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Primary oral health is an essential oral health care. Discuss

Topic: Primary Oral Health Is An Essential Oral Health Care. Discuss.

Despite the availability of effective prevention and treatment methods, we have seen only small improvements in oral health status over the past two decades.

New research is confirming what many have intuitively known for some time a person’s oral health impacts their overall health and quality of life.
Moreover, oral disease is preventable. Dental caries can be prevented with daily brushing and flossing, a healthy diet, and simple preventive measures such as fluoride. Limiting alcohol and avoiding tobacco is important for the prevention of oral cancer.

Primary Health Care
Primary health care is an essential health care based on practical scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

It forms an integral part of both the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community.It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of continuing health care process”

Primary Oral Health Care

Primary Oral Health Care basically is the understanding of the oral health problems of individuals, families and Communities, making them aware and appreciate the problems; and motivate them as individuals, families and communities to participate in solving them taking into consideration their social economic status.

Oral health problems of individuals:

All Individuals a person who has reached the age of being aware of his environment must know how his environment affects his health positively or negatively. He needs to be educated by those with the knowledge that will enable him to adapt Primary Oral Health Care, nutrition diet, oral hygiene and utilization of co-existing dental facilities.

Oral health problems of families:

A family is a group of more than one individual normally including children who are not aware of the environment. The health of children depends on the knowledge that parents have on Primary Oral Health Care. This starts from prenatal stage until the children leave home. This is the core of establishing oral health among the people ‘- often called the larger group.

Oral health problems of the community:
A Community is a collection of individuals and families who live in the same environment and are organized in some form of government. It is through the Community effort that programmes are made such as training of personnel, provision of technical facilities etc. The whole community must be aware of their oral health care.

Why Focus on Primary Oral Health?

Oral disease exacts a heavy toll on patients, families, and communities; and results in unnecessary healthcare costs for public and private payers as well as consumers. This section summarizes the costs and consequences of oral disease, describing why oral health should be a priority for primary care.

The Unrecognized Burden of Oral Disease

Primary Oral health, inextricably linked to overall health, is essential for healthy development8 and healthy aging. The consequences of oral disease are often minimized or discounted, yet oral complications reflect, exacerbate, and may even initiate, other health problems, and they can have a profoundly negative impact on quality of life.

Health Impact

Dental decay is an infectious disease caused by the disruption of the balance of normal oral bacteria and overgrowth of cariogenic organisms (primarily Streptococcus mutans, S. sobrinus and lactobacilli) as a consequence of diets increasingly rich in processed carbohydrates and refined sugar. If left untreated, decay can result in tooth loss, abscess and resulting bone loss, and systemic infection. In severe cases, these infections may lead to death.

Periodontitis (also known as gum disease) is a condition of chronic, and sometimes acute, inflammation, which over time causes the gums to pull away from the teeth, leaving pockets that become infected. Bacterial toxins and the body’s natural immune response break down the bone and connective tissue that hold teeth in place, resulting in tooth loss.

Periodontal diseases may be a risk to general health, particularly for patients with other chronic diseases. For example, new evidence is demonstrating a relationship between periodontal disease and diabetes. Among patients with diabetes, periodontal disease appears to accelerate both pancreatic failure and end-organ ischemic vascular disease (a group of diseases caused by arterial insufficiency), including stroke, myocardial infarction, and renal failure.
Periodontal inflammation is also associated with ischemic vascular disease in the absence of diabetes. Maternal periodontal disease during pregnancy may be associated with increased risk of pre-term delivery and low birth weight.
Impact of Primary Oral Health on Quality of Life

Oral disease also reduces quality of life and productivity, both at school and in the work place. Dental caries is associated with impaired growth in children and can affect their appearance, self-esteem, and speech.
Children with poor oral health have significantly higher school absence and poorer academic performance than their peers, independent of socioeconomic factors and race.33 For example, one study of disadvantaged children in California found that children (ages 5–18) lost an average of 2.19 school days per year due to oral health complaints; and in turn, their parents lost an average of 2.53 work or school days to caregiving. Students with toothaches were nearly four times as likely to have a low grade point average compared to children without oral pain.

Employed adults lose 164 million hours of work each year due to their own oral health problems or dental visits35–twice the amount of time required to assemble the three million new cars produced by the U.S. each year. Oral pain can restrict normal activity, disturb sleep, and reduce overall quality of life, particularly among older adults.10 Tooth loss can also have a significant indirect economic cost. Adults with missing teeth are more likely to report having trouble finding employment due to negative judgments on their appearance or speech. While data on the magnitude of indirect economic costs are limited, research has shown that treatment for oral health conditions can improve employment opportunities for low-income adults.

