ORAL HEALTH

1. The importance of Oral Health Promotion and Prevention ORAL HEALTH DrThommyMadiba, B. Dent .Ther, BDS (MEDUNSA), DHSM, MChD (UP) Thommy.madiba@gmail.com Department of Community Dentistry Senior Lecturer/ Head of Clinical Unit University of Pretoria 0845036175 Dr ThommyMadiba B. Dent. Ther, BDS(MEDUNSA), DHSM, MChD (UP) Specialist in Community Dentistry

2. Goal • This lecture aims to give the audience the importance of Oral health promotion and prevention

3. Scope • Why is oral health prevention and promotion important? • What is prevention and what is promotion? • Levels of prevention • Where does everybody fit in prevention and promotion? • Prevention strategies and Common risk factor approach • Heath promotion strategies • What is better ? To treat ,prevent or promotion of health • National Health Insurance, prevention and promotion

4. Definitions • Disease prevention covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established. • Disease prevention is considered to be action which usually emanates from the health sector, dealing with individuals and populations identified as exhibiting identifiable risk factors, often associated with different risk behaviours. • Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.

5. Determinants of health The following are factors that determine the health status of individuals and populations: • Biological • Environmental • Lifestyle • Health Care Services • Psychosocial stress

6. Aetiology of dental caries • Microorganisms (S. mutans, Lactobacillus) • Substrate (Fermentable carbohydrates) • Susceptible tooth • Time • The above are biological causes of disease

7. Pathogenesis Fermentation of CHO by cariogenic plaque bacteria • Acid Susceptible tooth Time Demineralization > remineralisation = CARIES

8. Behavioural and Psychosocial mechanisms Predisposing factors • Dietary risk factors • Feeding bottle : sugar-containing liquid • Pacifier covered in sugar • Prolonged and night feeding • Poor oral hygiene • Tasting baby’s food 1st before feeding the child. • Socioeconomic status • Level of education family income neg associated with ECC • Mother’s Dental IQ • Chronic use of sugar-containing medication • Systemic conditions

9. Prevention • Combination of 4 factors • Modification of 1of 4 factors  no caries • Caries is an infectious disease modified by diet and behaviour Prevention approaches • Community-based • Professional and home based

10. 1. Community based approaches • Education of mothers in ANC clinics • Early presentation to the clinics as soon as the 1st tooth erupts • Xylitol • OHI • Feeding practices • Education of sch. teachers • School-based tooth brushing programmes • School-based rinsing programmes • Diet counselling • ART • Fissure sealants • Water fluoridation

11. 2. Professional approaches

12. Prevention of transmission of mutans group Address the caregiver's bacterial load • Evidence that cariogenic bacteria are transmitted from mother to infants. • Xylitol • Has been demonstrated to reduce no. of mutans streptococci • Impairs adhesion of mutans streptococci to tooth surface • Chlorhexidine • Some studies demonstrated suppression of mutans streptococci in the short term • Evidence on high-risk group is insuffiecient • 10% Povidone iodine • Failed to prevent ECC

13. Aetiology of Oral diseases • The immediate causes of the major dental diseases, caries and periodontal disease are diet, plaque and smoking. Oral mucosal lesions, oral cancer, temporomandibular joint dysfunction and pain are related to tobacco, alcohol and stress and trauma to teeth and injuries . • Genetics

14. Behavioural and Psychosocial mechanisms Predisposing factors • Socioeconomic status • Level of education family income neg associated with oral diseases • Dental IQ • Environment • You are the product of where you come from/Health gradient • Systemic conditions

15. The common risk factor approach (Sheiham A and Watt RG. 2000)

16. The common risk factor approach • The immediate causes of the major dental diseases, caries and periodontal disease are diet, plaque and smoking. Oral mucosal lesions, oral cancer, temporomandibular joint dysfunction and pain are related to tobacco, alcohol and stress and trauma to teeth and injuries . • These causes are common to a number of other chronic diseases such as heart disease, cancer, and strokes, it is rational to use a common risk factor approach in the prevention and promotion of oral diseases and non communicable diseases

17. THE COMMON RISK FACTOR APPROACH cont.. • Focusing attention on changing a small number of factors that determine a large number of diseases. • Diet, smoking, alcohol, injury, hygiene, stress, and exercise are linked with a wide range of important diseases such as cancers, heart disease, and diabetes • Altering these factors will reduce the risks of these systemic conditions as well as oral diseases such as caries, periodontal disease and oral cancer • Such an approach is likely to be more effective and efficient than traditional isolated disease-specific actions.

