Eradicating Tooth Ache

Affordable Health Initiative (AHI) has launched a GLOBAL campaign to eradicating dental pain WORLDWIDE.

Dental caries is a highly preventable and easily treatable disease.

We invite you to work with us for the public benefit, to preserve and protect the health and to advance the education of people throughout the world. LEARN MORE>

Oral health is a major and neglected population health burden that affects physical and mental well-being of children all over the world. Dental caries is the most prevalent and health condition among all included in the Global Burden of Diseases study and, if left untreated, it may cause severe pain and mouth infection; and it may also affect mastication, speech and smiling (Slade 2001, Selwitz et al. 2007, Lawrence et al. 2008, Masood et al. 2017).

At AHI CIO, we are united by our vision: “A world in which every child is free of tooth decay and toothache.”

Dental caries, if left untreated, it may cause severe pain and mouth infection, affecting physical and mental well-being.

The role of the dental profession in global oral health

The Global Burden of Disease (GBD) study was instrumental to advocate with policy makers that oral conditions pose a very serious population challenge and must be included in the health agenda. Dental caries is the most prevalent health condition among all included in the GBD study 2017 reaching over two million cases. Dental caries, if left untreated, it may cause severe pain and mouth infection; and it may also affect mastication, speech and smile (Slade 2001, Selwitz et al. 2007, Lawrence et al. 2008, Masood et al. 2017). Thus, it affects physical and mental well-being.

Health policies and systems reform must now be responsive to the 2030 Sustainable Development Goals (SDGs). The perspective of addressing the burden of dental caries is reinforced in the SDG agenda, an outline to achieve a better and more sustainable future for humanity that compiles a series of 17 interrelated goals that includes “Good Health and Well Being” as its goal number 3 and the reduction of health inequalities within and between countries as its goal number 10 (United Nations, 2015).

Against this background, what is the role of the dental profession in global oral health?

Health systems around the world are now challenged to bringing oral health to the centre stage of global health priorities and dental professionals have an important role to play in improving population dental health. Promoting global health is about reaching beyond borders, disciplines and cultures to tackle vulnerabilities and health inequalities, but also about preparing the health workforce to tackle the effects of these threats of global dimension (MacFarlane, Jacobs, & Kaaya, 2008).

Beyond supporting dental policy makers in producing documents on addressing the broader determinants of oral health through mid- and upstream actions, dentists can actively and independently work towards ameliorate the global burden of untreated oral conditions.

Affordable Health Initiative (AHI) advocates clinical prevention of caries progression and minimally invasive dental treatment as the major approach to address the burden of tooth decay.

Relevance of Dental Caries

The latest estimates from the Global Burden of Disease study show that dental caries remains a neglected global health issue. Dental caries is the most prevalent health condition in the globe and the number of cases of untreated dental caries in permanent and deciduous teeth reached 2.5 billion and nearly 600 million respectively in 2017. The GBD findings showed that the current small decline observed in the prevalence of dental caries was balanced by the increase in number of cases mainly due population grown and ageing. Without urgent action, the number of cases is likely to keep increasing due to population growth and ageing. For example, if the population of a hypothetical country increases from 50 to 60 million citizens over a year and the prevalence of people with untreated caries remains stagnant at current level around 30% over that same period, then the absolute number of cases with untreated caries would increase from 15 to 18 million cases.

• Untreated caries in permanent teeth was the most prevalent condition globally (age-standardised prevalence: 29.4%, 95% UI: 26.8% to 32.2%) among all health conditions assessed in the GBD study, 2017.

• Untreated caries in primary teeth was ranked the seventeenth most common condition globally (age-standardised prevalence: 7.8%; 95% UI: 6.5% to 9.1%).

