Dental caries is an oral disease not just of the developed nations but fast becoming a public health issues in the developing countries1. Dental caries is one of the major oral health problems in Nigeria. Other oral health/diseases commonly seen in Nigeria include periodontitis, chronic gingivitis, acute necrotising gingivitis, oral cancer and ameloblastoma, cranio-facial developmental anomalies, orthodontic problems and cleft lip and palate2. The oral cavity though small is a important aspect of the human body. It is the gateway to the human digestive system. The teeth are an important part of the mouth. Their function in mastication of food and speech cannot be over emphasized. They also have aesthetic component as well as enhance facial appearance. Thus, any problem with oral health or diseases could present as pain and suffering which could have debilitating effects on individuals in particular and the community at large3. Oral diseases could lead to reduction in functional abilities and reduced quality of life. According to Petersen (2004) oral conditions are among the most expensive medical treatments in industrialized nations3. Nigeria is classed as one of the poorest countries in the world with 70% of its population leaving below 1 dollar a day.
Nigeria is one of the countries in West Africa, comprises of 36 states. She is one of the most populous countries in Africa as well as the eighth most populous country in the world with the population of 154,728 8924 and popularly known as the giant of Africa. In 2007 to date, Nigeria is ranked as the second largest economy in Africa, she is known for her rich cultures, natural endowment such as oil and gas. It is equally indisputable that her human resources are abundant. At the same, it is absurd to learn that about 70.2% of Nigerians are living in abject poverty. Although, the Health services in Nigeria has undergone transformation over the years. The provision of Nigeria health system can be categorized into Public and Private Health services. The public health services serves as the main backbone of Nigeria health care which in most cases is funded by the government on non-profit bases. These are divided structurally into the Primary Health Care (PHC), Secondary Health Care (SHC) and the Tertiary Heath Care (THC) 5, 6. But the dental care services are provided from secondary to tertiary care. This is due to the fact that dental care services are available in general hospitals (secondary health care) in some states and not at the primary health care bases, also in various teaching hospitals (tertiary health care) as well as private dental services.
Dental caries is known as a progressive destruction or demineralization of enamel, dentine and cementum on a susceptible tooth surface caused by microbial (Streptococcus mutans) activities such as the production of acids.7, 8 In most cases, the dental caries is not life threatening but can have an adverse effect on quality of life in individual childhood to old age such as dietary and health. It affects all age groups and it is the most important cause of tooth loss in young people9. Frequent consumption of sugar and sugary food and drinks has been implicated as predisposing factors for the cause of dental caries9, 10,11.
The sequelae of dental caries: Bacteria ferment sugar to produce acid. Acid dissolves tooth surface ® leads to dental caries which affects the enamel ® dentine ® pulp ® pulpitis ® periapical infection ® dental abscess12.
Years ago, dental caries is one of the most common diseases in industrialised countries for instance United Kingdom and a social class-related condition. There has been a tremendous increase of dental caries in developing countries in recent years due to increased sugar consumption as well as insufficient exposures to fluorides which Nigeria happened to be one of the countries. In Nigeria, DMF index is used in measuring tooth decays which counts the number of decayed, missing or filled teeth (DMFT) or surfaces (DMFS) in patient’s mouth as a result of caries both in deciduous and permanent dentition7, 8. In 1993, World Bank reported the dental caries incidence in 1990 among females of Sub-Saharan Africa is 0. 7 and the males is also 0.7 while the total world record in these categories are 9.6 and 9.8 repectively.13 Dental caries prevalence in Nigeria varies according to the areas from the studies Akpata carried out. It shows that dental caries in rural areas are very low of 3 dental caries cases compared with those in the urban areas which is 33 caries14.
The reasons for chosen dental caries:
Dental caries as pointed out above is a dental disease that affects all age groups although it is more prevalent among the adolescents and young children. It is one of the major oral health problems. Dental caries is a public health issue because of its impact on individuals and the communities.
