Proceedings of the International Conference on Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Faculty of Dentistry, Health Sciences Centre, Kuwait University Guest Editors J.M Behbehani, Kuwait E Honkala, Kuwait 21 figures, in color, 14 tables, 2003 Basel Ⴇ Freiburg Ⴇ Paris Ⴇ London Ⴇ New York Ⴇ Bangalore Ⴇ Bangkok Ⴇ Singapore Ⴇ Tokyo Ⴇ Sydney S Karger Medical and Scientific Publishers Basel Ⴇ Freiburg Ⴇ Paris Ⴇ London New York Ⴇ Bangalore Ⴇ Bangkok Singapore Ⴇ Tokyo Ⴇ Sydney Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Drug Dosage The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new and/or infrequently employed drug All rights reserved No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center (see ‘General Information’) © Copyright 2003 by S Karger AG, P.O Box, CH–4009 Basel (Switzerland) Printed in Switzerland on acid-free paper by Reinhardt Druck, Basel ISBN 3–8055–7586–6 Vol 12, Suppl 1, 2003 Contents Preface Behbehani, J.M.; Honkala, E An Evidence-Based Approach to the Prevention of Oral Diseases Spencer, A.J 12 Preventive (Evidence-Based) Approach to Quality General Dental Care Elderton, R.J 22 Tobacco and Oral Diseases Update on the Evidence, with Recommendations Reibel, J 33 The Evidence for Prosthodontic Treatment Planning for Older, Partially Dentate Patients Omar, R 43 Stem Cells and Tissue Engineering: Prospects for Regenerating Tissues in Dental Practice Thesleff, I.; Tummers, M 51 Dental Education in Kuwait Behbehani, J.M 56 Dental Education and Dentistry System in Iran Pakshir, H.R 61 Development of Oral Health in Africa Thorpe, S.J 65 Author Index 65 Subject Index © 2003 S Karger AG, Basel Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Access to full text and tables of contents, including tentative ones for forthcoming issues: www.karger.com/mpp_issues Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Med Princ Pract 2003;12(suppl 1):1–2 DOI: 10.1159/000069848 Preface This supplement is based on papers presented at the Second International Conference of the Faculty of Dentistry, Kuwait University, October 2–4, 2001 The conference provided an ideal opportunity to exchange ideas and discuss new developments in the field of dentistry, especially the latest trends in the evidence-based approach to dental care As the former President of Kuwait University, Professor Faiza M Al-Khorafi, stated in her opening remarks, ‘In science, we need to question continuously, what is the evidence? We look to science for answers, but quite often science can only give us the best estimate for probabilities Our research results need continuous reevaluation, and the evidence must be weighed according to the strengths and weaknesses of the scientific methods applied.’ The evidence-based approach has been widely discussed in various healthcare fields and has influenced teaching throughout the world With its emphasis on prevention and its use of previous, analogous evidence to design treatment plans, the evidence-based approach differs fundamentally from traditional methods of intervention, which focus on clinical outcomes The stages of the approach, including the synthesis and assessment of evidence, the application of that evidence to a particular case, and finally the monitoring and reassessment of the intervention, are presented in detail in this supplement The preventive aspect of this approach is also addressed in an article that re-evaluates traditional approaches to the restoration of carious teeth, which give rise to the ‘repeat restoration cycle’ and in fact mask the underlying disease process rather than prevent its occurrence The prevention of oral diseases caused by smoking is empha- ABC © 2003 S Karger AG, Basel 1011–7571/03/0125–0001$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/mpp sized in a review of the documented harmful effects of smoking on oral health; it is proposed that dentists should make time during office visits to counsel patients on these effects and guide them through smoking cessation programs As research in the field of dentistry develops and expands and the evidence-based approach gains widespread acceptance, traditional treatments are steadily giving way to new strategies of managing oral health issues A clear move away from tradition is discussed in an article devoted to treatment planning for older, partially dentate patients It is proposed that the usual method of total tooth replacement is not necessary, and the targeted ‘shortened dental arch’ is more effective and gives a high level of patient satisfaction Exciting new research on stem cells and tissue regeneration indicate a distant but hopeful possibility to grow new teeth to solve the everpresent problems of dental caries and periodontal disease The second theme of the conference was ‘The Development of Dental Education and Oral Health,’ with a regional emphasis The dental curricula of schools in two Gulf countries, Kuwait and Iran, are presented in this supplement, as is the issue of community health in Africa The dental curriculum at Kuwait University’s newly established Faculty of Dentistry aims to promote oral health in Kuwait through education, research and community involvement It incorporates recent trends in healthcare, including the evidence-based approach which has become an important component of comprehensive dental care clinical work In Iran, many new dental schools have been established over the past 20 years, offering both under- graduate and postgraduate training programs The number of dentists and specialists in Iran is steadily increasing, and just recently dental services have been incorporated into the public healthcare system Efforts are also underway in Africa to integrate oral health programs into general health services, through the technical and financial support of WHO/AFRO It is hoped that such preventive programs and new intervention strategies will improve the level of oral health in many African countries As reflected in the presentations at this conference, the vibrant research activity in the field of dentistry and the efflorescence in dental education and oral health promotion promise continued improvements in both dental healthcare delivery and patients’ quality of life in the coming years It was an honor for the Faculty of Dentistry at Kuwait University to host this conference and welcome Med Princ Pract 2003;12(suppl 1):1–2 professionals and researchers from around the world, and we look forward to another successful conference in December, 2003 We would like to express the Conference Organising Committee’s gratitude to Kuwait University for its continued support of our conferences, and the Advanced Technology Company for the financial support of this conference We are also indebted to the Medical Principles and Practice Editor-in-Chief, Professor Farida AlAwadi, and Editor, Professor Azu Owunwanne, for their help, strong support and commitment to publish this supplement Lastly, we would like to personally thank the authors for their participation, contributions and cooperation Dr Jawad M Behbehani Dr Eino Honkala Dean Chairman Faculty of Dentistry Organizing Committee Preface Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Med Princ Pract 2003;12(suppl 1):3–11 DOI: 10.1159/000069846 An Evidence-Based Approach to the Prevention of Oral Diseases A.J Spencer Social and Preventive Dentistry, The University of Adelaide, Adelaide, S.A., Australia Key Words Evidence-based W Prevention W Oral diseases Abstract The evidence-based approach has become the mantra of health care and service delivery But just what it means, whether it is feasible, how to build it and the outcome of its use are not well understood The aims of this paper are to provide an overview of an evidence-based approach to the prevention of oral disease, to examine the assessment of clinical trial evidence, to examine emerging approaches to assessing population-wide interventions and oral health promotion, and to illustrate some principles and issues through examples from preventive dentistry The evidence-based approach to prevention is presented using an evidence loop, which emphasizes that the evidence-base should begin with an understanding to the burden of oral disease and its determinants, rather than a consideration of the efficacy or effectiveness of interventions in clinical dental research A systematic review of evidence from clinical dental research is compiled and assessed, after which the intervention is decided upon and implemented The evidence loop is completed by the monitoring of outcomes and reassessment of the intervention process Attention is also given to steps in assessing non-randomized population-wide interventions and evidence on oral health promotion based on expert opinion The requirement for evidence ABC © 2003 S Karger AG, Basel 1011–7571/03/0125–0003$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/mpp creates a substantial challenge which can only be met by increased research activity, improved quality of information and the appropriate application of the outcomes of research to policy making for the prevention of oral disease Copyright © 2003 S Karger AG, Basel Introduction The evidence-based approach has become the mantra of health care and service delivery It includes all aspects of dentistry, not the least prevention But just what it means, whether it is feasible, how to conduct it and the outcome of its use are not well understood The evidencebased approach to the prevention of oral disease relies on knowledge of the effectiveness of identical, similar, or analogous interventions usually carried out and evaluated in a different setting at a different time Toward the end of the 1990s some journals published systematic reviews and meta-analyses, or evidence-bases, using