Dental services available in Nepal

DENTAL SERVICES IN NEPAL

Shekhar kumar mandalUsha kharel BDS IIICollege of Medical Sciences, Bharatpur,Nepal

IntroductionHealth is a basic right of every people. Dental health is a significant component of a general health.

The World Health Organization (WHO) has defined oral health as A standard of the oral and related tissues which enables an individual to eat, speak and socialize without active diseases, discomfort or embarrassment and which contributes to general well-being.

Dental health means more than just an attractive smile.

Health problems are often neglected and only treated if pain or another problem arises

Contd.(Intro)Oral disease shares common risk factors with the four leading chronic diseases: cardiovascular diseases; cancer; chronic respiratory diseases; and diabetes. Also, it shares risk factors with unhealthy diets, tobacco use, and alcohol use. Poor oral hygiene is also a risk factor for disease. Dental caries is the most prevalent oral disease in several Asian and Latin American countries.

A/C to World Oral Health Report 2003Globally dental health is a major public health problem affecting a large population and is most common in developing countries. Approx 5-10 % of public health expenditures relate to oral health.

The prevalence of dental decay worldwide is 60-90% in school children. More than 50 million school hours are lost annually due to oral health problems, which affect childrens school performance and success in later life.

contd...(Intro)

In developing countries like Nepal, Oral health has been a neglected field. The majority of Nepalese seek dental treatment only when they have pain. Nepal has one dentist per 20,000 people, with just over 1400 total dentists, including about 100 dental specialists.Most of the dentists practice in the major cities.

Nepal dental health service is still in its infancy. According to some recent studies, 65% of schoolchildren are suffering from dental caries and a significant number of children miss their classes because of dental pain. The government is not able to extend oral health service even up to the district level. Private dental hospitals and clinics are only based in some of the major cities of Nepal; people must travel hours for simple dental treatment.

History of Dental services in Nepal:-

Kathmandu, the historical and traditional city compromises of various temples and deities at its every nook and corner. Bangemudha is one among such locations where Washya Dyo or Danteshwori Devi shrine (meaning `Goddess alleviating toothache' according to local Newari Language) is located. The shrine has been in existence since the period of Lichchhavi era. The gold caved idol was however stolen about thirty years ago.

In proximity to such deity, a traditional street Na:ghal; meaning 'iron vessel' is located, where many traditional and few newer dental clinics are situated. According to local respondents, some clinics at Na:ghal are in existence for more than seventy years, and served by more than three generations of practitioners. Many of the concerned localities recall the history of Late Rana Prime Minister Chandra Shamsher, who sent Asta Man Rajbhandari and Ghana Man Rajbhandari of Na:ghal to India for training of dentistry more than one hundred years ago. Later qualified dentist Dr. Dwarika Man Rajbhandari commenced his practice in Na:ghal, which is followed by second and third generation of qualified dentist. Later various other organization like NDA(1990), Dental Hygienists Nepal Association(DHAN) in 2006 etc were established in order to enhance the dental services of Nepal.

Major Dental Health problems in Nepal :-

Dental caries/toothache

Periodontal diseases (gum)

Oral ulcer, mucosa and other related diseases

Oral Maxillofacial Injuries

Oro-facial Clefts Dental fluorosis has also been found to be a major dental problem in last decade in Nepal due lack of awareness. In the total OPD visit,only 3.08% are related to oral health.

Barriers to Dental Heath services in Nepal :-

Articles published in the British Dental Journal state that barriers to accessing and accepting dental care are made up of psycho-social determinants.Financial costs, especially in a poor country like Nepal, is a significant barrier to accessing dental care.

Barriers referring to individuals including:-Lack of perceived need Anxiety or fear Financial considerationsLack of access

Contd(Barriers to Dental ..)Barriers referring to the dental profession including:-

Inappropriate manpower resources

Uneven geographical distribution

Training appropriate to changing needs and demands

Insufficient sensitivity to patient attitudes and needs

Contd(Barriers to Dental )Barriers referring to society including: -Insufficient public support of attitudes conducive to health Inadequate oral health care facilities Inadequate oral health manpower planning Insufficient support for research

Other possibilities may include:- Cultural beliefs and rituals, especially within ethnic groups Lifestyle changes in modern world Influences of neighbouring countries Low value of oral health to the public Conditions within the clinic in relation to professionalism

Contd(Barriers to Dental )There is no governmental official dental council in Nepal, therefore there is no legislation that governs the practise of dentistry within the country. This allows many dentists to open up their daat banaune thau in place of proper dental clinic on the high streets and offer some unorthodox and outdated treatment. Because of the huge religious belief in Nepal, patients may wish to visit a witch doctor, also known as a dhami-jankari, to perform an elaborate offering to the gods and the jankari to take away the pain. There is even a toothache god idol in Nepal where people would go and hammer a coin believing that the toothache pain shall be transferred into the coin as an offering to the god. Because of these large religious and cultural beliefs, the patients are often hesitant to try anything new and prefer to keep their faith in the old traditions.