Social and financial issues: Majority of the population in Nigeria suffers from poverty and the government do not subsidize any kind of dental or medical treatment for the people that is from new born to 59 years but from age 60 pays half price which can still be a problem for people in this category. In fact, dental and medical treatment does not commence until the patient pay an agreed amount but there is always an exceptional case depending on the dentist or medical practitioner’s discretion. Therefore, most of the populations in Nigeria are in high caries risk. This is due to the fact that some of the parents cannot afford sending their children to school while some of the children have very poor attendance record in school and in most cases leads the children to consume more of confectionery and high carbohydrate diet15. Due to poverty, most people seek for alternative treatment when they have toothache such as the traditional medicine, application of herbs, as well as fake medicine (cheap) leaving majority of the cases untreated.
Tooth loss: Dental caries is one of the major causes of tooth loss which can affect on patients eating habits, self-esteem and quality of life. Majority of the patients visit their dentist when they have explored virtually all the alternative treatment mentioned above and still be in pain which tends to be unbearable or in some cases the area is infected or inflamed. This can lead to extraction of the tooth/teeth, which eventually might lead to tooth loss replacement with removable dentures or fixed prosthesis. Due to lack of affordability of the denture by some patients leads to loss of alveolar as well as deformity.
Infections: One of the sequelae of dental caries is infection due to bacteria in the cavity. Bacteria in the dental cavity secrete acids which dissolve the enamel and dentine and if untreated leads to pulpitis and subsequently periodontitis. Because so many people cannot afford orthodox dental care due to the cost of proper dental treatment some people chose alternative treatment as mentioned earlier. This can also leads to potential serious infection such as dental abscess or Ludwig’s Angina which is life threatening. Although, one of the treatment is administration of antibiotics and other medications but in Nigeria contest we have to battle fake drugs as in most cases one is unable to distinguish between original and fake drugs.
Need to create dental awareness: there are need to educate members of the public on how to prevent and control dental conditions as well as diseases
Strep viridians seen in dental caries can cause endocarditis in cardiac patients
Dental caries can form cystic legions in some patients
Dental caries can cause chronic periodontitis.
Dental caries is considered as a public health issue or a major problem in dental public health16 because it targets the entire population with unlimited time frame. Its socio-economic effect is great. People presents to dental clinics and hospitals when they are in severe pain and at the advanced stage of dental caries. Dental caries can occur in deciduous or permanent dentition thus affecting children as well as their parents. The cost of managing advanced dental infections is high. Being unable to identify early, people with high caries risk has also be one of the major challenges for public health.
2. The Community Oral Health Programme (COHP) was started in 1988 by the University of Ibadan in Nigeria by the Dental department. Since its inception it has become an integral part of the comprehensive Community Health Programme of the Preventive and Social Medicine (PSM) 17. The COPH main aims and objectives include prevention of oral diseases and provision of basic oral care services to communities. Major components of COPH are: School health programmes, health education programmes and on site dental care provision in hard to reach communities. Dental care has been a part of primary health care thus making very many communities disadvantaged. The health care delivery in Nigeria is such that dental health was been side-lined and the need for primary and secondary prevention of oral diseases in a developing country such as Nigeria where urbanization and westernization is creeping in. Studies carried out over the years have revealed a poor oral health status in many Nigerians18. An arm of this programme known as the Community Dental Education Health (CODEH) has been organizing activities such as dental awareness campaigns in communities, market places and schools. Financial sponsorships have been mainly from non-governmental organizations and dental companies like Unilever and GlaxoSmithKline19.
Evaluation of the programme: Evaluation is the process of assessing the possible relevance, efficiency, effectiveness as well as impact of the activities (efficacy) of a project or programme in accordance to its objectives through a systematic collection and analysis of data15, 20. It is equally very important to ascertain the quality assurance of the programme. Evaluation could be formative that is assessing the possibility of problem occurring while the programme is being developed or summative that is focusing on the impact as well as the effectiveness of the established programme21.
This programme has been evaluated by observing the criteria proposed to guide evaluation in public health22 such as:
Effectiveness: -this refers to the extent to which the aims and objectives are met which is to create dental awareness and promote oral health care. Also identify issues and questions of concern to stakeholders.
Acceptability: – to check if people are satisfied with the programme both the targeted and non-targeted population.
Appropriateness: – this is the importance of the programme which to reduce the prevalence of dental caries and promote oral health care.
Equity: – equal provision for equal needs for every individual
Efficiency: – this to ensure that results are achieved in most economical way and if the resources put into the programme is justified.