Primary Oral Health is concerned with the functional efficiency not only of teeth and supporting structures ‘but also of the surrounding parts of the oral cavity and of the various structures related to mastication and the. maxillofacial complex. So there is a tendency to talk more of oral health rather than dental health. Oral health cannot be separated from general health since oral disease may be a manifestation of or an aggravating factor of a wider spread systemic disorder.
The common oral health problems are:-
Dental Caries.
Periodontal disease.
Malocclusion and other dent of axial anomalies.
Traumata (accidents).
Oral manifestations of general disease and other health conditions.

As described above in the definition of Primary Oral Health Care, the understanding of the etiology and incidence of the diseases is a pre-requisite in planning of the delivery of primary oral health care. The understanding of the etiology and of the diseases is a pre-requisite in planning delivery of Primary Oral Health Care. However, here are more practical aspects that could be mentioned here :-

1. Intra-ministerial Cooperation:
As mentioned above oral health is a necessary part of general health. There are activities in other sectors of health which have a direct hearing on dental health. These are maternal and child health service, Food and Nutrition, Public Health Nursing and School Health. Ways’ have to be found whereby dental health aspect can be more emphasized in these activities from the training of personnel of the field activities.

2. Oral Health Education:
Oral health education will need special organization and techniques for it to be effective. This will depend on economic feasibility in putting into practice the dental health measures advocated in the education and the acceptability of the proposed dental health practices as regards customs, traditions, beliefs of individuals, families and Communities. Far too often, we become more academic than practical in our, health education delivery system without considering the patients’ side of things. We tell the public to eat foods we ‘know very well that they can’t get instead’ of making the best of what they have. They are told to buy modern toothbrushes which they can’t afford instead of investigating how best they can make use of chewing sticks.

Primary oral health care (POHC) is an integral part of PHC. After the conference, the PHC concept was further developed gradually during the 1980s by the health promotion approach. The European WHO Discussion Document in 1984 defined health promotion as follows:

• Health promotion involves the population as a whole, in the context of their everyday life rather than focusing on people at risk for specific diseases.

• It is directed towards action on determinants or causes of health

• It combines diverse, but complimentary, methods or approaches

• It aims at particularly effective and concrete public participation

• Health professionals have an important role in nurturing and enabling health promotion

The subject areas of health promotion were defined as access to health, development of an environment conducive to health, strengthening social networks and social support, promoting positive health behavior and appropriate coping strategies, increasing knowledge, and disseminating information.

Primary Oral Health Promotion

Primary Oral health promotion is based mainly on 6 different areas:

Nutrition (reduction in the frequency of sugar intake)

Oral hygiene (regular dental plaque removal)

Smoking cessation (smoking explains 50% of periodontal disease prevalence)

Preventing dental trauma (prevalence around 25%)

Changing environment (conducive for oral health)

Supporting individuals (empowering people to take care of their health behavior).

Dental traumas are a public oral health problem and there is some evidence that they are increasing.

Primary Oral health promotion aims to change oral health habits of people to be conducive to oral health. Habits are basically determined by the environment and lifestyle of the individual. When behavior is frequently repeated, it becomes an automatic habit, which does not require thinking about the act. Habits are acquired skills and actions, which become automatic only after significant repetition. Avoiding sugar and brushing teeth are the main oral health habits.

Dental caries can be prevented and low sucrose intake is the main preventive measure (sweets, sugar drinks, etc.). Fluoride can also be used to increase the resistance of hard tooth surface (enamel, cementum, den-tine). Efforts have been made to find alternative sweeteners to replace sucrose in the diet. Currently xylitol has shown itself to be the most promising one, but because of the laxative effect it can only be used in small doses between meals.

The effects of the risk factors on caries can be seen in the mean caries experience levels of the populations. Despite the availability of highly effective measures for primary prevention, dental caries remains one of the most common childhood chronic diseases. One effective preventive method for caries reduction is the use of fissure sealants , but its application has not been targeted at the high-risk caries groups, in many countries.

However, tooth brushing with fluoride toothpaste remains the most common preventive method for caries reduction. Although a simple task, there is a long way to go to get everyone to adopt this habit twice a day. In addition to the recommended frequency of tooth brushing, the proximal surfaces should also be cleaned with dental floss at least once a day. Flossing is not a new cleaning method, but it should be adopted by everyone. Smoking is a strong risk factor for lung cancer and several diseases such as periodontal disease. Therefore, dental professionals should work with other health care professionals to help patients to quit smoking.

