Dental Health Care Intervention

Affordable Health Initiative (AHi) offers a comprehensive operational model to integrate oral and general health primary health care that facilitate the inclusion of dental care in Universal Health Coverage. The AHi Health Promoting School (HPS) model consists of four interlinked components which are education, health promotion activities, health care services and community engagement. Activities complement each other and impact in a number of determinants of oral health. The AHi HPS model is a whole school and community approach which incorporates the principles of the Ottawa Charter and delivers a simple, scalable and sustainable operational model for the World Health Organisation’s (WHO) Health Promoting School initiative.

Relevance of Oral Health

Dental health care is included in the AHI HPS model because dental decay is the single most prevalent human disease in the world affecting 2.5 billion people (Permanent teeth) and 600 million small children (Milk teeth) worldwide [1,2] Poor dental health impacts on diet, nutrition, body mass index and the growth and development of children. [3,4]. Poor oral health affects mastication, which in turn impacts on selection of food (diet) with potential consequences for nutrition, grow and development. It also affects speech, smile and psychosocial well-being [5,6]. Dental caries, if left untreated, it causes severe pain and mouth infection [7]. Oral conditions accounted for Years Lived with Disability (YLDs) comparably to all maternal conditions combined, hypertensive heart disease, anxiety disorders and schizophrenia, and for more YLDs than 25 of 28 categories of cancer (Stomach, liver and trachea, bronchus and lung cancers ranked higher than oral conditions), cardiovascular and cerebrovascular diseases, and mental health other than depression [1]. Although there has been a decrease in the prevalence and the severity of dental caries in affluent children over the past few decades, the benefits have not been equally shared by most children in low-income communities. Dental caries care remains neglected worldwide [2, 8]. The AHI Dental Care Approach offers an operational model for the FDI White Paper on Dental Caries Prevention and Management [9].

sumary of Dental Caries management at the Affordable Health initiative

(6-8-year-old school children)

Relevant information to assess the dental care plan presented below:

The AHi Dental Care Plan was designed to be run at the school setting. It adopts an incremental approach enrolling school children from the age of 6 years old and engaging them until they leave school.
This Dental Care Plan is applicable to 6-8-year-old school children. Another plan is suggested for older ages.
At the age of 6-8-year-old, children have a mixed dentition, and first molars erupt and go through a post maturation during this period. Because this is the most vulnerable period to caries development, the AHi Dental Care Plan has included application of pits and fissures sealants to first molars.
Supervised tooth brushing with fluoride toothpaste twice a day at school is provided to all children. For this reason, the AHi Dental Care Plan has not included professionally applied fluoride therapy.dental care plan

CAST name, code and description followed by Treatment Plan. Click HERE to see with pictures)

-Sound (0): no visible evidence of a distinct carious lesion is present.

Primary teeth: No action.

Secondary teeth: application of sealant to pits and fissures to first molars. Alternatively, application of sealant to pits and fissures to first molar only in children with experience of caries in primary teeth or no action.

-Sealant (1): pits and/or fissures are at least partially covered with a sealant material.

Primary teeth: no action.

Secondary teeth: repair or application of new sealant to pits and fissures to first molars.

-Restoration, otherwise sound (2): a cavity is restored with an (in)direct restorative material and the tooth is sound.

No action.

-Enamel (3): distinct visual change in enamel only. A clear caries related discoloration is visible, with or without localised enamel breakdown.

Primary teeth: no action, or alternatively, cariostatic treatment with application of 38% (44,800 ppm fluoride ions) silver diamine fluoride.

Secondary teeth: application of fissure sealants to pits and fissures to first molars. Additionally, it may include application of 38% (44,800 ppm fluoride ions) silver diamine fluoride to smooth surfaces to arrest dental caries, but this may be unnecessary in the presence of supervised tooth brushing with fluoride toothpaste.

-Dentine (4): internal caries-related discoloration in dentine. The discoloured dentine is visible through enamel which may or may not exhibit a visible localised breakdown of enamel.

Primary and secondary teeth: application of an adhesive restoration material after selective carious removal (ideally with glass–ionomer or alternatively with zinc polycarboxylate cements). Alternatively, cariostatic treatment with 38% (44,800 ppm fluoride ions) silver diamine fluoride to arrest dental caries into dentine may be adopted.

-Distinct cavitation into dentine (5): The pulp chamber is intact.

Primary teeth: application of an adhesive restoration material after selective carious removal (ideally with glass–ionomer or alternatively with zinc polycarboxylate cements). Alternatively, application of 38% (44,800 ppm fluoride ions) silver diamine fluoride to arrest dental caries into dentine may be adopted.

Secondary teeth: application of an adhesive restoration material after selective carious removal using hand-instruments (ideally with glass–ionomer or alternatively with zinc polycarboxylate cements).

-Pulp (6): Involvement of the pulp chamber. Distinct cavitation reaching the pulp chamber or only root fragments are present.

Primary teeth: extraction.

Secondary teeth: extraction when referral to root canal treatment is not available.

-Abscess/Fistula (7): A pus containing swelling or a pus releasing sinus tract related to a tooth with pulp involvement.

Primary teeth: Extraction.

Secondary teeth: extraction when referral to root canal treatment is not available.

-Lost (8): The tooth has been removed because of dental caries.

Primary and secondary teeth: no action.

-Other (9): Defective restoration with or without recurrent caries.