Thank you.cont.

Dental treatments available in Nepal

Private servicesEndodontic treatmentOrthodontics treatmentOral medicine and radiologyMaxillofacial treatment Prosthodontic treatmentPeriodontal treatmentPedodontics treatmentPlastic surgeryImplantologyCommunity dentistry

Only limited dental services are given in governmental hospitals of Nepal like:Endodontics treatment like RCT and Restorations,Forensic dentistryProsthodontic treatmentPeriodontal treatmentOrthodontics treatmentPedodontics TreatmentOral medicine and radiologyCommunity dentistry

Governmental services

Number of Oral health professionals

Number of Different Oral Health ProfessionalsCategoryTotal NumberYearSourceDentists70520081)Dental Therapists720002)Chairside Assistants8020002)Dental Hygienists23420083)Dental Laboratory Technicians220002)

Source:-1) Nepal Medical Council ,Oral Care Nepal (NGO),2) Zilln PA & Mindak M. World Dental Demographics, Internat Dent J, 20003) Council for Technical Education and Vocational Training (CTEVT) and Nepal Health Professional Council .

In 2011, Nepals Ministry of Health and Population (MoHP) developed its Human Resources for Health (HRH) Strategic Plan (20112015). A/C to which:1 dentists per 1,00000/population. But 1 dentist per 20,000 a/c to recent data.A total of 230 dentist were working in various hospitals of Nepal by 2011. [ excluding]

A/C to Nepal health Professional Council 2011, There were 37 PCL dental assistant and 356 TSLC dental assistant with permanent registration. There were over 1000 dental hygienist in Nepal by 2012.

3. A/C to NMC

Total dental students in 2012 was 560 as announced by the Nepal Medical Council in Dec. 2012. .(NMC 2012).Total registered dentist and specialist by NMC:

Year Nos of dentist[BDS] Nos of dental specialist[MDS]Male FemaleTotalMaleFemaleTotal 2003--105---20076623013432008284421705 - - -20125077151222148201359784314409274166

YearGovernment

Service %Private

Practice %Universities%Other%2000 147844

Demographics of Dental manpower

A/C to HRH Assesment 2012: In a total of 230 dentists by 2011140 dentists were female and 90 were male. 176 worked in private hospitals. Proportion of female for both sectors: 61% Proportion of female for public sector only 42%. Governmental dental manpower: Private dental manpower:

Developmental RegionEastern CentralWesternMidwesternFarwesternNos of dentists5381220

AGE GROUPS51N.A.Nos.of Dentist101012-25

AGE GROUPS51N.A.Nos.of Dentist633310166

Developmental RegionEastern CentralWesternMidwesternFarwesternNos. of dentists91362341

Distribution of dental manpowers by facility type in governmental hospitalsA/C to HRH assessment 2012,

HospitalsPHC,SHPCentral JailCentral HospitalsDistrict hospitalsZonal hospitalRegional hospitalsTeaching hospitalTotalNos of dentists001921541757

NO GOVERNMENTAL DENTAL HOSPITAL.

DISTRIBUTION OF DENTAL MANPOWER BY ECOLOGICAL ZONE

A/C to HRH assessment 2012,

Major dentists are enrolled in major cities area of hilly region.

RegionsTeraiHillMountainNos of dentist541760

HUMAN RESOURCES FOR HEALTH PRODUCTION

A/C to HRH assessment 2012,

InstitutePublic dental trainingPrivate dental training provider[for profit]Private dental training provider[for Non- profitNos. 1 5 1

Dental schools in nepal

Because of the establishment of dental colleges in Nepal, the number of specialists has increased markedly. The dental manpower mainly produced by major universities and organisation in nepal are:-Kathmandu university- BDS programTribhuvan university-BDS and MDS programBPKIHS, Dharan-BDS and MDS programCTEVT- PCL and TSLC dental assistant and hygienist program.Bir hospital [MDS program}

Number of students enrolled and graduated from programmesA/C to HRH assessment 2012,

But due to recent establishment of major dental institute in Nepal nos. of students enrolled and graduated per year have increased markedly over 500 .There were over 1000 dental hygienists in nepal by year 2013.Production capacity for dental training courses as of 2011/12 : production capacity per year was 370 while enrollement per year was 321 and graduation per year was 296. (Source: Extracted from presentation by Rajendra Prasad Gupta, HRH Conference, June 2013).