18. Development of health promotion http://www.who.int/hpr/ • Oral diseases were/are highly prevalent • Aetiology and determinant of oral diseases is known • Preventive measures have been identified YET curative treatment dominates the oral health services….WHY? • Curative treatment services alone are not enough  gave rise to HP movement • Origin of Health Promotion: Public Health Movement/Pioneers of 1830s in Britain • Rapid industrialization overcrowded in working and living condition of the working class  disease epidemics  social/economic stability • Public health reformers recognition: poverty ↔ ill health  new public health measures • Dangerous working & • living conditions • Poor ventilation • Bad sanitation • Overcrowding • Poor nutrition Controlling these reduced disease even before medicine was discovered

20. 20 Health Promotion is the process of enabling people to increase control over determinants of health, and to improve, their health. Health promotion enables communities to make HP is more than just health education, it involves: Empowerment/enabling of communities and individuals Increase control over own health By controlling determinants of health (socio-econ, environ, indivbehav) It is a multi-discipline approach beyond the health sector • Prerequisites for Health: - • Peace • Shelter , education, food , income • Stable Ecosystem • Social Justice • Equity; and • Resources • The Ottawa Charter on Health Promotion” NB!! • Health Promotion Action Areas:- VERY IMPORTANT • Building Healthy Public Policy • Creating Supportive Environments • Strengthening Community Actions • Developing Personal Skills • Reorienting Health Services Definition of health promotion- 1986 ottawa charter

21. Building healthy public policy • HP goes beyond health care, policy makers in all sectors at all levels should have HEALTH in their agenda. • HP policy includes : legislation, fiscal measures and macro organisational change, regulations, guidelines, protocols, rules • Coordinated efforts and actions that lead to health, income and social policies • E.g Policies that ensure that services are provided equitably and healthy environments are maintained. Food policies, • Oral health promotion policies : • Anti-tobacco smoking Act, alcohol legislation controlling access, consumption, usage • Water fluoridation • Food policies enforcing low salt and sugar content on foodstuffs, proper food labelling • Supply of safe water etc.

22. Creating supportive environments Safe, stimulating, satisfying and enjoyable living and working conditions . The aim is to contribute to the improvement of environments which support health. MAKE HEALTHEIR CHOICES, EASIER CHOICES Areas of attention for oral health promotion: Encouraging shops near schools to stock  promote and display non-sugared foods. Periodically sampling sources of drinking water  analysed for contaminants and natural occurring fluoride. Fostering supportive attitudes towards breast feeding. Participating in community programmes which are aimed at improving the lives of women, young children, and adolescents. School tooth brushing programmes – subsidised tooth paste Non-smoking areas in restaurants Health Promoting schools/cities

23. Strengthening community actions • Involve more people in situational analyses, programme, planning and action. • Community action and community mobilisation health workers can: • Join with community activists /networks /coalitions /advocacy groups / awareness campaigns and work together on community issues of common concern. • Support school gardens  cooperative action & growing and eating healthy food. • Support: literacy and maternal child health programmes. • Organize a dental planning committee, fill half of the positions with lay members, and allow the committee to make meaningful oral health decisions.

24. Develop personal skills • Increase people's abilities for controlling oral disease and for improving oral health. • Enhance coping skills  educate communities and instil self-confidence = people can control their own lifestyle . • Health education = provide information intended to change attitude and behaviours through learning new skills. • Oral health promotion , dental practitioners can educate people to : • Differentiate between : good traditional practices & harmful practices that need to be changed. E.g. street teeth whiteners • Learning proper self-hygiene maintaining skills e.g. brushing, flossing, eating healthy • Examine at home the mouths of younger children, recognize developing problems, and know where and when to get help. • Choose tooth pastes that contain fluoride .