quantitative scientific methods and consulting scholars around the world about specific methods of appraising and quantifying the benefits and risks of interventions However, it was found that outside a few areas of health care, clinical trial evidence is scarce, particularly in many areas of dentistry Many everyday decisions on health care, including prevention of oral diseases, are based on public health programs and policies founded on less scientific evidence Prof A John Spencer Social and Preventive Dentistry The University of Adelaide Adelaide, SA 5005 (Australia) Tel +61 8303 5438, Fax +61 8303 4858, E-Mail john.spencer@adelaide.edu.au Fig An evidence loop for the prevention of oral diseases than is required or desired Not only is more evidence needed, but new ways of examining population-wide interventions and programs for oral health promotion are also needed to assist decision-making A number of levels of evidence and methods to assess them are being developed New concepts for an evidencebased approach and a range of old and new methods for the assessment of evidence seem to be gaining greater clarity This paper provides an overview of the evidencebased approach to prevention, and points out some of the limitations to applying evidence to population-wide interventions and some issues in oral health promotion Evidence-Based Approach to Oral Disease Prevention The evidence-based approach to prevention begins with the identification and definition of an oral health problem for which an objective for oral health gain can be stated Related evidence on the efficacy of interventions is synthesized and assessed, after which an intervention plan is decided upon and implemented Finally, the oral health outcomes among patients or populations are monitored and the whole process reassessed over time These fundamental components might be expanded into a more detailed evidence loop for the prevention of oral diseases, Med Princ Pract 2003;12(suppl 1):3–11 as presented in figure Each aspect of this evidence loop for the prevention of oral diseases is necessary for sound decisions on either an individual or population level Following the various stages ensures that resources are not used to address less important problems or alter less significant determinants, and that preventive interventions are not maintained beyond their useful life should the burden of disease alter The loop also recognizes that some interventions might work less satisfactorily in different contexts Burden of Oral Disease In the evidence loop the problem is first identified, defined and prioritized through information on the burden of oral disease, which is the assessment of the magnitude and impact of oral health problems among patients or populations To design the appropriate intervention, determinants of the disease are delineated and the level of avoidable disease is assessed – i.e how much of the disease is due to mutable risk factors and what proportion of the burden of disease is avoidable Numerous ways exist to measure the burden of disease Summary health measures such as Disability-Adjusted Life Years (DALYs) provide a common metric The DALY was first used in a comprehensive assessment of the global burden of disease and injury in 1990 by the World Bank [1] and has been adopted by the Spencer World Health Organization to inform health planning [2] DALYs provide a way to link the cause and occurrence of a disease to both short- and long-term health outcomes, including impairments, functional limitations (disability) and death One DALY is a lost year of ‘healthy’ life DALYs are a combination of years of life lost (YLL) due to premature death and equivalent years of life lived with disability (YLD) Such population-wide ‘summary health measures’ have been emphasized recently in the development of health policies A report on the burden of disease and injury in Australia [3] identified oral disease as one of the top dozen major disease groups for non-fatal burden of disease While mental and nervous system disorders were of substantially higher burden than any others, oral disease ranked in a group of diseases/disorders that are considered highly preventable, such as injuries and infectious diseases The oral diseases included were dental caries, periodontal disease and subsequent edentulism Years of life lived with disability were predominantly linked to dental caries (56.2%), then to periodontal disease (30.3%) and finally to edentulism (13.5%) Young and middleaged adults experienced more years of life lived with disability from dental caries than did older adults, while the years of life lived with disability from periodontal disease were distributed among middle-aged adult groups The main challenge of using summary health measures is ensuring that the burden of disease is appropriately estimated, so current estimates of the burden of oral disease in DALYs require further consideration Estimates of the incidence of new disease from cross-sectional prevalence data are not entirely reliable, because the assumptions made in the translation of prevalence to incidence data not recognize the recurrence of the most common oral diseases (dental caries and periodontal disease) at previously affected sites Furthermore, the estimates for the amount of disability associated with each oral disease need scrutiny The summary health measures cited above apply a system of averaged levels of disability, handicap, mental wellbeing, pain and cognitive impairment using a modified version of the EuroQoL health status instrument; by these measures, the disability weights for gingivitis and dental caries were the lowest of all diseases or disorders [4], indicating that the weights need further investigation Research using generic quality of life measures among dental patients has shown a low level of impacts; however, this type of research will help assess the relative weightings ascribed to common oral diseases Orally specific measures of quality of life show a greater sensitivity for oral impacts than measures for general quality of life [5], and they have been developed to identify those oral diseases of greater burden that should be considered as targets for prevention [6] An evidence-based approach to prevention, therefore, requires knowledge of the relative burden of disease associated with particular oral diseases at different stages of life and the proportion of that burden of disease that is avoidable given associations with mutable determinants of disease Evidence-Based Approach to Oral Disease Prevention Med Princ Pract 2003;12(suppl 1):3–11 Determinants of Oral Disease Preventive programs should be based on conceptual and empirical evidence of the determinants of variation in oral disease among patients or population groups in order to identify more points of intervention in the prevention of oral disease The conceptual model illustrated in figure identifies three discrete yet closely interrelated stages or levels of determinants: upstream, midstream, and downstream [7] Upstream level factors: The framework identifies social, physical, economic and environmental factors as being the most fundamental determinants of oral health These include a range of interrelated factors such as education, employment, occupation, working conditions, income, housing, and area of residence The framework also indicates that these fundamental determinants are themselves influenced by even more upstream factors, namely, government policies, globalisation, and culture Midstream level factors: Social, physical, economic and environmental contexts throughout life influence health either indirectly via psychosocial processes and dental health behaviours, or more directly, for example via injuries The dental care system also plays some part in determining oral health within a society However, it plays only a modest and moderating role Downstream level factors: Ultimately, oral diseases are a consequence of adverse biological reactions to changes or disruptions in various physiological systems The poorer health profile of some patients or population subgroups is due in part to longer-term adverse physiological and biological changes that are brought about by poorer psychosocial health and more harmful dental health behaviours The concept of ‘avoidable oral disease’ is based on an understanding of these wider determinants for most oral diseases and the evidence-base for the effectiveness of possible interventions Three issues at the centre of new approaches to prevention are multifactorial causes of chronic (including oral) disease, shared risk factors, and life stages It may be more effective and efficient to build Fig Determinants of oral disease preventive efforts around common risk factors than to develop separate preventive programs for each disease Activities to prevent many of the risk factors may be undertaken in common settings, such as schools or health centres Current knowledge suggests that oral health outcomes are likely to be best when prevention is promoted throughout life (beginning with the prenatal period and infancy and extending through childhood, adolescence, adulthood and older adulthood), because risks and preventive factors accumulate and interact over a lifetime in a dynamic process The principles, approaches and messages of health promotion (e.g empowerment, equity, health literacy, healthy behaviours, supportive environments) and specific preventive interventions are relevant throughout a lifetime, but each life stage also has unique contextual and behavioural aspects, and therefore particular strategies to reduce risk factors and strengthen prevention are needed Integrated models are emerging that address the continuum of opportunities for prevention, such as the