Relevance of Dental Pain

Epidemiological data on dental pain are sparse and of poor quality. There is an urgent need to include dental pain standardised measurement criteria in well-designed surveys using randomly selected community samples to fill this knowledge gap (Pau, Croucher and Marcenes, 2003). Systematic reviews showed:

• Prevalence of 'toothache' 7-32%, 'pain in teeth with hot, cold or sweet things' 25-38%, 'pain and discomfort needing medication or treatment' 7-9%, 'pain or discomfort in the mouth, teeth or gums' 19-66%, and 'oral and facial pain'40-44%, in the included publications (Pau, Croucher and Marcenes, 2003).

• Prevalence of dental pain 1.33 to 87.8% in the included publications for quantitative synthesis (n = 97). The overall pooled prevalence of dental pain was 32.7 (CI = 29.6-35.9). Two out of ten children below five years, four out of ten children between 6 and 12 years and three out of ten adolescents between 13 and 18 years have experienced dental pain (Pentapati, Yeturu and Siddiq, 2021).

There are more than half million cases of untreated dental caries in the globe causing unnecessarily suffering to children worldwide.

Shame

The unpleasant self-conscious emotion typically associated with untreated dental caries leading to distress and withdrawal motivations as well as, exposure to teasing, mistrust, powerlessness, and worthlessness.

‘Do what you can’

At AHI CIO we understand that everyone has a life and responsibilities that charitable work and professional development have to fit around.

AHI offers a combination of both; professional personal gains through training in the modern way to manage dental caries, as well as, help children worldwide to be free of the consequences of untreated dental caries.

All children deserve to be free of tooth decay, mouth infection, tooth ache and be able to eat heathy foods that require good dental health to chew and smile without embarrassment.

We estimate that 40 HOURS/YEAR dedicated to the initiative to eradicate dental caries and dental pain, would make 400 school children free of active decay, thus dental pain.

AHI health strands

Making decisions on adopting a community dental health care strategy should be based on evidence, population health improvement, cost savings and cost-effective analysis. Also, it should integrate oral and general health care. Decisions about what health care to offer to low-income communities is now more important than ever due to growing evidence that there are inequities in the distribution of diseases, current oral health public resources are far from optimal, there is a continuing growth in dental health care cost fuelled by new technologies and there is an urgent need to address the significant global burden of dental caries. Thus, AHI promotes equality by addressing the ‘inverse care law’ proposed thirty years ago by Julian Tudor Hart:

‘those who most need medical care are least likely to receive it. Conversely, those with least need of health care tend to use health services more (and more effectively).’  

Surprisingly, the burden of dental caries can be addressed with limited health budgets by adopting common sense dental health practices that does not require expensive technology, specialty training, or elaborate dental health care facilities.

Governments’, clinicians’ and academics’ efforts in providing effective health promotion programmes offer an example of how health promotion can lead to population wide risk reduction and cost savings. Contrary, health education programmes based on the dated believe that risk awareness leads to behavioural change in low-income communities is not effective and increases health inequalities. Furthermore, in addition to behaviour change programmes it is important paying increasing attention to the barriers low-income communities face to avoid health risk behaviours, and provide low-cost dental treatment to facilitate access to essential oral health care services to address the burden of diseases among those that failed to prevent its occurrence.

Integrating oral and general health care

Oral health share a number of behavioural risk factor with other conditions. Thus, it is rational and cost-effective to promote health as a whole rather than run a separately programmes for each disease. The key behavioural risks of diseases are poor diet, bad hygiene, lack of physical activities, alcohol abuse, tobacco and drug consumption, which are also key determinants of oral health. Addressing these risks though an oral health promotion strategy has the potential to largely contribute to improve general health and expand the role of oral health professionals. In conclusion, health promotion programmes should focus on common risks associated to oral and general health, independently whether they are developed by dental or any other health professionals.

Health Promotion at AHI

Vaccination is one of the most efficient tools for reducing the burden of infectious diseases and safeguarding health.

The Estrutural City Project

• Nearly 800 children were screened for dental caries and dental pain.

• More than 200 children received dental treatment to their normative needs.