25. Reorient health services • Underpinned by this action area is to “Do things better, differently” • Nurture a more holistic practice of dentistry and oral health promotion, • Move from biomedical to integration of psycho-socio model Oral health movement may implement this action area by: • Focus on prevention instead of only cure, ( HR strategies & plans) • Reach out to groups that are disadvantaged by taking their services to people and not require people to always come to them. • Create systems and technologies that are not dependent on the capital city or other countries for maintenance. • Function not in isolation but in association with other community health / development workers and their programmes.

26. Five Approaches to health promotion The 5 Health Promotion Approaches Preventive approach Educational approach Behaviour change approach Empowerment approach Social change

27. Preventive approach • Also referred to in most text as Medical approach • Traditional ‘old school’ Health Education • A top-down authoritative kind of approach • Aim : diseases reduction where medical prof. take the lead/are experts • Patients passive recipients of preventive care e.g. immunisation, fissure sealants application, oral cancer screening • LIMITATIONS: • Does not address underlying causes of diseases (only works downstream).

28. Behaviour change Knowledge ≠ Behaviour Change • Encourages people to take responsibility of own life and change lifestyle • It assumes that information will lead to change in behaviour • It also expert –led; may be one-on-one or mass media awareness • Desired lifestyle changes are determined by professionals and imposed on patients. • e.g. OHI = Oral HE on a dental chair /or to a group of children in a class • LIMITATION • Education does not always result in behaviour change

29. Educational approach • To make a decision to change, people must have knowledge but also they need to have the right attitude & skills. • Also expert-led • This approach aims at behaviour change but differs from the previous one in that it provides people with choices. • It does not persuade/push one into one direction but gives people choices so that they can CHOOSE. • It uses a variety of methods to assist people to make an informed choice about behaviour change. • Explore and share beliefs/values towards ‘weight issues & healthy eating’ using one-on one counselling/group discussions. • E.g. How support, mentorship and counselling in support groups works; LIMITATIONS • Still expert-led, • Ignores fact people require resources to change

30. Empowerment approach • Empowers people to identify own needs, concerns and priorities and skills in addressing them. • Bottom-up approach where health professional just facilitate the process • Led by communities, they identify problems & seek solutions themselves • Professionals just play a role of advocacy, facilitation • E.g. communities/individuals acting as a group • POWA; places of ‘safety’/schools/common meeting sessions for the victims

31. 31 e. Social change approach Aims at making change at a macro socio-economic level to address the determinants of health = Social Action Requires change at policy and political levels. Maybe expert-led or led by communities champions.

32. Which is the best approach? • Approaches to health promotion in South Africa • There are 4 major approaches to health promotion adopted in South Africa • Policy, advocacy and healthy environments • The settings approach • Education and information • Re-orienting health services and community participation.

33. HP SETTINGS approach • Settings are places where people live, work, learn and play. • * SCHOOLS are one important setting for HP. • A certain setting/environment is emphasized in order to promote health • The settings approach in SA: Crucial pillar of HP in SA  ‘healthy' or ‘health promoting’, • Nationally, there is a wish to move away from vertical health topics and health services to these settings approach: • Wellness programmes in work places : support and sustain positive health outcomes through policies and programmes” • Health Promoting schools: • Early childhood development, • The rights of children & addressing malnutrition through vegetable gardens. • Gauteng Integrated Schools Sanitation Improvement Programme (GISSIP) run by DoE & DPW • Healthy Cities project (READ MORE_SELF- READING)

34. E.G. health promoting school focusing on nutrition • Healthy public policy • the school authorities decide that food supplies available in the school will reflect dietary guidelines resulting in adequate and cheap supplies of fresh fruit and limited or no access to high- sugar, low-fibre processed foods. . • Supportive environment • the school has proper locations, both internally and externally, which enable students to eat quietly and to dispose of food and packaging waste in an environmentally sensitive manner. • Community action • where the local food producers and retailers participate with the school in assisting students to develop skills in food cultivation, purchase and preparation. . • Develop Personal skills • where the students are taught and coached in food purchasing and preparation and buying a balanced food supply on a finite budget. • Reorient Health services • where the local health practitioner (dietician, GP, DENTIST, etc.) works with the teachers, parents and students to support the planning and implementation of a schools programme.

