FINAL
REPORT
Dr.
Robert Yee
Consultant to Oral Health
Focal Point
Director of United Mission to Nepal
Oral Health Programme
Dr.
Praveen Mishra
Chief
Consultant
Oral Health Focal Point
Management Division, DOHS
Ministry of Health
Recommended
citation:
Yee
R, Mishra P. Nepal Kathmandu , Nepal :
Oral Health Focal Point, Ministry of Health, HMG Nepal
EXECUTIVE
SUMMARY
A Nepal August 20, 2004 . The survey is an essential activity of the
Nepal National Oral Health Policy and National Strategic Plan for Oral Health
for Nepal
AIMS
AND OBJECTIVES
The specific
objectives of the Nepal National Oral Health Pathfinder Survey are to collect
information on the following:
1.
The oral health status of
schoolchildren and adults in the key age groups:
- 5-6 years
- 12-13 years
- 15-16 years
- 35-49 years (Younger Adults)
- 50+ years (Older Adults)
Oral health status includes information on:
1. Oral mucosal condition
2. Need for immediate care
3. Fluorosis of teeth
4. Periodontal status
5. Dentition status
2.
Knowledge, attitude, reported
oral hygiene behaviour, dietary habits, oral health impacts on the quality of
life and use of dental services amongst the Nepali people.
The survey has
attempted to gather information from at least 2 sites from each of the 5
developmental regions and 3 physiographic divisions (Upper Hills, Middle Hills
and Terai). A total of 16 sites wee
surveyed across Nepal
SUMMARY OF RESULTS
Dentition Status, Use of Dental Services and
Quality of Life Impacts
Dental caries prevalence and experience is low or very
low for all age groups in Nepal Nepal Nepal
Periodontal Status
The periodontal health of Nepalis decreases with age
but is not the main reason for loss of teeth in adolescents and adults age
35-50 years of age. The presence of
calculus is prevalent in all age groups and is indicative of poor oral
hyiene. 43.8% of
Younger Adults and 34.3% of the Older Adults have the highest CPI score of ‘4-5
mm pockets’, but the mean number of sextants affected is 1.6 sextants for these
age groups. The mean number of sextants
in Younger and Older Adults with periodontal pockets 6+ mm is small, 0.4 and
0.5 sextants respectively. The percent
of 35-50-year-old adults with deep pocketing (21.6%) is normal compared with
other populations or subgroups in the world.
Comparison of CPI data with data collected in Nepal Nepal
Oral Hygiene Habits
More than 99% of the adolescents and 90% of the
Younger Adults use their own brush for oral hygiene, while a toothbrush is used
by a lesser proportion of the Older Adults.
More urban Older Adults (80.2%) than rural Older Adults (63%) use a
toothbrush. Level of education is an
important factor in the type of tool used for oral hygiene amongst adults with
the more educated using a brush and the less educated using other instruments. Although most Nepalis surveyed preceived a
need to brush more often, brushing once a day is still a social norm. However, the number of adolescents brushing
more than once a day has increased over the last 5 years. Approximately 75% of
12-13-year-olds and 80% of 15-16-year-olds use a fluoride toothpaste while the
use of fluoride toothpaste is considerably lower in Younger adults and Older
Adults (50% and 28.2% respectively). The
consumption of fluoride toothpaste is significantly higher in urban subjects
and lower in the Terai; and higher in schoolchildren attending private
schools. The percent of 12-13-year-olds
using fluoride toothpaste has remained at the same level over the last 5
years.
Sugar Consumption
The pattern of sugar consumption is starting to
change. It was once thought that the
frequency of sugar consumption was higher in urban children than rural children
but almost equal proportions of urban and rural adolescents consume sugar
containing foods on a daily basis. In
adults, significantly more urban adults than rural adults consume sugar foods
daily. Daily sugar consumption was also
significantly higher in the Western Region and Mid Hills.
Tobaccco Usage
Tobacco is a risk factor for oral cancer and poor
periodontal health. Tobacco and tobacco
related products are used infrequently by adolescents while cigarettes is the
most common product used by Younger and Older Adults. Tobacco use is significantly related to level
of education as a greater proportion of
Younger Adults who are illiterate use tobaaco than those who are more
educated.