one presented in figure 3, which was developed for Australia’s chronic disease strategy [8] In such models people are distributed across different target groups: the well population, those at risk, those diagnosed with disease, and those with controlled disease Interventions are specific to these stages and have different objectives, such as preventing movement into the at-risk group, preventing progression to established disease, or averting recurrence of disease and loss of oral function In such as approach to pre- Med Princ Pract 2003;12(suppl 1):3–11 vention, the evidence-base on different interventions is a key component of the support systems Synthesis of the Evidence-Base for Preventive Interventions and Decision-Making The evidence-based approach makes use of evaluative research on the effects of an intervention to determine the likely benefits or adverse consequences of intervention for particular individuals or populations When possible, evidence of beneficial outcomes, rather than biological plausibility or anticipated effects, is used [9] Evidence of benefits is derived predominantly from epidemiologic research, which provides quantitative estimates of efficacy or effectiveness Summary estimates of effectiveness are generated by a critical review of research data from two or more studies using systematic review methods [10] Subgroup analyses may be used to identify characteristics of people for whom an intervention is most or least effective The starting point for the traditional evidence-based approach, therefore, is the searching for and collation of the scientific evidence on a given intervention Questions concerning the intervention should be considered carefully and in detail Narrow rather than broad questions assist the systematic review of evidence, but the question must still be likely to support practical and potentially useful interventions given favourable evidence Considerable emphasis is placed on the transparency and reproducibility of the literature search Finding studies relevant to an intervention is not easy; beyond sifting Spencer Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Med Princ Pract 2003;12(suppl 1):51–55 DOI: 10.1159/000069843 Dental Education in Kuwait J.M Behbehani Faculty of Dentistry, Health Sciences Center, Kuwait University, Kuwait Key Words Dental education W Curriculum W Evidence-based approach W Community-based learning W Comprehensive dental care Abstract For a long time there has been a need to establish a dental school in Kuwait, due to the fact that the majority of dentists working in Kuwait are expatriates from various countries An Amiri decree in 1996 made it possible, and the first dental students were admitted to the Kuwait University Faculty of Dentistry in 1998 The mission of the Faculty of Dentistry is ‘to promote oral health in Kuwait through education, research and cooperation with other professional health care institutions as well as the community at large’ A 6.5-year dental curriculum was completed after years of committee work and was accepted by the University Council in 2001 This curriculum incorporates current trends in medical and dental education, such as the evidence-based and community-based approaches, problem-solving methodology for outcomebased learning, and competency achieved through comprehensive patient care Copyright © 2003 S Karger AG, Basel ABC © 2003 S Karger AG, Basel 1011–7571/03/0125–0051$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/mpp Introduction Dental care in Kuwait is delivered by expatriates as well as Kuwaiti dentists who received their training abroad, mainly in Egypt, the United States, the United Kingdom, and the Republic of Ireland While the Faculty of Medicine was established at Kuwait University in 1973, plans for establishing a Faculty of Dentistry did not start until the early 1980s The Gulf War delayed these plans until May 26th, 1996, when an Amiri decree was issued for the establishment of the Faculty of Dentistry The first class of 26 students was admitted to the dental program in September 1998, and they will graduate in January 2005 Once the Faculty of Dentistry was established, a curriculum committee was set up to plan, evaluate and revise the program The dental curriculum is presently a 6.5year, 13-semester program, including 1.5 years or semesters of preprofessional studies in the Faculty of Science, 2.5 years or semesters of preclinical courses in the Faculty of Medicine, and finally 2.5 years or semesters of clinical training in the Faculty of Dentistry Dental subjects were incorporated into both the preprofessional and preclinical programs in order to expose the students to clinical experiences early in their training, and medical courses which were less relevant to dentistry were replaced by dental courses (fig 1) For instance, the Introduction to the Dental Profession course was incorporated into the preprofessional program in the 2nd year, and Dr Jawad M Behbehani Faculty of Dentistry, Health Sciences Center, Kuwait University PO Box 24923 Safat 13110 (Kuwait) Tel +965 2664502, ext 7101, Fax +965 2634247, E-Mail jawadbeh@hsc.kuniv.edu.kw Table Major sheet: course titles, numbers and credit hours by years 1–7 a Preprofessional program Depart- Course ment1 No CH2 Course Year 1, semester 181 English 115 Finite Mathematics 110/111 Chemistry and Chemistry Laboratory or 121/125 Physics and Physics Laboratory Elective Course Fig The integration of dental subjects into the preprofessional and preclinical programs of the B Med Sc a = Introduction to the dental profession; b = oral anatomy; c = oral microbiology; d = oral and systemic pathology; e = oral neuroscience; f = dental biomaterials; g = preclinical oral and maxillofacial radiology; i = preclinical operative dentistry and cariology; j = preclinical removable prosthodontics Year 1, semester 182 English 110/111 Chemistry and Chemistry Laboratory or 121/125 Physics and Physics Laboratory 101 Biology Introduction to Health Professions/Elective Course Year 2, semester 00 201 183 122 127 114 103 Introduction to the Dental Profession3 English Physics Physics Laboratory Chemistry and Chemistry Laboratory Biology Total CH dental courses (those with course numbers ending in ‘D’) were introduced into the preclinical program in the 3rd and 4th years of the curriculum (table 1) Simultaneously with curriculum development, the departmental structure of the faculty was determined (table 2) The Development of the Dental Curriculum The mission of the Faculty of Dentistry is ‘to promote oral health in Kuwait through education, research and cooperation with other professional health care institutions as well as the community at large’ A communitybased dental curriculum that focuses on the community and empowers local residents is recommended by the World Health Organization (WHO) [1] In such a program, close cooperation between the community and the educational institution is necessary, creating a new role for dental schools and a new kind of responsibility in teaching [2] Social sensitivity is therefore considered an important criterion in the recruitment of students, who rotate in different community clinics and extramural programs No existing curriculum was accepted as a model for the dental program, so the experienced members of the multinational academic staff of the new Faculty of Dentistry were consulted to establish a modern and realistic dental 52 Med Princ Pract 2003;12(suppl 1):51–55 5 3 48 Departments refer to the Faculty of Dentistry only; see separate list below One credit hour (CH) equals h of theoretical studies or at least h of practicals per week for semester Coordinated by the Vice-Dean for Academic Affairs curriculum suitable for the needs of Kuwait The curriculum was completed in years (1999–2000) and accepted by the University Council in 2001 It incorporates current trends in medical and dental education, which are summarized by Harden [3] as follows: (a) education for capability; (b) community orientation; (c) self-directed learning; (d) integration and multiprofessional education; (e) outcome-based education; (f) adaptive curriculum, and (g) assessment-led innovation These trends reflect the shift that is taking place in the dental profession, from diagnosis and treatment to disease prevention, health maintenance, and health promotion [4] Several of these trends appear among the nine basic principles that form the philosophy of education at the Faculty of Dentistry (table 3) The principles apply mostly to the clinical program and to those clinical courses that have been incorporated into the preclinical program (courses with numbers that end in ‘D’) Both didactic and clinical dental education was integrated into medicine, since the Faculty of Medicine makes Behbehani Table (continued) Table (continued) b Preclinical program c Dental clinical educational program Depart- Course Course ment No Year 2, semester 302 Anatomy 302 Behavioral Science 302 Biochemistry 302 Physiology CH 4 16 Year 3, semester 303 Anatomy 303 Behavioral Science 303 Biochemistry 303 Physiology 4 16 Year 3, semester 304D Anatomy 304 Behavioral Science 304 Biochemistry 304 Physiology 4 16 Year 4, semester 400 Pathology 400D Microbiology/Oral Microbiology 400 Pharmacology 400D Neuroscience/Oral Neuroscience 4 3 14 Year 4, semester 401D Oral and Systemic Pathology 401 Pharmacology 401D Neuroscience/Oral Neuroscience 10 411 Dental Biomaterials 30 431 Preclinical Oral and Maxillofacial Radiology 40 441 Dental Anatomy and Function 40 442 Preclinical Operative Dentistry and Cariology 40 443 Preclinical Removable Prosthodontics 3 2 Depart- Course Course ment No Year 5, semester 20 521 Pediatric Dentistry I 20 522 Orthodontics I 30 531 Oral and Maxillofacial Radiology I 30 532 