35. Levels of prevention

36. Risk • Attempting to prevent a disease is only worthwhile if there is a risk of that condition occurring. • Preventive strategies are about reducing risk by altering the determinants of disease. • How those determinants affect the rate at which disease occurs in the population has an effect on the approach that is adopted towards preventing that disease.

37. Strategy prevention approaches Rose (1992) divides strategy approaches into two distinct groups: • those aimed at the whole population - whole-population approach, • and those in which certain sections of the population are identified, either as a group or as individuals. - the risk approach. The risk approach has two subdivisions. • Where population subgroups are identified it is known as the directed or targeted approach, and • where individuals are identified it is known as the high-risk approach.

38. What is NHI • NHI is a healthcare financing system that ensures that every member of the population is covered to access quality health care services. • Present system two –tiered • - medical schemes,out of pocket & hospital plans (16%) • -Fiscus for public sector (84%)

39. Why the need for NHI • Health care is a human right that every one of us is entitled to – this is a widely accepted • International principle. This right should not depend on how rich we are or where we happen to live. The right to obtain healthcare is written into our Constitution • 3 fundamental principles in SA • Everyone has the right to access health services • Right to emergency care • State to strive for the realization of the above

40. Four things important for NHI • Transformation of health service provision & delivery • Overhaul of health care system • Radical change of management & administration • Re-engineered Primary Health Care

41. Re-engineered PHC System • What is Primary Health Care • essential health care; based on practical, scientifically sound, and socially acceptable method and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and self-determination (WHO/UNICEF 1978)

42. Re-engineered PHC System 1 • PHC services will be re-engineered to focus mainly community outreach, will ensure that the composition of a defined comprehensive primary care package of services extends beyond services traditionally provided in health facilities such as clinics, community health centres and district hospitals

43. Re-engineered PHC System 2 • Primary health care services will be re-engineered to focus mainly on health promotion, preventative care, whilst also ensuring that quality curative and rehabilitative services appropriate to this level of care are rendered. • These services will be population orientated with extensive community outreach and home based services, and in which community health workers form an essential part. • District health system (DHS) will be the vehicle by which all PHC is delivered

44. Re-engineered PHC System 4 • Primary health care services shall be delivered according to the following three streams: • a) District-based clinical specialist support teams supporting delivery of priority health care programmes at a district • • b) School-based Primary health care services • c) Municipal Ward-based Primary Health Care Agents

45. References 1 .Department of Health [Homepage on internet]. The primary health care package. [cited 2012 May 01] Available from: http://www.doh.gov.za/docs/policy/norms/full-norms.html Comprehensive health care services package for South Africa. [cited 2012 May 01] Available from: http://www.capegateway.gov.za/eng/pubs/policies/C/3183 .Department of Health. New South African National Oral Health Strategy. Draft for comment. 2010 October The Constitution of the Republic of South Africa. Act 108 of 1996. [Cited 01/05/2012].Available on http://www.doh.gov.za/docs/Legislation/index.html An overview of Health and Health care in South Africa 1994-2010:Priorities, progress and prospects for new gains. Henry J.Kaiser Family Foundation, Jan 2010 Department of Health [Homepage on internet].National Health Act, No. 61 of 2003 [cited 2011 November 19] Available from: http://www.doh.gov.za/docs/index.html Green paper on NHI. Government Gazette Vol. 554, No. 34523, Pretoria: Government Printer. 12 August 2011 . White paper on NHI. available on www.health.gov.za/index.php/nhi?download=2257:white-paper-nhi-2017 Google pictures

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