Primary and secondary teeth: seal or repair the restoration, if possible, rather than replace the defective restoration. Otherwise, as for code 5 (Secondary teeth); application of a new adhesive restoration material after selective carious removal using hand-instruments (ideally glass–ionomer or alternatively zinc polycarboxylate cements).

Best Practice Dentitry

Best practice dental care prevention [9] at AHi involves four strands: (1) healthy diet; (2) good oral hygiene; (3) use of fluoride toothpaste and (4) fissure sealants for secondary teeth. It focusses on preventive dental care based on the interception of disease at an early stage, and also on dental treatment to alleviate the suffering caused by severe disease observed following caries progression. By adopting an incremental approach starting at the age 6-8-years-old, the AHi HPS model allows managing dental caries and maintaining good oral health in a highly cost-effective way. This is because of the low cost of managing dental caries at early stages.

AHi HPS model places great emphases on alleviating the suffering caused by severe disease observed following caries progression when prevention fail and adopts the principles of minimum intervention dentistry, the modern medical cost-effective approach to the management of tooth decay [10-13] and silver diamine fluoride (SDF) solution may be used to arrest dental caries in primary teeth [14-16]

Several interlinked health promotion interventions are carried out to encourage adopting a healthy lifestyle. Health literacy is achieved through a set of five school class sessions: introduce a topic using e-learning and apply a quiz game (first session); moderate a debate on the topic a week later (second session), moderate a topical group discussion in the following week (third session) and set an individual goal for each topic (last session). By example, dietary investigation (diet inventory) and data analysis are used to guide the school children towards an achievable goal and to design tailored interventions. Human development teaching addresses major social-psychological determinants of health behaviour (i.e.: motivation) and is delivered using the format described above. A health topic (i.e.: diet) and a human development topic (i.e.: self-esteem) are addressed monthly (two topics/eight sessions/month). The Health Detective game helps to consolidate adopting a healthy lifestyle. Healthy food distribution addresses the socio-economic barriers to adopt a healthy diet. Supervised hand washing and tooth brushing with fluoridated toothpaste is provided in the hygiene practice school activity. See the full AHI HPS model for details.

Clinical preventive and curative dental care are provided at school setting and dental treatment is offered preferably at breaking time or study time as appropriate and, if necessary due to high demand, during lesson time. In the latter scenario, the children would be excused from attending class in pairs to have dental treatment, while the other children remain attending lessons. All children undergo oral diseases assessment. AHI acknowledges that the detection and proper assessment of caries lesions is the foundation to develop evidence based dental care planning. Clinical examination includes several categories and allow to compute several caries assessment indices often used in oral epidemiology including the index proposed by WHO and the Caries Assessment Spectrum and Treatment System (CAST).

Following the screening of school children for dental diseases, AHI HPS model adopts the principles of minimum intervention dentistry and focusses on preventive dental care based on the interception of disease at an early stage [10]. MID consist of biologically managing caries progression with best practice prevention. It includes application of an adhesive restoration material after selective carious removal Dentinal caries is sealed into the tooth and separated from the oral cavity by application of an adhesive restoration material over the decay (glass–ionomer or zinc polycarboxylate cements). This includes the Atraumatic Restorative Treatment (ART) technique [11, 12, 13], which is the use of hand instruments alone to remove carious tooth substance and the restoration of the cavity using glass ionomer restorative cement, without any injections or drilling.

Alternatively, 38% (44,800 ppm fluoride ions) silver diamine fluoride (SDF) solution may be used to arrest dental caries. Application of SDF to arrest dental caries is a non-invasive procedure that is quick and simple to use. However, it stains the carious teeth and turns the arrested caries black. It also has an unpleasant metallic taste that is not liked by patients, especially children. The low cost of SDF and its simplicity in application suggest that SDF is an appropriate therapeutic agent for use in school dental health programmes. Reports of available studies found no severe pulpal damage after SDF application. The current literature suggests that SDF can be an effective agent in preventing new caries and in arresting dental caries in the primary teeth in children. It allows definitive restoration to be performed in following years [14, 15, 16].

Retained roots, and teeth for which the crowns are unrestorable, 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.

References

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GBD 2017 Oral Disorders Collaborators, Bernabe E, Marcenes W, et al. Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study. J Dent Res. 2020;99(4):362-373. doi:10.1177/0022034520908533.
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Nigel Pitts and Domenick Zero. White Paper on Dental Caries Prevention and Management A summary of the current evidence and the key issues in controlling this preventable disease. https://www.fdiworlddental.org/sites/default/files/media/documents/2016-fdi_cpp-white_paper.pdf.
Innes NP, Manton DJ. Minimum intervention children's dentistry - the starting point for a lifetime of oral health. Br Dent J. 2017;223(3):205-213. doi:10.1038/sj.bdj.2017.671.
Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview. Clin Oral Investig. 2012;16(5):1337-1346. doi:10.1007/s00784-012-0783-4.
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Dorri M, Martinez-Zapata MJ, Walsh T, Marinho VC, Sheiham Deceased A, Zaror C. Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries. Cochrane Database Syst Rev. 2017;12(12):CD008072. Published 2017 Dec 28. doi:10.1002/14651858.CD008072.pub2.
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Contreras V, Toro MJ, Elías-Boneta AR, Encarnación-Burgos A. Effectiveness of silver diamine fluoride in caries prevention and arrest: a systematic literature review. Gen Dent. 2017;65(3):22-29.
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