Principles in Medicine I 40 541 Prosthodontics I (Fixed) 40 542 Prosthodontics II (Removable) 40 543 Endodontics I 50 551 Periodontology I 50 552 Oral and Maxillofacial Surgery I 00 501 Comprehensive Dental Care I1 84 The grand total credit hours for the Bachelor of Medical Sciences (BMedSc) degree in the dental program is 132, comprising 48 CH in the preprofessional program and 84 CH in the preclinical program The grand total credit hours for the Bachelor of Dental Medicine (BDM) degree is 236 CH comprising 48 CH in the preprofessional program, 84 CH in the preclinical program and 104 CH in the dental clinical educational program Departments in the Faculty of Dentistry (Faculty No 12) as referred to in this Major Sheet: Department of Bioclinical Sciences (BCS) = No 10, Department of Developmental and Preventive Sciences (DPS) = No 20, Department of Diagnostic Sciences (DS) = No 30, Department of Restorative Sciences (RS) = No 40, Department of Surgical Sciences (SS) = No 50, Nondepartmental activities coordinated by the Vice-Deans = No 00 Coordinated by the Vice-Dean for Academic Affairs Coordinated by the Vice-Dean for Research Coordinated by the Vice-Dean for Research Dental Education in Kuwait 2 2 2 23 Year 5, semester 20 523 Dental Public Health I (Preventive Dentistry) 20 524 Pediatric Dentistry II 20 525 Orthodontics II 30 533 Principles in Medicine II 40 544 Prosthodontics III (Fixed) 40 545 Operative Dentistry 40 546 Endodontics II 50 553 Periodontology II 00 502 Comprehensive Dental Care II1 2 2 22 Year 6, semester 20 621 Pediatric Dentistry III 20 622 Dental Public Health II (Preventive Dentistry) 20 623 Dental Public Health III (Oral Epidemiology) 20 624 Orthodontics III 30 631 Principles in Medicine III 30 632 Oral Medicine and Clinical Oral Pathology I 40 641 Prosthodontics IV 50 651 Periodontology III 50 652 Oral and Maxillofacial Surgery II 00 601 Comprehensive Dental Care III1 00 602 Community Rotation I2 2 2 2 2 24 22 Total CH CH Year 6, semester 20 625 Dental Public Health IV 20 626 Pediatric Dentistry IV 30 633 Oral and Maxillofacial Radiology II 30 635 Oral Medicine and Clinical Oral Pathology II 40 642 Prosthodontics V 50 653 Oral and Maxillofacial Surgery III 00 603 Comprehensive Dental Care IV1 00 604 Community Rotation II2 2 2 22 Year 7, semester 00 701 Comprehensive Dental Care V1 00 702 Community Rotation III2 00 703 Elective Project Study3 13 Total CH Med Princ Pract 2003;12(suppl 1):51–55 104 53 Table The departmental structure of the Kuwait University Faculty of Dentistry The Department of Bioclinical Sciences Oral Biology Oral Neurosciences Oral Microbiology Biomaterial Science The Department of Developmental and Preventive Sciences Dental Public Health Orthodontics Pediatric Dentistry The Department of Diagnostic Sciences Oral Pathology/Medicine Oral and Maxillofacial Radiology General Medicine Temporomandibular Disorders The Department of Restorative Sciences Dental Anatomy and Function Fixed/Removable Prosthodontics Operative Dentistry Endodontics Dental Materials The Department of Surgical Sciences Periodontics Oral and Maxillofacial Surgery Table Basic principles of dental education Didactic and clinical education integrated with medicine Competency-based curriculum Comprehensive patient care clinical education Emphasis on preventive dentistry and oral health promotion Evidence-based approach, outcome-based education Problem-solving methodology for treatment planning or case management Promotion of ethical behavior and professionalism Community-based learning Lifelong learning many pedagogical decisions for the core courses in the four faculties (Medicine, Dentistry, Pharmacy, and Allied Health Sciences and Nursing) of the Kuwait University Health Sciences Center (HSC) Dental students take the same preprofessional courses as other HSC students, plus the Introduction to the Dental Profession course in the 2nd year and an elaborate course in Principles in Medicine that is spread over the clinical years 54 Med Princ Pract 2003;12(suppl 1):51–55 The community-based approach is introduced during the Introduction to the Dental Profession course and is emphasized in the Dental Public Health courses (II and III) during the first semester of the 6th year Also in the 6th year, community rotations are arranged in cooperation with the Ministry of Health As a future employer of our graduating dentists, the Ministry of Health plays an important role in the execution of the dental curriculum; several senior staff members of the Ministry of Health give lectures and supervise dental students in their community rotations and other extramural courses, while faculty members work days a week in the Ministry of Health clinics The community-based approach is also an integral part of some elective studies that require data collection from society and therefore rely on cooperation with community institutions Comprehensive dental care education involves adult dental care Contrary to the department-/discipline-based model where a patient consults various specialists, each of whom treat the specific problems that fall into his or her field of expertise, one ‘mentor’ supervises all the treatment procedures across discipline borders Students learn to treat the whole patient rather than see the patient as separate disease states Courses on comprehensive dental care start in the first semester of the 5th year and continue until the end of the program In addition, treatment planning seminars that comprehensively integrate various aspects of different disciplines are conducted in the clinics during the clinical years A competency-based curriculum lists the competencies to be achieved by the students by the end of the courses and uses an assessment system based on competency rather than clinical requirements for different treatment procedures The courses in the clinical program are competency-based, and students must acquire competency in one area before moving on to the next Preventive dentistry and oral health promotion are emphasized in many classes throughout the dental program, and treated in detail in two separate courses on Dental Public Health (I and II) during the 5th and 6th years The evidence-based approach is used in several seminars that are part of traditional lecture courses as well as in comprehensive dental care clinical work Students, patients, and colleagues can question the evidence presented, contrary to the traditional approach whereby no one questioned the experts For an elective study project, students concentrate on the evidence-based approach and compile a comprehensive literature review Students choose their topics, and advisors are nominated from the specific departments that specialize in those topics Behbehani The problem-solving methodology for treatment planning is introduced during the students’ early exposure to patient clinics before the didactic clinical courses, as well as in the seminars about comprehensive dental treatment planning Some studies have shown that problem-based learning is superior to traditional education [5, 6], but attempts to implement it in the dental program involved changing the teaching philosophy of the Faculty of Medicine Therefore, the problem-based method is still not used very much, and lectures cover the bulk of didactic teaching The importance of ethics and professionalism is promoted in the course on Dental Public Health (IV) and by mentors who act as role models in comprehensive dental care clinics Finally, lifelong learning goals are adopted along with required computer literacy skills Gathering information from the Internet is a major feature of all the courses, while elective studies concentrate on obtaining information from original publications rather than textbooks and reviews The first Medline-based seminar is a part of the Introduction to the Dental Profession course The dental curriculum at Kuwait University is unique in that the students are exposed at an early stage to the healthcare system in Kuwait, when they go on their first field visits during the Introduction to the Dental Profession course in the 2nd year In fact, many practical training sessions take place in the national healthcare system, especially in the Kuwait School Health Programs where students implement preventive programs such as sealant and fluoride applications Dentists from the Ministry of Health supervise students at the Ministry of Health dental clinics in the three community rotation courses during the last years of the program, and they also give lectures at the university In addition, subjects such as Oral Health in Kuwait, Healthcare Policy in Kuwait, School Oral Health Programs in Kuwait, and Legal Issues of Dentistry in Kuwait are covered in the Dental Public Health course (IV) Such integration with the national healthcare system has been strongly recommended by the WHO, but few colleges in the world have been able to accomplish it Conclusions By incorporating the latest trends in the dental and healthcare professions, the new 6.5-year dental curriculum at Kuwait University’s recently established Faculty of Dentistry aims to promote oral health in Kuwait through education and research as well as cooperation with healthcare institutions and the community The program’s emphasis on community involvement early in the program and the Faculty’s close cooperation with the Ministry of Health make it unique to Kuwait The curriculum was accepted in 2001 by the University Council, and it will be continuously scrutinized and revised as students proceed through the program in the coming years Acknowledgments I am grateful to all of my colleagues in the Faculty of Dentistry, who contributed so much to creating the dental curriculum for the Faculty of Dentistry, Kuwait University