YEARStudents enrolled Graduated 2009 318195 2010315203 2011190198

Dental services and Nepal Health Care System

Oral health conditions are estimated by WHO to account for 0.6% of DALYs lost in Nepal, and account for 3% of Outpatient Department (OPD) visits recorded in DoHSs 2007-08 Annual Report.More than 57% of Nepalese children at six years of age and 69% of adults above the age of 50 suffer from untreated dental caries affecting more than three teeth. Untreated dental caries is the most prevalent childhood disease in Nepal more prevalent than malnutrition (53%) and vitamin deficiency (56%).Nepal ranks among the top 15 countries in the world where periodontal disease in the age group of 35-44 years is prevalent.However, GoN has made significant progress formulating an Oral Health Policy (2004) and has an Oral Health Strategic Plan. It also has advocated for fluoridation of toothpastes that are produced in Nepal.

There have also been changes to health care legislation in some provinces affecting the scope of practice of dental hygienists and denturists, but nothing significantly altering the funding of dental care services in the Nepal health care system.There are different divisions working under the Department of Health Services, but not the Oral Health Division. The second long term health plan (1999-2017) has put oral health into essential health care services and oral health for the first time into a primary health care approach. Although the oral health policies and strategies are established, the limited fund resources and manpower are a constraint to implementation.

No insurance policy has been made regarding dental checkup for patients.A/C to a recent tourist who visited Nepal My recommendation for those coming to Nepal for long enough is to get your trip off to a great start by getting your dental work done first in your own country.Everyone comes early and sits there patiently waiting. I see it as a waste of time to wait more than hours. (http://frugaltravelsnepal.blogspot.com/2014/05/dental-values-in-nepal-seriously.html

Expenditures of GoN on Dental Services

GoN has been allocating 5-6% annual budget in Health sector. And few part of this budget is allocated for Oral health in Nepal:

[source: NSHP 2010]

Oral Health budget2010/112011/122012/132013/142014/15Proposed Budget for NHSP-2 (2010-2015) - NPR IN 100,000859398108119

Patients ExpenditureComparison of patient expenditures on oral health services in Nepal and USA:-

[source: WHO report on oral health 2013]

YEARNEPALUSAPRIVATE200075.1%56.8%200862.3%52.2%GOVERNMENTAL200024.9%17.1%200852.2%18.7%

To treat 9.3 million Nepalese children from the age of 6 to 14 years using western technology would cost the heath care system more that $US 5 million a year. It is also costly for Nepalese families. The estimated cost to treat a 6-year-old child with 3 decayed teeth is approximately 800NRs, not including loss wages, travel and accommodations. This is enough money for food for a month in nepalese family.

Number of Dental Patients

Annually, among total cases visiting to opd, 3 % cases are of oral health problems.Annual report onDental caries/toothachePeriodontal casesOral ulcer, other disease of mucosaOther cases2009/20103,92,83173,3091,13,81962,7472010/20114,02,14275,0991,16,17457,3482011/20124,21,033 77,3601,24,32865,2462012/20134,33,28276,5471,24,36862,5452014/20154,44,08894,1301,13,81973,224

Economic Burden of Oral Health Disease

It is estimated that 2.26 million school days and 4.15 million working days for adults are lost annually due to dental visits or dental sick-days. An estimated 40.36 million hours are lost from normal activities, school or work on an annual basis due to check-ups or problems with teeth.. In Nepal condition is more severe.The number of dentists in Nepal is incredibly low at 1 dentists per 100,000 of the population.[HRH 2011] Nepalese workforce, age 15-49 years (13 million) lost one hour per person per annum due to oral diseases or conditions, total lost days per annum is estimated to be 541,666. Improvements in the oral health of the Nepalese people will have a direct impact on Tenth Plan to alleviate poverty and improve prosperity.

Oral Health Indicators in Nepal

Major population of Nepal live in rural areas, where there is lack of quality dental professionals as well as dental clinics. These all predispose them to a bad oral heath.The first and only national oral health survey was conducted in 2004.The 2004 National Pathfinder Survey shows that 58% of 56 year- old schoolchildren suffer from dental caries . More prevalent that malnutrition and Vitamin A deficiency which is reported to affect 53% and 56% of the child population. The Survey reported pain and discomfort due to untreated dental caries in 18% of 56 year-olds and 64% in older adults.