Before the evaluation, decision on the kind of information that is needed is taken. To ensure that relevant data are gathered at the appropriate time, an eight-stage framework for evaluation of health promotion interventions proposed by Rootman et al in 200123 was adopted. These stages are
Describing the programme, as well as clarifying the aims and objectives
Identifying the issues and fears of stakeholders
Designing of information-gathering process like questionnaire, records of behaviour change such as plaque scores, indices, documented record on dental caries rate (this was achieved with the help of dentists and hygienist in the allocated areas of the programme) also question and answer session with patient or during the dental awareness campaign.
Take action or implementation
Evaluation is an empowering experience which should involve all stakeholders. Although, evaluation of this dental awareness and oral care promotion is challenging as there are complex, context-specific programme which also focus on the socioeconomic and environmental determinants of well-being.
Determine of outcomes: the outcome of the programme is influenced by the timing of the evaluation. The outcome of this programme after assessing the effects of intervention can be said to be immediate (impact), intermediate and long-term for some patients.
Dental awareness and Oral health care programme had the following effects:
Improves people’s knowledge and perception about oral health care
Improve the oral health care of the communities in the programme
Improve the oral health care and awareness among school children
It motivates patients that are afraid of visiting dentist
It motivates and encourage most of the participants to be going for regular check-up
Impact evaluation was inculcated into the programme as the stage ends. This is the stage where the public worker or oral health educator includes review of the programme at the last session. The intermediate and long-term evaluation involves assessment for longer effect. This was ascertained by comparing the participant oral health related behaviour before and after the programme but in most cases after a year some participants discontinue from the programme due to death or loss of interest.
Effectiveness of the evaluation: the evaluation was effective as it shows that the aims and objectives of the programme were met. For instance, the aims and objectives for Community Oral Health Programme (COHP) are prevention of oral diseases and provision of basic oral care services to the communities while the Community Dental Educational Health programme (CODEH) is to organise dental awareness campaign in the communities, market places and schools. This shows that the programme is a success and dental team as well as all the workers efforts in the programme are worthwhile.
3. Key elements in the success or failure of the programme:
There have been elements and factors that have led to the success and failure in some aspects of the programme.
Communication: good communication network between the public health teams, from dentists to their patients and from oral health educators to varieties of patients or the public is paramount to the success of the programme. It is important to make patients feel at ease and demystify the fear of visiting the dentist by answering their questions clearly. Communication can take place at two levels: cognitive (understanding) and emotional (which relates feelings) which is very important when treating a patient7. Effective and good communication helps the patients to feel relaxed while discussing their oral health problems and devise solutions.
Communication barriers: these can lead to failure of a programme. Therefore, it is always advised for professionals to identify any existent of communication barriers during the first stage of communication with the patient. These barriers could be:
Social/cultural barriers which involves ethnic backgrounds, cultural/religion beliefs, social class, sex and age
Limited receptiveness of patients due to mental health problems, pain, dementia, fear or low self esteem
Negative attitude by the patients towards dental professionals due to previous bad experience or believes that they know it all.
Dental professionals failing to give insufficient emphasis on dental education. Continuous dental professional development needs to be incorporated in the training for all stakeholders involved in the implementation of the COHP programme.
Contradictory messages of oral health care to patients from other health professionals leaving the patients confused as well as use of some dental jargons by the dental professionals to the patients.
Strategic planning and evaluation of the programme: planning oral health strategy need to be permissible within the political and policy constraints of Nigeria government. This can lead the programme to success by being more productive and effective on what can be implemented in promoting dental awareness and oral health care such as:
Oral health needs assessment: this is to assess unmet dental health needs in a systematic approach to ensure that the public health service uses its resources to promote and improve the dental health of the population. The information gathered for the assessment does not only based on DMF data but also from other sources like data from oral health determinants, caries prevalence, prevalence due to toothache, public demand, existence of dental services as well as policy development14. These information gather will build a focus in monitoring the rate of dental caries which will be useful at the national level during planning dental health educational programmes, future demand and utilization of oral health organisation and financing. It will help plan strategies to improve oral health care of the people through public health interventions. Monitor services provided by the dental team and the extent in which the strategies have improved the oral health of the population after the implementation of public health interventions as well as changes to the services.