References Hausen H: Oral Health Sciences Education: Relevance to the Community Geneva, World Consultation on Oral Sciences Education, WHO Workshop, 1994 Formicola AJ, McIntosh J, Marshall S, Albert D, Mitchell-Lewis D, Zabos GP, Garfield R: Population-based primary care and dental education: A new role for dental schools J Dent Educ 1999;63:331–338 Dental Education in Kuwait Harden RM: Curriculum change and the assessment of clinical competence Proc First GCC Conf Faculties of Medicine, Medical Education in the GCC Countries Kuwait, Faculty of Medicine, Kuwait University, Health Sciences Centre, 1999, pp 169–178 Slavkin HC: The future of clinical dentistry J Dent Educ 1998;62:751–755 Norman GR, Schmidt HG: The psychological basis of problem-based learning: A review of the evidence Acad Med 1992;67:557–565 Albanese MA, Mitchell S: Problem-based learning: A review of literature on its outcomes and implementation issues Acad Med 1993; 68:52–81 Med Princ Pract 2003;12(suppl 1):51–55 55 Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Med Princ Pract 2003;12(suppl 1):56–60 DOI: 10.1159/000069844 Dental Education and Dentistry System in Iran Hamid Reza Pakshir School of Dental Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Key Words Dental education W Dentistry system W Iran Abstract Before 1979, there were only undergraduate dental schools in Iran with a total admission of 200 students per year, and only 2,000 dentists and about 50 specialists practicing in the country Currently, there are 18 dental schools with a total admission of 750 undergraduate students, postgraduate programs in 10 disciplines with a total of 100 students, more than 11,000 dentists (1 dentist per 5,500 population) and nearly 1,000 specialists in the country Two new schools have recently begun offering specialty training courses in disciplines The length of the dentistry curriculum is years Students take general and basic science courses during the first years, then continue on the predental and dental courses for the remaining years The curriculum has been revised over the past 20 years to establish intership and specialty programs and introduce courses reflecting current trends in the dental profession Dental services in Iran are provided by both public and private sectors Oral health care was integrated into the Public Health Care network by 1997, and levels of a Dental Health Care Delivery System were established The first level is concerned with primary prevention at ‘health houses’, where auxiliary health workers called ‘behvarzes’ provide periodic examinations, referrals, and oral health education At the next level, oral hygienists and dentists in ‘health centers’ per- ABC © 2003 S Karger AG, Basel 1011–7571/03/0125–0056$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/mpp form basic oral health care services such as fillings, scaling, and extraction At the third level, dentists manage and treat oral diseases in ‘urban health centers’, while the last level is for advanced treatment by specialists in university health centers in the cities Copyright © 2003 S Karger AG, Basel Profile of the Country The Islamic Republic of Iran, with an area of over 1,648,000 km2, is a vast region in southwest Asia and ranks 16th in the world in surface area The country is divided into 28 provinces, 285 districts and over 66,000 villages Based on the latest census, the population of Iran is estimated to be 60,550,000 with a density of 36.44/km2 The percentage of the total population residing in cities is 61.3%, while 38.44% live in rural areas The annual growth rate in 2000 was 1.47%, with about 46% of the population under 14 years of age, 51.38% under 20, and 4.32% aged 65 years and older Thus the population of Iran is regarded as one of the youngest in the world (table 1) [1, 2] National Education System Article 30 of the Constitution of the Islamic Republic of Iran states, ‘The government is duty-bound to prepare free education facilities for all people upon graduation Hamid Reza Pakshir Orthodontic Department, School of Dental Medicine Shiraz University of Medical Sciences Shiraz (Iran) Tel +98 711 6280456, Fax +98 711 6270325, E-Mail dentdean@sums.ac.ir from high school Higher education should be available to all aspirants as the self-sufficiency of the country prescribes’ [2] The educational system of Iran consists of year of preschool (5 years old), years of primary school (6–11 years old), years of guidance school (12–14 years old), years of high school (15–17 years old), and year of preuniversity programs (18 years old) To enter dental school, a student must have a secondary education diploma or a preuniversity certificate for higher education as well as a passing grade on the National University Entrance Examination Of the nearly 500,000 preuniversity students in the experimental sciences who apply for higher education in medical universities each year, only about 700 enter dental schools [1, 2] Another route to dental schools is available to oral hygienists who are selected from the local communities and trained for years in special dental schools, during which they learn skills such as simple fillings, scaling and extraction After years of service in local rural communities and after passing the entrance examination at the end of their service, they may continue their education to obtain the degree of Doctor of Dental Surgery [1] Profile of Dental Schools As shown in table 2, before 1979 only dental schools in cities (2 in Tehran, and the other in Shiraz, Isfahan and Mashad) offered undergraduate dental education to a total of 200 students each year, and only schools offered postgraduate training in disciplines Currently there are 18 dental schools in Iran, with an annual total admission of 750 undergraduate and 100 postgraduate students Four of the undergraduate schools offer training programs for dental assistants, with an annual total admission of 100 students, while schools have training programs for dental technicians with the same number of admissions In 1975, there were only 250 academic staff members working in dental schools By 1990, there were 400, and currently there are around 800 academic staff members working in different departments in all the schools (table 3) Approximately 700 new dentists graduate each year [3] In addition to undergraduate programs, the older dental schools, known as ‘mother schools’, now offer postgraduate programs in 10 disciplines Recently, new dental schools have also started postgraduate programs in disciplines Following the increase in the number of schools and academic staff, the annual number of post- Dental Education in Iran Table Country profile of the Islamic Republic of Iran Official name Official language Land area, km2 Number of provinces Number of districts Number of villages Population Density of population Annual population growth rate, % Population under 20 years, % Population 65 years and over, % Population/physician Population/dentist Population residing in cities, % Population residing in rural areas, % The Islamic Republic of Iran Persian (Farsi), Turkish, other 1,648,000 28 285 over 66,000 60,550,000 36.44/km2 1.47 51.38 4.32 2,821 5,500 61 39 Table Profile of Iranian dental schools 1979 Dental schools Dental students (undergraduate) Dental students (postgraduate) Total admissions/year (undergraduate and postgraduate) Graduates/year Postgraduate programs Postgraduate disciplines Academic staff Schools for hygienists Schools for laboratory technicians 2000 1,000 20 18 5,000 400 200 150 150 (1990) (1990) 850 700 5–7 10–11 800 3 Table Number of academic staff members in various departments of Iranian dental schools Oral and maxillofacial surgery Oral and maxillofacial pathology Oral and maxillofacial radiology Oral medicine and diagnosis Pediatric dentistry Restorative and aesthetic dentistry Periodontics Prosthodontics (removable) Prosthodontics (fixed) Orthodontics Endodontics Total academic staff members in dental schools Med Princ Pract 2003;12(suppl 1):56–60 88 27 32 48 71 96 99 63 87 92 90 793 57 Table Dental school curriculum in the Islamic Republic of Iran Stage Year Year Stage Year Year Years and General courses and a few basic sciences Advanced basic sciences Comprehensive examination Related medical courses such as Otolaryngology and Internal Medicine, and preclinical technique courses Completion of preclinical courses and start of clinical courses Pure clinical courses, community-based dentistry Degrees offered: DMD, DDS graduate students admitted to the programs has increased from 30 to 100 students, and at the present time, around 400 postgraduate students are actively involved in the programs (table 2) [4] Dental Education Program The dental curriculum consists of 56 main subjects to be taken over years, or 12 semesters As shown in table 4, these courses are presented in two stages In the first stage, which lasts years, students complete a total of 68 credits: 24 credits for general courses and 44 credits for biomedical (basic) sciences The general courses include: The Islamic Revolution and Its Origin (2), Computers (2), English language (9), Persian Language (3), Family Planning and Population Control (2), Physical Education (2), and History of Islam (4) The basic sciences include: General Pathology (6), Anatomy (6), Immunology (3), Human Histology (3), Biochemistry (5), Embryology (1), Physiology (6), Microbiology (4), Parasitology and Virology (2), Biophysics (2), Public Health (2), Genetics (2) and Psychology (2) [4] The first stage includes a total of 925 contact hours, of which 568 h are lectures and 357 h are practical training (demonstration and laboratory work) At the end of the first years, students take a comprehensive examination in the basic sciences After