Dr Mauricio Bartelle, AHRC Associate Researcher, is responsible for the AHI activities in Distrito Federal, Brasil.

Under the leadership of Professor Soraya Leal, the AHI Dental Health Care model is being implemented in schools serving Estrutural city, Distrito Federal, Brasil.

Professor Leal is a world expert in the Atraumatic Restorative Treatment approach to manage tooth decay. She has carried out research in collaboration with Professor Frencken for many years and published seminal papers on the ART technique. Her clinical skills are remarkable.

Associate Professor Erica Negrini Lia has joined the team to assess the impact of the intervention on dental pain in school children in Estrutural city. She is a Consultant Paediatric Dentistry, with expertise in assessing dental pain in children.

The voluntary work of Ms Isadora Maciel, BDS, MSc, has been instrumental to eradicate tooth decay and tooth ache in Estrutural City.

Ms Maciel will continue screening and providing treatment to school children in Estrutural throughout 2021-22.

ASSESSMENT

Adopt a school

AHI argues that a global health network of dental health professionals can be created to address the burden of dental caries in low-income communities. The AHI dental health care model is simple, scalable and sustainable. It has been piloted and can be easily reproduced in schools worldwide. AHI supports minimally invasion dentistry, the modern approach to managing dental caries.

• If you are a dentist and you want to get active in your community, you can lead on activities within your locality and work with local volunteer dentists and donors to implement the AHI Dental Health Care model in one or more schools in your locality.

• If you are linked to a dental school, you can lead on activities within your dental school to developing outreach clinics for teaching undergraduate minimally invasion dental care through and to implement the AHI Dental Health Care model in one or more schools in your locality.

• If you are linked to post-graduate programmes as a PhD or MSc supervisor, there are good opportunities for collaborative post-graduate projects. Protocols for data collection including electronic questionnaires and for data analysis were developed by the AHI and are available under request. See current AHI projects>

Personal benefits

As a partner of the AHI CIO you can develop your personal skills and/or advance the teaching of managing tooth decay, make your voice heard, present and/or attend online seminars, discuss health promotion issues and share your experiences (AHI Dental Health Blog). You will also be kept updated on our news, including opportunities to get financial support for your own research, MSc and PhD projects.

Also, you may request support from the AHI CIO Research Centre to assess the impact of the intervention in your locality. AHI CIO virtual office offers support to partners to do the best work for everyone everywhere you are in the globe. AHI provides a research protocol to assess the implementation and impact of the dental care component of the AHI HPS model.

Best practice dentistry at AHI. 

Alleviating Suffering

Promoting a healthy lifestyle alone will not address the disabilities caused by common diseases in low-income communities.

Dental health care at AHI includes dental treatment at school setting and adopts the principles of minimally invasive dentistry to address the burden of tooth decay. Alternatively, 38% (44,800 ppm fluoride ions) silver diamine fluoride (SDF) solution may be used to arrest dental caries in deciduous teeth. Retained roots, and teeth for which the crowns are not restorable, or dental nerves (pulps) are exposed with active caries (still progressing) or where the clinician decides the tooth is likely to cause the patient pain or infection before it exfoliates (falls out) are managed by extraction.

Management of dental caries at AHI

AHI advocates focussing on the management of tooth decay at early stages and the interception of disease progression as early as possible. Management of tooth decay at early stages reduces significantly the cost of dental treatment; a unique feasible approach to address the significant global burden of untreated dental caries. For this purpose, AHI adopts an incremental approach starting from the age 6-years-old when children enter in schools and keeps them enrolled in the programme until they complete formal education to maintain them in good oral health. Each year a new cohort joins the programme.

Research opportunities at AHI:

A multi-centre study was designed to assess the implementation and impact of the Dental Care component of the AHI HPS model. Researchers will continually be recruited to provide a data on a large sample of schools from a number of countries and from all continents. The recruitment of centres and co-investigators is based on dedication and commitment in a team effort to achieve goals that cannot be reached by a single centre effort. The philosophy among collaborators within and between centres is consensus.