The most practical advice for health care professionals would be to use the five ‘A’s method: ask, advise, assess, assist and arrange. All patients should be asked about their tobacco use and findings should be documented in patients’ records. We should advise all smokers to stop smoking and inform them about the consequences. The willingness of patients to quit smoking should also be assessed. We should assist the patients in stopping, help them to set a stop date, provide self-help material, and consider nicotine replacement therapy. The other option is to refer the patient to professionals and then to follow-up at subsequent visits. Finally, follow-up contacts should be arranged, success should be congratulated, and if tobacco use has reoccurred, recommitment should be elicited.

Most chronic non-communicable diseases (about 80%), such as dental caries and periodontal disease, are related to people’s behavior, which is heavily dependent on the social environment of individuals. The extensive review of Marmot et al. in Europe suggested that inequalities of health are dependent on social environment.

The effect of social determinants can be seen on the prevalence of periodontal disease and caries experience, resulting in clear socio-economic differences in the number of teeth and in edentulous patients.

Evidence of The Effectiveness of Primary Oral Health
Primary Oral health education is an important part of POHC. Health education should be conducted at primary care clinics and hospitals, schools and colleges, preschool education and care, local authority services, commercial organizations, workplaces, community-based initiatives, and the residential homes of the elderly. Dental health education has been shown to be quite ineffective in changing people’s behavior. The current principles of dental health education have been listed as follows:
Integration – dental health education should be integrated with general health education
Diverse educational approaches – as target groups are different
Early intervention
Emphasis on educational process
Community participation
Encouragement of self-efficacy
Healthier choices – easier choices
Dental anxiety as a barrier to success
The importance of educational and behavioral outcomes
Appropriate goals – realistic, measurable, positive, important to the person and time-related.
Evaluation as a necessary component.

Several models describe the factors related to behavioral change, which are important for understanding the difficulties and barriers to changing behavior. The KAB-model (knowledge, attitude, behavior) is the traditional medical model, which is clearly out-of-date, too simplistic and does not work in practice. Knowledge does not necessarily change the attitude and attitude does not necessary change the behavior. The locus of control theory was based on the concept of self-efficacy, which can be internal (my life is determined by me) or external (my life is determined by somebody else other than me, e.g. God, others, fate). The salutogenic model was designed by Antonovsky and is based on stress management and on a sense of coherence. The sense of coherence is based on perceived comprehensibility, manageability and meaningfulness. The current health behavior models, which have been shown to be effective in health education programmes, are based on two-way communication.

One of them is the trans-theoretical model, which was designed by Prochaska and DiClemente in 1983. It is based on the situation analysis of the following:
Lifestyle and its determinants by the individual
The individual’s attitude and beliefs about oral health care
The individual’s health habits and concern about them
The individual’s readiness for change – his or her expectations and goals.
Subjects should be evaluated for their readiness to change. The defined stages of this behavioral change process are:

Instruction strategy options accordingly are:
Offering knowledge
Assessing the need for change and increasing the readiness for change
Discussion and consideration of the change process. Listening to the subjects is required for implementing this behavioral strategy.

Benefits of Regular Dental Visits
The traditional belief has been to see a dentist every 6 months. However, the evidence for the effectiveness of frequent dental visits for oral health has been questioned by several studies. The Cochrane Systematic Review of the effectiveness of recall intervals for oral health in primary care patients concluded that there is no evidence from randomized controlled trials of any conclusions on this.

Iatrogenic effects of frequent visits have been well demonstrated, because of the high variance in caries diagnostics and treatment planning. Rytömaa et al. conducted a study at the Department of Cariology in Helsinki in which the same 10 students were examined by 12 teachers, and the mean number of teeth considered needing restorations varied drastically – on average 5.0 teeth (the number of teeth ranged from 31 to 72 between the dentists).
In another study in the UK, Elderton and Nuttal sent 18 dental students to 15 dentists and reported a considerable variation in the number of filled surfaces planned for replacement, unfilled surfaces planned for restorations, and number of teeth planned for extraction. Only 2 surfaces were agreed by all of these 15 dentists and altogether 184 surfaces (over 50% of all) were suggested to be filled by only 1–2 dentists. Elderton also followed the subjects, who had been examined in the National Oral Health Survey 1 year earlier.
Altogether, 1,053 surfaces were filled by the National Health Service, but only 131 of the surfaces were those from the 559 surfaces which could have been expected to be filled based on the diagnosis of dental caries in the survey conducted 1 year earlier. These studies demonstrate the iatrogenic effect of frequent dental visits because of inconsistent diagnoses and treatment decisions.