successfully passing the courses in the first stage and the comprehensive examination, students take the predental (preclinical) and dental (clinical) courses in the second stage, which lasts for the remaining years, or semesters The preclinical section in the second stage requires a total of 35 credits in the following courses: Oral 58 Med Princ Pract 2003;12(suppl 1):56–60 and Maxillofacial Pathology (6), Dental Anatomy (4), Internal Medicine (3), Psychiatry (1), Oral Biology (1), Oral and Dental Histology (3), Ear, Nose and Throat (1), Infection Control in Dentistry (1), Dental Emergency (1), Dental Materials (2), Pharmacology (2), Medical and Dental Terminology (4), Methodology in Medical Sciences (2), Nutrition and Oral Health (1), Medical Ethics (1), Medical Law (1) and Dental Instruments and Equipment (1) This part has a total of 680 contact hours, including 476 h for lectures and 204 h for practical training [4] In the clinical part of the second stage, which is devoted purely to the dental sciences, students take a total of 115 theoretical and practical credits, including 661 h of lectures (approximately 40 credits) and 2,550 h (approximately 75 credits) for practical courses The courses are: Orthodontics (7), Endodontics (10), Oral Diagnosis (8), Periodontology (7), Removable Partial Prosthodontics (8), Removable Full Denture (9), Fixed Prosthodontics (11), Oral and Maxillofacial Surgery (11), Restorative and Aesthetic Dentistry (9), Pedodontics (8), Oral Radiology (6), Community Dentistry (6), Comprehensive Dental Treatment (7) and the thesis (8) [4] In summary, students should successfully pass a total of 218 credits in their 6-year training program as follows: (a) general courses, 24 credits; (b) basic sciences, 44 credits; (c) predental courses, 35 credits, and (d) dental courses, 115 credits Finally, students submit a thesis to obtain the degree of Doctor of Dental Surgery But before newly graduated dentists can practice, they must first fulfill certain commitments, such as years of military service or service in deprived areas of the country, after which a license from the concerned ministry can be obtained [2] The dental curriculum has been revised three times since 1982 The main objective of the first revision was to reduce the dental credits from 220 to 213 by omitting some general courses In the second revision in 1988, small changes were made in the number of credits, but two major quality changes were also applied: the comprehensive examination was established at the end of the first stage, and an internship program was instituted in the last semester Finally, the curriculum was changed dramatically in 1999 with the introduction of courses in Community-Based Education, Primary Dental Health Care, Hospital Dental Strategies and Assessment of Medical Emergencies [4] The postgraduate dental program was also revised in 1999 to update specialty and subspecialty programs such as Maxillofacial Prosthesis, Laser Surgery, Orthognathic Surgery and Implants in Dentistry [3] Pakshir Oral and Dental Services Background Dental services are provided by both public and private sectors In cities, where 60% of the population resides, about 80% of dental services are provided by private practices, while in rural areas 70% of oral health services are delivered by the governmental sector [1] After 1979, the Ministry of Health and Medical Education designed the health system based on the Primary Health Care (PHC) network The Oral Health Department of the PHC network implemented a pilot project in 1995 and 1996 to integrate oral health care into public domains in districts, and the Dental Health Care Delivery System (DHDS) was established By 1997, the project had expanded all over the country and embraced the following objectives: (a) promotion of public awareness and improvement of community behavior in oral health, and (b) quantitative and qualitative improvements in delivering oral health care services [1] Before discussing the levels of oral health care and the DHDS, it is worthwhile giving a brief description of the health network system Health Care Delivery System In 1972, Iran collaborated with the World Health Organisation (WHO) to streamline health care delivery into levels: health houses, health centers, urban centers, and district centers A health house is the most basic rural facility, covering one or several villages and around 1,500 people Each health house is staffed by a male and female auxiliary health worker, or ‘behvarz’, who offer PHC services to the population in the area ‘Behvarzes’ are selected from among young and interested residents and are trained for years at ‘behvarz’ training centers At the present time, there are nearly 15,000 health houses and 30,000 ‘behvarzes’ in the villages, covering 85% of the rural population [1] A rural health center is a village-based facility covering 1–5 health houses and approximately 2,500 people It is staffed by a physician, several health technicians and administrative personnel An urban health center has the same personnel as a rural health center and provides services to approximately 12,000 people A district health center is a managerial planning and supervising entity, which supports the preventive and ambulatory health care systems in the district The district hospital accepts referral cases from both the rural and urban health centers [1] Dental Education in Iran Table The Dental Health Delivery System (DHDS) Level Trained professionals Treatment ‘Behvarzes’ Oral hygienists Dentists and dental nurses and technicians Specialists Primary Health Care (PHC, primary prevention) health and treatment (secondary prevention) management and treatment (tertiary prevention) research and evaluation, implants, laser, maxillofacial prosthetics Dental Health Delivery System The integration of oral health care into the PHC network was completed by 1997 and aimed to improve community behavior in oral health care Four levels of the DHDS were established (table 5) [5] The first level of the DHDS is concerned with primary prevention and designed to remove risk factors ‘Behvarzes’ at the health houses are responsible for oral health education, periodic examination of teeth, and referrals to higher levels (rural and urban health centers) They also supervise sodium fluoride mouth rinsing in rural areas In addition to ‘behvarzes’, school health workers and oral hygienists are also involved at this level [1, 5] At the second level, which covers the early diagnosis and primary treatment of simple dental problems, oral hygienists and dentists in health centers supervise the ‘behvarzes’ in the health houses in their area They also deliver primary oral health care services such as fillings, pulpotomies, extraction of infected roots, fluoride therapy and scaling [1, 5] At the third level, or tertiary prevention level, dentists together with dental nurses and technicians are responsible for the management and treatment of dental and oral diseases in urban health centers and clinics Finally, at the fourth level, advanced treatment is offered by specialists in different disciplines at university health centers in the cities This specialized treatment will be transferred to district health centers when the required facilities and manpower are available [1, 5] Oral Health Manpower The number of dentists in Iran was estimated to be 2,000 before 1979 There are now more than 11,000 (66% men and 34% women), with dentist for every 5,000– Med Princ Pract 2003;12(suppl 1):56–60 59 Table Dental and oral health manpower in Iran 1990 Dentists 3,500 Population/dentist 15,000 Male dentists, % – Female dentists, % – Employed in public sector, % – Employed in private practices, % – Employed in universities, % – Employed in other selected occupations, % – Specialists 100 Hygienists 200 Laboratory technicians 170 2000 11,000 5,500 66 34 10 79 7.3 3.7 1,000 640 570 6,000 citizens, and the number is growing steadily as 700 new dentists graduate each year from dental schools [6] Only 10% of dentists work in public services, 7.3% at universities and 3.7% in other selected occupations including the armed forces and industries, while the remaining 79% have private practices Around 1,000 specialists work either in the universities or in private practices During the past 10 years the number of oral hygienists and laboratory technicians has increased from 200 to around 650 and from 170 to 570, respectively Finally, more than 30,000 ‘behvarzes’ offer PHC services, including oral health care, to the population in their areas (table 6) [7] Conclusions Both dental education and the dental profession in Iran have expanded considerably since 1979 The number of undergraduate schools increased from to 18, and the number of postgraduate programs increased from to 7, with a corresponding increase in enrollment from 200 to 850 students annually (750 undergraduate and 100 postgraduate students) In addition, dental schools now offer programs to train dental nurses, oral hygienists and dental technicians The dental curriculum has been revised times since 1982 and was recently launched in all dental schools The number of dentists has increased from 2,000 in 1979 to more than 11,000 in 2000, while the number of specialists has increased from around 50 practicing in the capital to nearly 1,000 all over the country Oral health has been integrated into public health domains through the DHDS, which consists of levels, from primary prevention through oral health education in the rural areas at the first level up to special types of treatment by specialists in the cities at the fourth level References Country Report on Oral Health in the Islamic Republic of Iran Ministry of Health and Medical Education, Undersecretary for Public Health, Oral