Oral Health Care Services
Oral
examination, dental extraction and cleaning/scaling were the major services
provided during dental visits for both Younger and Older Adults. The Older
Adults received more extraction (54.4%) but less cleaning/scaling (15.2%) than
Younger Adults (35.7% and 33.9% respectively). Those who had visited dental
clinics also received other services such as fillings, crown, bridge and root
canal treatment but these services were almost negligible. The majority of
Younger and Older Adults (67.8%-94.9%) were satisfied or happy with the
services such as appointment at a suitable time, location of the dental
clinics, reception, and cleanliness, etc.
Knowledge, Attitude and Source of Oral Health
Information
Knowledge concerning the prevention of oral diseases
is high and universal but knowledge concerning the benefits of fluoride is very
low in all age groups. Oral health
knowledge was associated with education status in the 12-13-year-old age group
only but knowledge on brushing as a method for the prevention of caries and gum
problems was not associated with education level of the parents. The most important sources of information on
oral health for children are the parents and the school teachers. In the past 12 months subjects oral health
subjects taught in school related to oral hygiene practice and the importance
of oral health.
RECOMMENDATIONS
The dentition status and periodontal status of Nepalis
appears to be improving. However, there are gender, regional,
geographical and social inequalities in oral health. The National Oral Health Policy and the
National Strategic Plan for Oral Health (Ministry of Health, 2004a, 2004b)
contain sound strategies to reduce inequalities in oral health based on the
guiding principals of Health for All (WHO, 1978) and the Ottawa Charter for
Health Promotion (WHO, 1986) in an environment of scarce financial and human
resources. Priority should be given to the implementation of the following
strategies in the National Strategic Plan for Oral Health:
- Promotion
of oral health targeting schoolchildren through the integration of
evidence based and culturally appropriate oral health preventive messages
in the school curriculum. Emphasis
should be placed on the benefits of fluoride, brushing twice a day with a
fluoride toothpaste, avoidance of the risk factors which contribute to
dental caries, periodontal diseases and oral cancer; and regular visits to
a dentists.
- Promotion
of oral health amongst the general public with special attention on women’s
oral health, the oral health of pre-school children and the elderly. In addition to the above mentioned
points, the importance of the deciduous dentition and the importance of
proper oral hygiene for young children at an early age should be
emphasised. Influencing the toothpaste manufacturing industry to
incorporate the appropriate oral health messages into their advertising is
more efficient and more effective than the Oral Health Focal Point
spending limited funds on mass media communication. Oral health can be promoted in the
community through the training of primary health care workers such as
auxiliary nurse midwives, maternal child health workers, traditional birth
attendants, village health volunteers and female community health
volunteers to integrate oral health into their general health messages.
- Create a
more supportive environment for improved oral health through affordable
fluoride toothpaste and salt fluoridation.
The use of quality fluoride toothpaste is improving the dentition
status of the adolescent schoolchildren and reducing the oral health
impacts. The use of fluoride
toothpastes by the adult population is also associated with healthy
periodontium. To make quality
fluoride toothpaste more affordable and available to the general populace,
the removal of taxes on effective fluoride toothpaste which meet defined
criteria has been recommended in the National Strategic Plan for Oral
Health. Currently 50% of Younger
Adults and 28.2% of Older Adults use a fluoride toothpaste. There are also disparities in fluoride
toothpaste consumption in relation to physiological division and location
type. The problem of inequitable
access to fluoride toothpaste can be resolved through the fluoridation of
salt which is part of the National Oral Health Policy. Salt is consumed by 99% of the
population and reaches all socio-economic groups.
- Along with
oral health promotion, primary health care workers (health assistants and
auxiliary health workers) in the health posts should continue to receive
training in the delivery of basic oral health care, primarily oral health
education and pain relief throught the extraction of teeth. The majority of Nepalis only attend a
health post or dental clinic for pain relief. Scaling of teeth as a part of a package
of basic oral health care is not recommended as a priority (van Palenstein
Helderman et al., 1999). Calculus
is highly prevalent but does not lead to a large mean number of sextants
with deep periodontal pockets and loss of teeth. It is also unrealistic economically to
propose regular removal of calculus on a population basis (Manji and
Sheiham, 1986). A small shift in the whole population brushing their teeth more
often with fluoride toothpaste and reducing their exposure to tobacco
products will have a major impact on the prevalence and incidence of
calculus and periodontal disease.
Every effort should be made to implement
these equitable whole population strategies to reduce inequalities in oral
health and thereby improve oral health for all.