Another study conducted in Nepal among 911 years old schoolchildren had reported that 45% of children suffered from tooth pain. In the same study, it was reported that 93% of children had never visited a dentist and the decayed component constituted almost entire dmft/DMFT index.

About 61% of children reported to have received oral health education. More than 82% children did not know about fluoride and its benefits on dentition. Only 56% school children brushed their teeth daily. The study reported 80% children rinsing mouth with water. The most common aid used for maintaining oral hygiene was toothbrush and toothpaste. Tooth brushing once a day is a norm in Nepal. Low dental visit and 100% untreated caries could be due to lack of access to affordable health care services

Strategies of National Oral health Policy for development of Dental services in Nepal

The development of Human Resources for Oral Health Strategy 1. The prevention of dental caries and periodontal disease.Strategy 2. The strengthening of quality assurance programmes to ensure the proper practice of infection control and occupational health and safety protocols.Strategy 3. The development of infrastructure for oral health. The Development of Public/Private Sector CooperationStrategy 1. The establishment of increased funding for oral health.

Oral Health Promotion and the Prevention of Oral Disease Strategy 1. The prevention of dental caries and periodontal disease Strategy 2. The strengthening of community oral health education Strategy 3. The prevention or oral cancer, oral submucous fibrosis, developmental defects, and oral trauma. Strategy 4. The establishment of data collection and research procedures needed to support evidence based oral health policy development. Appropriate Curative Care of Oral Disease Strategy 1. The expansion of basic oral health care to rural communities. Strategy 2. The strengthening of quality assurance programmes to ensure the propwe practice of infection control and occupational health and safety protocols. Strategy 3. The development of infrastructure for oral health.

Different organization involved to provide quality dental services in Nepal

Different surveys and projects in Nepal

National oral Health survey, 2004Human resources for health assesment 2013Global dental reliefKaski oral health care projectWorld alliance for murcery free dentistry(WAMFD)Eva NepalDental Himalayan health projectHasilo Nepal dental projectNetherlands oral health society for Nepalese people

Conclusion

From all above datas and analysis we can say that dental health services in Nepal is still in its infancy stage. In low income countries like ours, there is no proper governmental budget allocated for dental services to have sound development.There is no sufficient data to make a proper plan and project, that forces us to carry out the important project based on community or locality rather than national based.Major dental manpower are centralized toward central development region whereas FWR have only few dentist.Even in such circumstance, more than 75% dentist are involved in private clinics. They are focused in earning more money. This trend has led to find a data in which more than 60% of dentist works less than 48 hours per week in Public hospitals. This shows that dental services in Nepal is totally for rich and well incomed people but more than 80 % people in Nepal are still poor.

Its quite strange to listen that there has not even been a single dental hospital or maxillofacial trauma center run by our Government. Dental caries has also been major problem in Nepal although various steps for its prevention has been adopted.Major focus is should be prevention rather than cure of the oral disease. Government has been trying to focus in its development but in a glacial speed. Government has included the oral health care in the list of primary health care.Nepali culture of rinsing mouth and brushing early in morning has played important role in preventing oral disease. Many more national and international agencies are involved in development of the oral health of Nepalese people in both rural and urban areas of Nepal. More man power are being produced due to increase in more teaching hositals.As Brain drain is major problem in field of dentistry in Nepal, gov. should focus to prevent that and from our side, as a future dentist, we should try to think for our earthquake affected country because WE HAVE TO RISE AGAIN.

References

National Oral health policyAnnual report 2066/67, 2067/68, 2068/69,2069/70,2070/71 by DoHSCentral Bureau of Statistics, by GoN World Health Organisation Website www.who.org WHO Oral Health Country/Area Profile Programme http://www.whocollab.od.mah.se Report on global oral health by FDIWorld Health Organisation Website www.who.org 2World Gazeteer Webiste www.world-gazetteer.com WHO Estimates of Health Personnel http://www3.who.int/whosis/health_personnel/health_personnel.cfm Health Situation in the South-East Region, 1994-1997. www.whosea.org Health Situation in South-East Asia Region http://w3.whosea.org. Freeman R. Barriers to Accessing and Accepting Dental Care. British Dental Journal 199911. WHO Oral Health Country/Area Profile Programme http://www.whocollab.od.mah.se Orthodontic Journal of Nepal, Vol. 3, No. 1, Global goals for oral health 2020. International Dental Journal 2003Teachers note

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