Health Department, 2000 Asia-Pacific Centre of Educational Innovation for Development United Nations Educational, Scientific and Cultural Organization website Available at: http://www.unescobkk.org/education/acid/higher-edu/Handbook/HB_Iran htm 60 Revised Postgraduate Education Program Ministry of Health and Medical Education, Curriculum-Planning Committee, 2001 Dental Education Program in Dental Schools of the Islamic Republic of Iran Ministry of Health and Medical Education, Council for Dental and Subdental Education 1st ed., 2000 Med Princ Pract 2003;12(suppl 1):56–60 Sadr SJ: Dental education in Iran: A retrospective review for two decades (1978–1998) Beheshti Univ Dent J 2001;18:1–2 WHO Oral Health Country/Area profile program WHO collaborating centre website Available at: http://www.whocollab.od.mah.se/ emro/iran/data/iranmanpow.html/ Iran, General Information, Dental Workforce, Dental Education, FDI World Dental Federation website Available at: http://www fdi.org.uk/assets/pdf/informations/Iran.pdf Pakshir Evidence Based Practice in Dentistry Kuwait, October 2–4, 2001 Med Princ Pract 2003;12(suppl 1):61–64 DOI: 10.1159/000069847 Development of Oral Health in Africa Samuel J Thorpe World Health Organization Regional Office for Africa, Harare, Zimbabwe Key Words Poverty W Oral disease W Determinants W Strategy W Africa Abstract Around 80% of African communities can be considered to be materially deprived The presence of widespread poverty and underdevelopment in Africa means that communities are increasingly exposed to all of the major environmental determinants of oral disease Previous approaches to oral health in Africa have failed to recognize the epidemiological priorities of the region or identify reliable and appropriate strategies to address them Efforts have consisted of providing unplanned, ad hoc and spasmodic curative oral health services, which in most cases are poorly distributed and only reach affluent or urban communities Realizing the limited impact of existing strategies, the World Health Organization Regional Office for Africa (WHO/AFRO) developed a regional oral health strategy to assist African countries and their partners in identifying priorities and planning preventive-oriented programmes, particularly at the district level The long-term objective is to provide equitable and universal access to cost-effective quality oral healthcare and thereby significantly reduce the incidence of oral diseases in Africa Copyright © 2003 S Karger AG, Basel ABC © 2003 S Karger AG, Basel 1011–7571/03/0125–0061$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/mpp Introduction According to the United Nations, 32 African countries are among the world’s 48 least developed nations, and 80% of the people in the region fall into the low socioeconomic category [1] Where affluence does occur, it is limited to a small urban elite whose lifestyles are similar to those in industrialized countries The severe lack of financial and technical resources has had a direct impact on the health of the population, and while progress is being made on a number of health-related issues in Africa, the health situation in the region gives cause for concern The main causes of illness and death of children who survive the neonatal period include diarrhoea, acute respiratory infections, malaria, measles alone and in combination, and malnutrition For women, the main causes of illness and death include complications associated with childbirth For men and women, they include communicable diseases such as malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) All of these diseases are often aggravated by emergencies and disasters such as armed conflicts, drought and famine, as well as inadequate access to safe water, sanitation, nutritious foods, essential drugs, primary and secondary education, and family planning In addition, noncommunicable diseases are emerging in Africa, especially diabetes and hypertension, due to an increase in their associated risk factors (cigarette smoking, use of alcohol, obesity and sedentary lifestyles) The presence of widespread poverty and underdevelopment in Africa means that communities are also exposed to all of the major environmental determinants of oral disease Dr Samuel J Thorpe Regional Advisor Oral Health, WHO Regional Office for Africa PO Box BE 773, Belvedere, Harare (Zimbabwe) Tel +263 706951/705043, ext 9366, or +1 321 7339366, Fax +1 321 7339009 E-Mail thorpes@whoafr.org Current Oral Health Situation in Africa Dental caries and periodontal diseases are generally considered to be major oral health problems around the world In African countries, however, they appear to be neither as common nor as severe as in the developed world The profile of oral disease is not homogenous across Africa, with health indicators varying among countries and across groups within countries Therefore each community needs to be individually assessed in terms of the basic epidemiological criteria of prevalence, severity (morbidity and mortality), and age-adjusted distribution in the population Based on this form of analysis, the most severe oral health problems in Africa amongst low socioeconomic communities include cancrum oris (NOMA), acute necrotising gingivitis (ANUG), oral cancer, oral manifestations of HIV/AIDS, facial trauma, and lastly dental caries NOMA and the associated ANUG are still common among children in Africa The most recent figure for the annual incidence of NOMA is 20 cases per 100,000 children aged 3–6 years There are about 140,000 cases of NOMA each year, and tragically about 90% of these children die without receiving any care NOMA flourishes where poverty is greatest, nutrition is poorest, and general and oral hygiene are neglected As poverty increases and many children remain malnourished or undernourished with compromised immune systems, the prevalence of conditions such as NOMA is likely to increase [2, 3–6] The prevalence of oral cancer is also on the increase in Africa In developing countries, the incidence of oral and pharyngeal cancer is estimated to be 25 cases per 100,000 inhabitants Rapid urbanization and the increasing use of tobacco and alcohol are considered to greatly increase the incidence of oral precancer [7, 8] Africa has the highest prevalence of HIV and AIDS infections in the world Studies have shown that oral manifestations of HIV/AIDS are very widespread, and most commonly include fungal infections such as those caused by candida, necrotizing gingivitis or oral hairy leukoplakia In a study conducted in South Africa in 1995, 74.4% of HIV-infected patients presented with one or more oral mucosal lesions [8–10] Maxillo-facial trauma has increased in many countries as a result of interpersonal violence, motor vehicle accidents, and war Chronic destructive periodontal disease is known to occur in a small proportion of most populations, regardless of location or socioeconomic status [11] Harmful practices, such as the removal of tooth germs of deciduous canines, extraction of upper and lower anterior 62 Med Princ Pract 2003;12(suppl 1):61–64 teeth, and the trimming or sharpening of upper anterior teeth, still prevail in Africa [5] Fluorosis, which is more likely to occur in malnourished children, is very common in certain parts of Africa such as the Rift Valley area of East Africa [12] Edentulism, congenital malformations and benign tumors occur, but little prevalence data is available According to national surveys and smaller studies the prevalence of dental caries is quite low in Africa, but there are substantial regional variations Data on dental caries prevalence (DMFT) in children aged 12 years, available in AFRO from 39 sub-Saharan countries, show that 13 countries (33%) have a very low DMFT (0.0–1.1), 19 countries (44%) have a low DMFT (1.2–2.6), and (23%) have a moderate DMFT (2.7–4.4) About 90% of these cases represent untreated caries and the inadequacy of current oral health systems to address the problem The situation is completely different, for example, in some Latin American countries where the DMFT among 12year-olds ranges from high to very high (5–8) [8, 12–14] Determinants of Oral Health Problems in Africa Poverty is arguably the most important determinant of health and ill-health The presence of widespread poverty and underdevelopment in Africa exposes communities to all of the major environmental determinants of oral disease In a continent where the majority of the population is desperately poor, preventable oral diseases such as NOMA and oral cancer are rife In addition, increasing urbanization has been shown to lead to observable increases in the prevalence of oral disease, and high levels of bottle feeding in cities have been associated with high rates of baby bottle tooth decay Greater access to alcohol is associated with higher levels of interpersonal trauma and oral cancer The African region also faces an acute lack of recent, reliable and comparable data, as well as processes for converting data into information for planning Previous Approaches and the Response of the World Health Organization Previous approaches to improving oral health in Africa have been modelled on those of affluent countries and have therefore failed to recognize the epidemiological priorities of the region and identify reliable and appropriate strategies to address them Efforts have consisted of Thorpe providing unplanned, ad hoc and spasmodic curative oral health services, which in most cases are poorly distributed and reach only affluent or urban communities [5, 8, 15] The main problems can be traced to the following: E lack of national oral health policies and plans, E inappropriately trained dentists, E services that benefit only affluent and urban communities, E services that