Resources and Support: this is to ascertain from the dental budget the fund available for oral health services and promotion to meet with demand and supply of the population as well as educational programme is very essential. As this will help facilitate the programme, involving experienced and trained public health professional, build and equip dental services and the outreach units with modern equipment if needed as well as developing professional network between the program and community8. Although, in some cases professional barriers can be encountered leading to failure whereby the local dentists does not comply with strategy due to threats on their private dental service business or if their employment terms and conditions are affected.
Evaluation: this is an effective way of interventions in a programme, providing feedback to both participants and other part of the team as well as the stakeholders; ensure that appropriate use of resources and other guidelines are followed. During planning of the programme, the programme is evaluated to assess how strategy was implemented and at the end of the programme, evaluation is used to determine what has been achieved.
Oral health preventive promotion: there are two ways to achieve this through clinical and public health preventive approach
Clinical preventive approach: this approach depends on the proficiency and skill of the dentist also this takes place in dental clinics whereby chair-side oral health educational counselling is given to the patients after the administration of one or two clinical preventive agents are used for instance topical fluorides and fissure sealants. This approach has some down falls such as limited coverage of the population, it can be very expensive leading to increase in health inequalities, less community involvement, in some cases fail to pin-point the causes of poor oral health and can easily leads to conflicting messages.
Public health preventive approach: this approach stress on the determinants of health for instance stipulates the attributes of oral health problems as shown in Fig. 1 below illustrating the impact of economic, political, environmental conditions to oral health, not to mention people’s lifestyle which is under the social and community context, although some oral health related behaviour can be influenced by some of the social factors depending on individuals, educating patients through oral health educators, dentists and other trained dental professionals. Oral health education is the one of the channels of promoting oral and promote equity and lessen the rate of health inequalities, be in partnership with various agencies and sectors to achieve their goals, creating dental awareness, increasing people knowledge and getting them involved in self-care.
Diagram of Social determinants of oral health15
Oral health care outreach and information centre: this is preventive dental unit where oral health education can be given to individuals or small groups. This is an avenue whereby the dental public health team or oral health educators motivates, communicate also establish friendly and informal relationship with the patients. This kind of preventive treatment can be a success or failure of the programme depending on the patient and staff cooperation. Therefore, it will be wise to evaluate each teaching sessions by using question and answer session with patients and questionnaire on the performance of the educator. The patient feedback should be used to assess the progress of the unit. In Nigeria, majority of preventive dental units in public and private sectors are located in urban areas where most of the dentists are practising. Leaving those in rural areas with minimal or no access to modern dental treatment.
4. Recommendations for the future of the programme:
Nigeria government should fund dental fissure sealant for children in the following categories: mentally or physically handicapped, those with nursing or bottle caries as well as those who have primary and first molars.
Dentists should be able to clinically give treatment or advice to the patients without language barriers. This implies that there should be available provision a translator if the need arise.
Both systematically and topically administered fluoride should be made available and affordable to the population for instance drinking water, salt, milk and use of fluoride toothpaste. Bearing in mind that, some part of Northern Nigeria is endemic of dental fluorosis due to relative high fluoride ingestion through drinking water14.
The clinicians should be ready to adapt to the culture of the people and note the cultural differences for instance some cultures or religion forbids a male doctor or nurse to treat a female patient which applies to oral health care.
Ability to in cooperate dental health care awareness into schools
Public health workers should endeavour to identify children with high caries risk status
More oral health awareness should be created as well as dietary education for parents and children. Highlighting on the need to reduce sugar intake and promote consumption of sugar free both in medications and drinks, fruits and vegetables as well as the need for good self oral hygiene practice
It has been proven that most parents bring their children to clinics during holiday therefore will recommend that most dental clinics should be school led that is opening till late.
Regular dental check-ups should be encouraged by the oral health team for early identification of dental problem
Dental health education programmes should be conducted in the communities (both in rural and urban areas) and regularly
The government should encourage the implementation of various community fluoride programmes by funding
During epidemiological studies of dental caries, DMF index should always be used
All Nigeria dentists should also adopt advances methods of diagnosing dental caries which should be considered when recording and reporting caries in future and ensure that this does not affect historical and international comparisons15.