TECHNICAL
ABSTRACT
Objectives:
·
To collect and analyse data on
the oral health status of children and adults in rural and urban Nepal
·
To collect and analyse
information on oral health knowledge, attitude, reported oral hygiene
behaviour, dietary habits, oral health impacts on the quality of life and use
of dental services by Nepali children and adults of rural and urban Nepal
Design: Cross-sectional
oral health ‘pathfinder’ survey conducted by trained and calibrated examiners;
and enumerators trained to collect data through an interviewer-administered
structured questionnaire. Clinical oral
health data was collected according to WHO methodology and criteria. Multi-stage cluster sampling for the random
selection of schools.
Setting: 16 rural and urban sites from the 5 development regions and 3
physiographic divisions (Upper Hills, Middle Hills and Terai). Survey of children was conducted in private
and government schools in urban centres and government schools in rural areas.
Subjects: The study population covered 5 age groups: 5-6 years (n = 1027), 12-13 years (n = 1047),
15-16 years (n = 1074), 35-49 years (n = 603) and 50+ years (n = 616).
Results:
- Dentition Status
5-6-year-old dental caries prevalence was 57.5%, mean dmfs was 5.47
and the mean dmft was 2.70. In the
12-13-year-old age group the dental caries prevalence was 25.6%, mean DMFS was
0.74 and the mean DMFT was 0.50. The
dental caries prevalence, mean DMFS and mean DMFT of 15-16-year-olds was 25.6%,
0.74 and 0.50 respectively. The
prevalence of dental caries and mean DMFT of adults age 35-49 years was 57.5%
and 2.71, and for 50+ year adults it was 69.6% and 6.40. The the mean number of teeth per person is
30.7 for 35-49-year-olds and 26.1 for 50+ year adults. Fluorosis amongst younger children and
adolescents was very low and not of public health significance. There is a
trend of increasing caries in female age cohort. Nepalis of all age groups in the Western
Developmental Region have the highest prevalence of decay while residents of
the Terai have the lowest prevalence. A
strong association between father’s education or education level and DMFT in
15-16-year-olds (p<0.01) and Younger Adults (p<0.000) was observed. There appears
to be a decline in the prevalence of dental caries in Nepal Nepal
- Periodontal Status
CPI score of 2 (gingivitis and calculus)
was dominant in young children and adolescents: 5-6-year-olds (58.2%),
12-13-year-olds (62.8%) and 15-16-year-olds (61%). 43.8% of 35-49-year-old
adults and 34.3% of the 50+ adults have the highest CPI score of ‘4-5 mm
pockets’, but the mean number of sextants affected is 1.6 sextants for these
age groups. The mean number of sextants
in 35-49-year-old and 50+ adults with periodontal pockets 6+ mm is small, 0.4
and 0.5 sextants respectively.
35-49-year-old adults from the Upper Hills had significantly poorer
periodontium (p<0.000). The percent
of 35-49-year-old adults with deep pocketing (21.6%) is normal compared with
other populations or subgroups in the world.
Comparison of CPI data with data collected in Nepal
- Oral Mucosal Lesions
The prevalence of oral mucosal lesions
amongst the adults was very low (6.5% 34-49-year-olds and 7.5% 50+ adults) with
1.2% of the lesions in 35-49 year adults and 0.5% of the lesions in 50+ adults
classified as leukoplakia. No oral
cancer was detected.
- Pain And Quality Of
Life Impacts
The report of pain and discomfort due to
toothache ranges from 18% in 5-6-year-olds to 64% in 50+ year adults. Amongst adolescent schoolchildren, the most
frequent reported impact of pain and discomfort is the inability to eat,
followed by the inability to speak, lauigh and sleep. With a decrease in dental caries amongst the
adolescents, impacts due to pain and discomfort has decreased in the last 5
years. 55% of 50+ year adults reported having trouble
eating hard foods.
- Oral Hygiene Habits
More than 99% of the adolescents and 90% of
the 35-49 year adults use their own brush for oral hygiene, while a toothbrush
is used by a lesser proportion of the 50+ year adults ((females,
75.4% and males, 68.5%). More urban 50+ year adults (80.2%) than rural
50+ year adults (63%) use a toothbrush.
Level of education is an important factor in the type of tool used for
oral hygiene amongst adults with the more educated using a brush and the less
educated using other instruments (p<0.000 in 35-49 year adults and
p<0.001 in 50+ year adults).
