Improving Global Oral Public Health and Perception through Outreach Clinics: A Case

Study in Chiquilistagua, Managua

David Ocon

University of South Florida

davidocon@mail.usf.edu

Abstract

Oral Health is an integral component of general health and quality of life. Poor oral

health and subsequent untreated oral diseases can affect the most basic of human needs,

including the ability to eat and drink, swallow, maintain proper nutrition, and communicate. The

perception that oral health is in some way less important than and separate from general health is

false. Oral disease is a significant public health problem and burden, owing to the high

prevalence and incidence rates in all regions of the world, particularly among poor and

disadvantaged populations in underdeveloped countries. Using case study results of a temporary

international outreach clinic established in Chiquilistagua, Managua in 2010, this paper will

analyze sustainable and equitable methods to help improve public perception of oral health and

population-based preventative treatments. By identifying risk factors for oral disease and

determining cost-effective and practical treatment approaches --- the prevention, diagnosis and

management of global oral health can be greatly improved.

Introduction

According to the 2003 World Oral Health Report administered by the World Health

Organization (WHO), dental caries (cavities) remain as the most prevalent oral disease in the

world, affecting 60–90% of schoolchildren and the vast majority of adults in both developed and

underdeveloped countries (Petersen, 2003). The WHO report makes it clear that the main

etiological risk factors for the formation of dental caries stem from dietary habits with high sugar

consumption, inadequate exposure and accessibility to fluorides, and lack of oral health

awareness and research.

The WHO report (2003) addresses sugar consumption as one of the main etiological

factors for dental caries, in particular noting the damaging effects of processed or refined foods

and the consumption of soft drinks loaded with sugar. For countries with high sugar consumption

levels, it is recommended that national health authorities and policy makers formulate both

country and community-specific goals to reduce the consumption of free sugars in the

population. Studies on the role of diet in chronic disease recommend that refined or processed

sugars in foods and drinks should remain below 10% of total caloric intake and the and be

limited to a maximum of four times per day (WHO, 2003b). However, many countries currently

undergoing nutrition transitional policies simply do not provide access to adequate fluoride

exposure, one of the most basic dental needs (Moynihan & Peterson, 2004; WHO, 1994a).

From a clinical perspective, dental caries is reasonably well understood as a disease

process, yet current potent preventive modalities, such as water fluoridation measures and access

to fluoride toothpaste and mouth rinse, are successful yet underutilized (McDonagh, et. al, 2000).

Fluorides operates on tooth surfaces by creating low levels of fluoride in saliva, which reduces

the rate at which minerals are dissolved from tooth enamel, the outer protective surface of the

tooth (Pizzo, et. al, 2007, Levine 1991). However, this capacity for demineralization is limited.

When foods or drinks containing sugars enter the mouth, bacterial plaque forms on the surface of

the tooth, rapidly converting sugars into acid, greatly increasing the rate mineral loss from tooth

enamel. The net mineral loss from the enamel surface results in dental caries, through which

bacteria can penetrate and infect the inner structure of the tooth, causing significant tooth decay

if left untreated.

Case Study: Chiquilistagua, Managua

Nicaragua is recognized as the poorest country in Central America and the second

poorest country in the Western Hemisphere (CIA, 2011). Home to nearly six million people, the

country faces economic and social challenges relating to poverty, underemployment, literacy,

political corruption, and natural disasters. As a result, most Nicaraguans have extremely limited

access to basic healthcare.

Health disparities are commonly associated with populations whose access to health care

services are compromised by environmental factors such as poverty, limited education or

language skills, geographic isolation, age, gender, disability, or an existing medical condition

(Goldberg, et. al., 2004). Additionally, in underdeveloped countries such as Nicaragua, those

wishing to seek care may be faced with health care practitioners who lack the training and/or

cultural competence to communicate effectively in order to provide the medical services needed. 

Programs and coordinated efforts that have the ability overcome these barriers, such as clinical

outreach and education conducted through dental schools and other health professional schools

and residency programs, should be highlighted and replicated globally in high risk communities. 

Since 2005, the New York University College of Dentistry (NYUCD) has set up a

temporary treatment and outreach clinic in Chiquilistagua, an impoverished rural village in

Nicaragua with 11,000 inhabitants and no local dentist. Each year, the NYUCD have brought a

team of 30-35 dental students, including faculty members, oral surgeons, pediatric specialists,

graduate students, and staff members for a week-long clinic. The aim of the mission focuses to

improve oral health, through a unique sustainable model designed to combat the devastating

effects of sugar consumption by basic oral health education and treatment.