are almost entirely curative, E lack of equipment and materials, supplies, and maintenance [16] A successful approach to oral health in the region needs to take these circumstances into account in order to effectively address the real determinants of oral disease Prevention-oriented services need to be properly planned, administered, and evaluated, especially those that relate to participatory health education and oral health promotion The community should be involved in identifying oral health problems, needs and interventions, and the proper balance between personnel types and population needs should be maintained At its 48th session in September 1998, the World Health Organization/Regional Office for Africa (WHO/ AFRO) adopted an oral health strategy for Africa for the period 1999–2008 that would assist countries in identifying priorities and planning viable programmes The long-term vision is that all people of the region should enjoy improved levels of oral health through the realization of the following objectives: E a significant reduction of all oral diseases in the region, E equitable access to cost-effective quality oral healthcare, E the adoption of healthy lifestyles [16] To guide and sustain the effective implementation of this strategy, the following principles were adopted: E The promotion of oral health and the prevention of oral diseases should be given high priority E Oral health interventions should be focused on the district and its communities E Interventions which have proven efficacy should be used E Oral health should be integrated into all public healthcare programmes E Communities should participate in oral health activities To focus the limited resources more effectively on these various priorities, the following five strategic orientations have been identified: Advocacy and social mobilization: using social marketing and participatory methods to mobilise support for oral health Capacity building: developing human resources through appropriate training and retraining programmes Information, education and communication: providing appropriate information to individuals, families and communities for healthy oral health lifestyles Equitable access to quality oral health services: achieving greater equity in oral health services, particularly for rural, peri-urban and underserved communities Promotion of operational research: developing a research culture in order to encourage essential research on oral health problems and needs [16] Development of Oral Health in Africa Med Princ Pract 2003;12(suppl 1):61–64 Partnership and Coordination The district health management team has the primary responsibility for implementing these programmes, strategies and interventions In order to facilitate the implementation of oral health activities and mobilise resources, partners are being identified and a wide network of interested parties is being established Partnerships between community interest groups and health and development workers are instrumental for the successful operation of district oral health plans At the national level, partners include professionals in commerce, industry, dentistry, medicine and allied fields, as well as professional associations, NGOs, aid agencies, WHO and other UN agencies At the regional level, countries exchange information about their experiences in implementing oral health programmes, in the spirit of Technical Cooperation among Developing Countries (TCDC) In addition, WHO collaborating centres for oral health in the region provide expertise and resources, particularly in the areas of capacity building and research promotion [16] Coordination among partners is crucial for the implementation of oral health programmes and extends well beyond the mere sharing of information Where a provincial organizational level exists in a country, it has the responsibility to support district health activities and coordinate programmes that cross district boundaries, providing the link between district and national levels of activity The provincial level helps districts with the coordination of tender processes, data collection and analysis, planning processes and resource allocation The national level is responsible for overall coordination, as opposed to programme or service delivery, and must be properly 63 equipped for this role At the regional level, coordination is carried out by the Division of Noncommunicable Diseases, in collaboration with existing WHO structures and governing bodies [16] Conclusion A new way of interpreting and responding to oral health problems in Africa is long overdue It should begin with a systematic interpretation of oral health information through the application of basic epidemiological principles at the most local level possible Taking the unique context of each community into consideration, strategies must be built that address the social, economic and environmental circumstances that put communities at risk of ill-health, in order to limit or eradicate known determinants of oral ill-health and disease To this end, WHO/AFRO has designed preventive programmes and new intervention strategies that aim to provide equitable and universal access to quality oral health services through the district health system It is quite clear that the successful delivery of interventions that are affordable and effective in improving community oral health depends on the degree to which they can be integrated with general health services, and the extent to which the political, economic and professional powers that govern decision-making in health and development sectors are involved References World Bank: World Development Report 1994 World Bank Contreras A, Falkler AW Jr Enwonwu CO, Idigbe EO, Savage KO, Afolabi MB, Onwujekwe D, Rams TE, Slots J: Human Herpesviridae in acute necrotizing ulcerative gingivitis in children in Nigeria Oral Micrbiol Immunol 1997;12:259–265 Enwonwu CO: Review of oral diseases in Africa and the influence of socioeconomic factors Int Dent J 1981;31:29–38 Enwonwu CO: Infectious oral necrosis (cancrum oris) in Nigerian children: A review Community Dent Oral Epidemiol 1985;13: 190–194 Enwonwu CO: Societal expectations of oral health: Response of the dental care system in Africa J Publ Hlth Dent 1988;80:84–93 Enwonwu CO: Noma: A neglected scourge of children in sub-Saharan Africa Bull Wld Hlth Org 1995;73:541–545 64 Hille JJ, Shear M, Sitas F: Age standardized incidence rates of oral cancer in South Africa, 1988–1991 J Dent Assoc S Afr 1996;51:771– 776 Hobdell MH, Thorpe SJ: Oral health in Africa: where are we now and why is there inequity? Proceedings of the joint CDA/WHO workshop; in Myburgh NG (ed): Promoting Equity in Oral Health Cape Town, Faculty of Dentistry and WHO Collaborating Centre, University of the Western Cape, 1996 Arendorf T, Sauer G, Bredenkamp B, Cloete C: Guidelines for the Diagnosis and Management of Oral Manifestations of HIV Infection and AIDS Cape Town, Faculty of Dentistry and WHO Collaborating Centre, University of the Western Cape, 1997 10 Tukutuku K, Muyembe-Tamfum L, Kayembe K, Kandi K, Ntumba M: Oral manifestations of AIDS in a heterosexual population in a Zaire hospital J Oral Pathol Med 1990;19:232–234 Med Princ Pract 2003;12(suppl 1):61–64 11 Cuttress TW: Periodontal health and periodontal disease in young people: Global epidemiology Int Dent J 1986;36:146–152 12 Manji F, Mosha H, Frencken J: Tooth and surface patterns of dental caries in 12-year-old children in East Africa Community Dent Oral Epidemiol 1986;14:99–103 13 Manji F, Baelum V, Fejerskov O: Dental fluorosis in an area of Kenya with ppm fluoride in drinking water J Dent Res 1986;65:659–662 14 Fejerskov O, Manji F, Baelum V: The nature and mechanisms of dental flurosis in man J Dent Res 1990;69:692–700 15 Thorpe SJ: A Regional Overview of Oral Health Services in Africa Proceedings of the Medic Africa 1995 workshop on oral health policy; in Myburgh NG (ed): Future Directions for Oral Health in South Africa Cape Town, Faculty of Dentistry and WHO Collaborating Centre, University of the Western Cape, 1995 16 World Health Organization, Regional Office for Africa: Oral Health in the African Region: A Region Strategy (1999–2008), 1998 Thorpe Author Index Behbehani, J.M 1, 51 Elderton, R.J 12 Honkala, E Omar, R 33 Pakshir, H.R 56 Reibel, J 22 Spencer, A.J Thesleff, I 43 Thorpe, S.J 61 Tummers, M 43 Subject Index Africa 61 Bioengineering 43 Community-based learning 51 Comprehensive dental care 51 Dental caries 12 – curriculum 51 – education 51, 56 – practice 12 – treatment 12 Dentin 43 Dentistry system 56 Determinants, oral disease 61 Enamel 43 Evidence-based approach, dental education 51 – oral disease prevention – dentistry 12 – practice 33 ABC Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com © 2003 S Karger AG, Basel Accessible online at: www.karger.com/mpp Iran 56 Limiting treatment goals 33 Oral disease(s) 3, 61 – health 22 Periodontal diseases 12 – ligament 43 Poverty 61 Progenitor cells, bone/tooth development 43 Prosthetic dentistry 33 Repeat dental restorations 12 – restoration cycle 12 Shortened dental arch 33 Smoking 22 Stem cells 43 Strategy, oral health 61 Tobacco 22 ... stage of the evidence loop is the monitoring of patients or population groups and the reassessment of the value and necessity of continuing the intervention While the importance of this final... empirical evidence of the determinants of variation in oral disease among patients or population groups in order to identify more points of intervention in the prevention of oral disease The conceptual... from traditional methods of intervention, which focus on clinical outcomes The stages of the approach, including the synthesis and assessment of evidence, the application of that evidence to