Approximately 75% of 12-13-year-olds and 80% of 15-16-year-olds use a
fluoride toothpaste while the use of fluoride toothpaste is considerably lower
in Younger adults and Older Adults (50% and 28.2% respectively). The consumption of fluoride toothpaste is
significantly higher in urban subjects (p<0.000) and lower in the Terai
compared to oterh physiographic divisions (p<0.000); and higher in
schoolchildren attending private schools than government schools
(p<0.000).
- Sugar Consumption
Tea with sugar was the most common sugar containing food
consumed. Subjects surveyed in the
Western Developmental Region consumed more sugar tea daily than other
regions. Daily
sugar consumption is also the highest in the Western Developmental Region which
may be reason for higher caries in this region, but no association was found
between dental caries and sugar consumption in this region. Daily sugar consumption pattern is similar in
rural and urban adolescents: urban
12-13-year-olds and 15-16-year-olds, 76.1% and 77.8% respectively compared to
rural 12-13-year-olds and 15-16-year-olds, 74.9% and 74%, respectively. There was no association between gender
and daily sugar consumption in all age
cohorts except for male 35-49-year-olds (p<0.006).
- Tobacco Use
Cigarettes was the most common product used
by 35-49-year-old adults (22% every day) and 50+ year adults (26% every day)
and the average daily consumption wass 8 and 7 cigarettes per day
respectively. More 35-44 year-old adults
from the Upper Hills (52.2%) use tobacco products (cigarettes, khaini, surtti)
than Mid Hills (39.6%) and Terai (37.2%)(p<0.024). Education is significantly associated with
tobacco use amongst 35-49-year-old adults (p<0.042) and 50+year adults
(p<0.004). The higher the level of
education, the less the use of tobacco.
- Knowledge And Attitude
Knowledge concerning the prevention of oral
health problems is high amongst the subjects surveyed. A high proportion of the adolescents
(94-97%), 35-49-year-old adults (83-86%) and 50+ adults (71-74%) believe or
know that brushing is a healthy habit and eating sweet and consuming tobacco
are unhealthy habits. However, knowledge
concerning fluoride is very low with 72-87% of the adolescents and 88-97% of
the adults ignorant on the protective effects of fluoride. There was no significant differences in
knowledge and attitude based on location type and education status of
adults. In 12-13-year-olds, knowledge
concerning tobacco, water fluoride and sweets was associated with parent’s
level of education and location type in favor of higher education and urban
location.
- Oral Health Care Services
63.5% and 18.3% of the 35-49-year-old and 50+ year adults reported
that they did not visit a dentist in the last 2 years because they did not have
a need or did not have any serious dental problem. Of the 35-49-year-old adults who reported
visiting a dentist, 89.6% went because they had a problem. A very small percentage stated cost or
distance to the clinic as barriers to accessing care. Adolescents also report
that the main reason they visit a dentist is for relief of pain. Oral examination, dental extraction and
cleaning/scaling were the major services provided during dental visits for both
adult age groups. The 50+ year adults received more extraction (54.4%) but less
cleaning/scaling (15.2%) than 35-49-year-old adults (35.7% and 33.9%
respectively). The majority of both
adult age groups (67.8%-94.9%) were satisfied or happy with the services such
as appointment at a suitable time, location of the dental clinics, reception,
and cleanliness.
-
Source of Oral Health
Information
Parents and teachers are the most important
sources of information on oral health for the adolescents followed by
television and radio. 45-55% of the adolescents report receiving oral health
education in school the last 12 months which emphasised oral hygiene,
importance of teeth and healthy diets. A
greater percentage of adolescents in urban schools reported receiving oral
health education in schools than in rural schools.
Conclusions: The dentition status and periodontal status of Nepalis appears to be
improving. However, there are gender, regional, geographical and social inequalities
in oral health. Priority should be given
to the implementation of the following strategies in the National Strategic
Plan for Oral Health:
- Promotion
of oral health targeting schoolchildren through the integration of
evidence based and culturally appropriate oral health preventive messages
in the school curriculum.
- Promotion
of oral health amongst the general public with special attention on
women’s oral health, the oral health of pre-school children and the
elderly.
- Create a
more supportive environment for improved oral health through affordable
fluoride toothpaste and salt fluoridation.
- Along with
oral health promotion, primary health care workers (health assistants and
auxiliary health workers) in the health posts should continue to receive
training in the delivery of basic oral health care, primarily oral health
education and pain relief throught the extraction of teeth.
Every effort should be made to implement
these equitable whole population strategies to reduce inequalities in oral
health and thereby improve oral health for all.