The site of the clinic was at Nino Jesus de Praga, a small school ranging from grades pre-

kindergarten to high school with an age range of 3-18 years old. The preventive based aspect of the

mission utilized the school’s classrooms as a platform for teaching children preventive oral health

measures and procedures, such as how to brush teeth correctly and the importance of fluoride

varnish applications. The team introduced a very original game for introducing the basics of oral

hygiene and nutrition education. In each of these classrooms, prior to beginning oral assessments, a

Spanish-speaking student or resident would moderate the game, which consisted of a “happy tooth”

and a “sad tooth” on a large piece of felt. The children were then challenged to decide whether a

certain food was good or bad for their teeth by attaching foods where they belong (i.e. candy and

sweets on the sad tooth, fruits and vegetables on the happy tooth). This interactive approach was a

fun and educational way to provide basic nutritional counseling and oral hygiene education for the

school children, whom were all eager and adamant in wanting to participate.

Following their mission of continued sustainable care, the NYUCD team partnered with

the Nicaraguan Ministry of Health and the Dental School at the Universidad Americana

Managua to train their dental students to reapply the fluoride varnishes every three months for

one year. Additionally, local health care workers and teachers from the school were trained to

provide follow-up treatment, leaving behind the fluoride and supplies necessary for future

quarterly applications.

NYU’s pediatric dental team also provided comprehensive care to every preschool,

kindergarten, and first- and second-graders in their respective classrooms in order to apply fluoride

varnish, perform an oral assessment and arrange for follow-up care throughout the week if needed.

Emergency dental care was also available to all other children in the community on a walk-in basis if

accompanied by a parent or guardian. The site provided four separate rooms to set-up as treatment

areas, which included triage, adult restorative care, oral surgery, pediatrics care and endodontics or

root canal therapy. In addition, a sterilization area was set up in the kitchen.

Children requiring follow-up or emergency treatment were given color-coded wristbands

to make them easily identifiable among the crowd of patients awaiting treatment at the clinic. A

list of children requiring care was given to school administrators, who then sent reminder notes

home with the children to their parents. Along with the children, the need for emergency dental

care among the adult population was virtually endless once word spread that the team was in

town. Throughout the week, schoolchildren returned to the clinic with parents or older siblings

for necessary treatment. In addition to children, each day over a hundred adults came seeking

treatment. Over the week long period, the team provided 547 children and adults with sealants,

fluoride varnishes, restorations, extractions, and emergency care services.

Age Total 0-10 0-12 13-20 21+Total 829 250 282 78 219

Tooth Decay 546 (66%) 156 (62%) 174 (62%) 53 (68%) 163 (74%)Avg teeth w/decay 3 2.9 2.8 2.3 3.3

           Existing Condition(per patient)          

Caries 534 (64%) 160 (64%) 177 (63%) 51 (65%) 146 (67%)Crown 2 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (1%)

Fillings 141 (17%) 14 (6%) 20 (7%) 21 (27%) 86 (39%)Sealants 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Whole Missing 223 (27%) 33 (13%) 36 (13%) 18 (23%) 136 (62%)           

Work Needed(per tooth)          Extractions 460 166 171 27 267

Fillings 1159 569 623 149 441Sealants 307 263 285 34 10

           Work Done (per tooth)          

Composite 92 24 37 29 39Amalgam 140 4 6 33 103

Extractions 377 150 157 24 203Sealants 175 123 160 51 1

Exams 153 120 141 23 10

Data gathered from the 2010 Chiquilistagua clinic showed that tooth decay rate among

children at the school, all whom were under the age of 12, was a staggering 64 percent. This

shows that early childhood caries (ECC) is prevalent among children in Nicaragua. Among

those aged 13+ and older, the rate of doth decay was 71 percent, showing an increase in

prevalence of tooth decay when early caries are left untreated. Simply put when left untreated, a

simple cavity may affect the overall well-being of a child by posing serious health risks well into

their adult life. Preventive treatments for oral tooth decay, such as crowns and sealants, were

almost non-existent in the population.

How to Improve Public Policy and Perception

Though each country faces its own idiosyncratic challenges, modest goals yield only

modest outcomes. Significant results and change occurs when commonly held assumptions are

challenged, resources are targeted, and collaborations are synergistic. The oral health community

must be ready to act to address the nation’s overall health agenda, in a manner oriented to

primary health care and prevention. Efforts to overcome these attitudes and beliefs can start at

the grassroots level, which can then lead to coordinated national movements to increase oral

health literacy.

In order to meet the global challenge of improving both the perception and treatment of

oral health care effectively, public health care administrators and policy-makers need the tools,

capacity and information to assess and monitor health needs in high risk areas, choose

intervention strategies, and design policy outlines. It is vital that health professionals,

policymakers, and the general public understand that oral health is essential to general health and

well-being at every stage of life. By raising a community’s level of awareness and understanding

of oral health through coordinated efforts, policymakers can make informed decisions and

articulate their expectations of oral health care at the community level. In this way, the

prevention, early detection, and management of oral diseases can become integrated in health

care, community-based programs, and social services.