Primary Oral Health is an Essential Oral Health Care

From the POHC point of view, what is to be considered ‘essential’ oral health care is crucial, especially in developing countries. The main reason to see oral health professionals in developing countries is still dental pain, and the main treatment is extraction to relieve this pain.
Essential POHC should be able to provide extractions for people who have pain because of dental infection . The Atraumatic Restorative Treatment (ART) system was developed for POHC, especially for developing countries where rotary dental equipment or electricity were often not available. It is based on the removal of the infected tooth substance and the preparation of the cavity for glassionomer restoration only with hand instruments. Caries lesions in developing countries most commonly have been only on the occlusal surfaces, when sugar consumption was at the lowest level.
ART restorations could be considered as POHC treatment, which could prevent the progress of the caries lesions and consequently reduce the need for extractions and loss of teeth. Based on multi-center ART studies , it seemed to be a practical method for providing restorative treatment in developing countries for primary and permanent teeth as well as for older people who could receive treatment in their homes. ART as a POHC method has also been tested in the Middle-East.
Primary Oral health is essential for healthy development and healthy aging, yet nationwide there is an unacceptably high burden of oral disease. This new white paper makes the case for incorporating preventive oral healthcare as a component of routine medical care and structuring referrals to dentistry. It outlines an Oral Health Delivery Framework, which consists of five actionable steps primary care teams can take to protect and promote oral health, including offering preventive interventions and structured referrals to dentistry.
These actions directly align with how primary care teams manage preventive, acute, and chronic care needs for a wide range of clinical conditions, and are within the scope of practice for primary care providers and their teams. The Framework was developed in partnership with a panel of experts, including primary care and dental care providers; leaders from medical, dental, and nursing associations; payers and policymakers; a patient and family partnership expert; and oral health and public health advocates.
Moreover, oral disease is preventable. Dental caries can be prevented with daily brushing and flossing, a healthy diet, and simple preventive measures such as fluoride. Limiting alcohol and avoiding tobacco is important for the prevention of oral cancer. Yet many Americans do not benefit from available preventive measures because they have not successfully incorporated oral self-care into their daily routine, lack access to dental care, or live in communities without fluoridated water. This “prevention gap” results in an unnecessarily high burden of oral disease nationwide.

Most Oral Disease is Preventable
Dental caries is the most common chronic disease of childhood. One-quarter (25%) of children aged 2–5 and half (50%) of children aged 12–15 suffer from tooth decay.7,8 Nearly 25% of adults aged 20–64 report having untreated dental caries, which at any age can lead to pain, tooth loss, and infection. Among older adults (65 years and above), 25% have lost all of their teeth—putting them at risk for compromised nutrition and other complications.7, 10 Oral and pharyngeal cancers, often diagnosed too late, kill more than 7,800 Americans each year, nearly double the number of patients who die from cervical cancer.
Oral disease impacts systemic health, particularly for patients with chronic diseases, such as diabetes. Failing to prevent or control the progression of oral disease may increase the risk of serious adverse health outcomes.

Dental caries is the most common chronic disease of childhood. One-quarter (25%) of children aged 2–5 and half (50%) of children aged 12–15 suffer from tooth decay.7,8 Nearly 25% of adults aged 20–64 report having untreated dental caries, which at any age can lead to pain, tooth loss, and infection. Among older adults (65 years and above), 25% have lost all of their teeth, putting them at risk for compromised nutrition and other complications. Oral and pharyngeal cancers, often diagnosed too late, kill more than 7,800 Americans each year, nearly double the number of patients who die from cervical cancer.
Oral disease impacts systemic health, particularly for patients with chronic diseases, such as diabetes. Failing to prevent or control the progression of oral disease may increase the risk of serious adverse health outcomes. Primary health care is essential health. Care based on practical scientifically sound. and socially acceptable methods and technology made universally accessible to individuals and families in the community through.


Delivering preventive oral health care in the primary care setting offers the opportunity to expand access for nearly all patients, particularly high-risk and vulnerable patients who bear the greatest burden of oral disease. Primary care teams have the skills necessary to understand and intervene in the oral disease process; the relationships needed to engage patients and families in oral health self-care; and a structure for coordinating referrals to dentistry and supporting patients during transitions of care.

Advanced primary care practices such as PCMHs are positioned to implement the Oral Health Delivery Framework in full. Primary care practices still developing advanced capacities (such as team-based care) can consider an incremental approach to implementation. All primary care practices will need support from dentists, payers, policymakers, and other stakeholders in order to make the delivery of preventive oral health care viable and sustainable. Nonetheless, the basic resources—including an organizing framework, training options, and exemplar models—are already available.

You can get the file by clicking on the link below.

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