AHI research materials

• Research protocols to assess the impact of the school intervention were developed at AHI and are available under request.

• Electronic questionnaires and clinical examination tools were also developed at the AHI and is available under request.

• A secure data manage approach and guidance to use it was developed and is available under request.

• On line statistical support is available at AHI central office under request.

• Training and materials to implement the intervention may also be provide by AHI central office.

Assessing the implementation and the impact of the AHI intervention

Study I

Prior to run the Dental Care component of the AHI HPS model, researchers assess the stake holders intention towards transforming the school in a health promoting school and to identify the determinants of stakeholders’ behaviour towards implementing this initiative. AHI researchers use a cross-sectional survey design to assess the domains of implementation research acceptability, adoption, appropriateness and feasibility (intention to implement). The reason to include only four domains to assess whether school teachers would support implementing the Dental Care component of the AHI HPS model in their schools is because the four domains not included are related to the experience in running the AHI HPS model. Cross-sectional surveys assess the view of respondents and related information in groups of individuals at one point in time. This study design uses a systematic approach to collect data from survey respondents in a way that allows one to compare data collected in a wide range of environments. The subjects of this study are stack holders , in particular school teachers.

Study II

In order to assess effectiveness of the AHI HPS model in the real world, a controlled before-after study is proposed. In this study design observations are made before and after the implementation of an intervention, both in a group that receives the intervention and in a control group that does not or in an active control group, in which participants engage in some task during the intervention period. To produce evidence-based reform in health and education experimental studies must include a control group. First, it is necessary to assess school children’s current dental health and experience of dental pain (baseline data) and identify those in need of treatment. For this purpose, AHI advises to carry out a cross-sectional survey. The subjects in this study are school children enrolled in schools implementing the Dental Care component of the AHI HPS model (intervention group) and in schools implementing the local routine oral health care (active control group). Alternatively, an uncontrolled before-after study may be carried out; in which observations are made before and after the implementation of an intervention in a group that receives the intervention without including a control group. This alternative research design serves only as an exploratory study and do not provide evidence on the impact of the AHI HPS model.

The first step in this study is to assess school children’s current dental health state and experience of dental pain (baseline data), and identify those in need of treatment. For this purpose, AHI advises to carry out a cross-sectional survey. The subjects in this study are school children enrolled in schools implementing the Dental Care component of the AHI HPS model (intervention group) and in schools implementing the local routine oral health care (active control group), generally referral to local health services. The impact of the initiative is assessed at six, 12, 24 and 36 months after implementing the initiative.

Ethical concerns

As it would be unethical to withhold treatment from a control group, this study will use an active treatment concurrent control group, which serves as a benchmark. In this type of study design, one group is given the intervention and the other group is given an existing treatment. Parents of schoolchildren in the control group will be notified if their children have a health condition needing treatment. Researchers organise the referral for treatment at local primary health care units and monitors the process to asses if they receive treatment.

This study may also use a “delayed intervention” design in which the control group gets the intervention after the study is over. In this way, having been in the control group in the short term may serve to improve the school in the long run.

Finally, it is important to note that this study is testing a novel intervention, thus it is not proved to be more effective than the current model adopted by schools, and it is not widely used that not to use the intervention in the control group would be unethical. In fact, it would be unethical to widely implement an intervention that was not tested in a sound experimental study design.

Eradicating tooth decay and tooth ache in Estrutural City

AHI chose Estrutural City to launch the campaign to eradicate dental pain because it is a small community characterised by one of highest level of social deprivation in the world. Estrutural City formation was due to an invasion of garbage collectors near the sanitary landfill of the Federal District. Estrutural City remains economically marginalised and lacking infrastructure.

Estrutural City is located less than 20 kilometres from the centre of Brasilia, Brasil capital city; the country's government ministries, congress and presidential palace, has a poor sanitation system and only a health centre.

Estrutural City is is serviced by three schools.