teenagers from picking up the habit.
(ii) Protect people from second hand smoke.
(iii) Help people quit.
(i) Keep people specifically teenagers from picking up the habit.
One of the earliest but most effective step in tobacco prevention is to keep teenagers from picking up the habit. It is here that role of parents is important. The most effective manner in which parents can help prevent the habit is by serving as effective role models i.e. being non consumers of tobacco themselves. Secondly parents and schools should be involved in programmes that elaborate harmful effect of tobacco consumption. Stressing the fact to kids that tobacco consumption is not a habit but addiction is also important. These simple steps go a long way in preventing teenagers from picking up the habit.
(ii) Protect people from second hand smoke
This requires formulation and implementation of policies that make public places smoke free zones and also creating awareness of the dangers of second hand smoke through media campaigns.
(iii) Help people quit
About 70% of people addicted to tobacco try and quit sometime though without success. During this period a person requires proper counseling and support. Groups should be set up consisting of health professionals and social workers that help quit the habit of tobacco consumption, and most importantly information regarding such support groups must be disseminated properly. These groups or organizations should be easily accessible and consist of trained professionals to provide proper counseling and medications like nicotine replacement patches.
For the work in our community to progress and prosper in the long term , there will have to be a constant move to reach new heights. An important contributor to reaching new heights is the willing of the people now in the leadership of the prevention work to allow active and honestly committed newcomers to become part of the effort ,as equals with the rest. this will allow an increasingly large segment of the population to be informed and involved .Success is achieved when the population at large understands how people are being influenced and recruited in to tobacco use and takes the initiative in preventing or counteracting these influences.
All we need to keep looking for ways to reach out repeatedly and regularly to the public at large. So we as health professional should take the responsibility to eliminate this taboo from the society and thus create a Tobacco free environment.
Expected outcome of the Workshop
It is expected that the participants will discuss and formulate roadmap for future directions in Oral Health Promotion and Tobacco Cessation by the Oral Health Professionals. They are also expected to formulate guidelines for Dental Institutions for implementing community intervention programmes on primary oral health care. At the end of the Workshop, a working document will be prepared for Integration of Common Risk Factor approach in various health programmes. It will also outline measures for tobacco cessation and prevention of tobacco related oro-dental diseases.