A focus on intervention strategies to reduce the risk factors and burden of oral disease

should be based on applied research, through clinical and local population-based studies such as

the Chiquilistagua outreach, oral health clinics, and demonstration projects. Specifically, these

outreach missions should be designed, organized, and categorized in a manner that helps build a

detailed epidemiological picture of the local area, focusing on the following:

Focus on health promotion and disease prevention.

Service coverage of highest risk regions and subpopulations and analysis of highest risk

groups based on demographics, i.e. age, gender, etc.

Training of local health care workers to provide follow-up treatment

Leaving necessary sustainable, low-cost supplies to promote sustainable care, i.e.

toothpaste and brushes, floss, etc.

Development of methodologies for setup procedures and post-evaluations of the

effectiveness of community oral health programs. Such evaluations should be

documented and translated in multiple languages in order to allow sharing of experiences

from the programs to the worldwide community.

By gathering and developing such information, those in health care and academia can

evaluating the scientific evidence and promoting effective interventions. The generation of such

data can filter its way through local health professions school curriculas, continuing education

programs and residency education. Additionally, the oral-health related content can help

incorporate new findings on diagnosis, treatment and prevention of oral diseases and disorders.

In addition, promotion and partnerships among research, providers, and educational communities

through different activities, such as organized workshops and conferences, are ideal to develop

ways to meet the educational, research, and oral health service needs of local communities.

The results and designs of outreach missions, such as the one conducted by the NYUCD,

can be documented, evaluated, and made available to the public, policymakers, and health care

providers. The results will send a concise and relevant message so that policymakers can then

explore policy changes that can enhance patient access to care. A lack of understanding and

indifference to oral health care in developing countries as evidenced in Nicaragua may explain

why community water fluoridation and school-based dental sealant measures fall short of full

implementation, even though the scientific evidence for their effectiveness has been proven for

years.

A simple population based approach to help improve the prevalence of oral disease and

tooth decay can be accomplished through water fluoridation treatment. In simplest terms, water

fluoridation is the controlled addition of fluoride to public water supplies to established levels

known to reduce tooth decay. Non-fluoridated communities continue to suffer unacceptably high

levels of tooth decay (Moynihan & Peterson, 2004; WHO, 1994a). Research has shown that

simple increases in water fluoridation and use of fluoride toothpastes and mouth rinses

significantly reduce the prevalence of dental caries by as much as 18-40% (Center for Disease

Control, 2007; WHO, 1994c). A systematic review of water fluoridation, by McDonagh, et. al

(2000), which included 214 studies, found that dose-dependent increases in water fluoridation

were associated with an increased proportion of children without caries and a reduction in the

number of teeth affected by caries. The WHO (1994d) recommends a level of fluoride from 0.5

to 1.0 mg/L (milligrams per liter), depending on the climate. Independent reviews and studies of

relevant medical and scientific literature over many years have found no evidence that water

fluoridation has any adverse effect on human health other than reducing tooth decay.

From a public health perspective, protocols to establish fluoridated water at levels for the

prevention of tooth decay and accessibility to affordable fluoridated toothpastes is necessary as a

preventative modality for the improvement of oral population health. Therefore a call to action

must be made to bear the responsibility of national health authorities to ensure implementation of

feasible fluoride programs for their country.

The NYUCD Chiquilistagua clinic is just one example of the type of programs that can

change the perceptions of a widespread public, policymakers, and health providers. As a group,

the NYUCD team was able to develop messages that were culturally sensitive and linguistically

competent to enhance the oral health literacy of an entire community by showing them the value

of regular and consistent oral health care. Through the help of all the diverse venues available in

today’s media conscious culture (which vary from country to country), messages can continue to

be communicated to energize and empower the public to implement solutions to meet their oral

health care needs.

In addition to the impact on the local community, the mission outreach is a

transformative experience for everyone who is involved. The outreach team participants are

exposed to a unique, global perspective of oral healthcare, providing them with a more public-

health oriented view of their role as a healthcare provider. They are simultaneously afforded an

educational experience that strengthens their skills as clinicians and increases their appreciation

for the practice of oral public health.

Conclusion

Improvement of oral health, such as the prevalence of dental caries, may be

systematically targeted by the joint action of communities, professionals and individuals. To

affirm that oral health is essential to general health and well-being, strategies must be formulated

with the backing of strong leadership, effective advocacy, high visibility, and widespread

community engagement. Through clinical and local population-based studies such as the

Chiquilistagua outreach, risk prevention policies in high risk areas can be formulated to

determine optimal, cost-effective, and practical treatment approaches that synergistically

increase public awareness and understanding of oral health. Through these efforts, a significant

improvement in the prevention, diagnosis and management of global oral health can become a

reality.

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