Faculty Bibliography

High prevalence of poverty diseases such as diarrhoea, respiratory tract infection, parasitic infections and dental caries among children in the developing world calls for a return to primary health care principles with a focus on prevention. The 'Fit for School' program in the Philippines is based on international recommendations and offers a feasible, low-cost and realistic strategy using the principles of health promotion outlined in the Ottawa Charter. The cornerstone of the programme is the use of school structures for the implementation of preventive health strategies. 'Fit for School' consists of simple, evidence-based interventions like hand washing with soap, tooth brushing with fluoride toothpaste and other high impact interventions such as bi-annual de-worming as a routine school activity for all children visiting public elementary schools. The programme has been successfully rolled-out in the Philippines covering 630,000 children in 22 provinces and it is planned to reach 6 million children in the next three years. The programme is a partnership project between the Philippine Department of Education and the Local Government Units with support for capacity development activities from the German Development Cooperation and GlaxoSmithKline.

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

Appropriate compensation of tobacco use prevention and cessation (TUPAC) would give oral health professionals better incentives to provide TUPAC, which is considered part of their professional and ethical responsibility and improves quality of care. Barriers for compensation are that tobacco addiction is not recognised as a chronic disease but rather as a behavioural disorder or merely as a risk factor for other diseases. TUPAC-related compensation should be available to oral health professionals, be in appropriate relation to other dental therapeutic interventions and should not be funded from existing oral health care budgets alone. We recommend modifying existing treatment and billing codes or creating new codes for TUPAC. Furthermore, we suggest a four-staged model for TUPAC compensation. Stages 1 and 2 are basic care, stage 3 is intermediate care and stage 4 is advanced care. Proceeding from stage 1 to other stages may happen immediately or over many years. Stage 1: Identification and documentation of tobacco use is part of each patient's medical history and included into oral examination with no extra compensation. Stage 2: Brief intervention consists of a motivational interview and providing information about existing support. This stage should be coded/reimbursed as a short preventive intervention similar to other advice for oral care. Stage 3: Intermediate care consists of a motivational interview, assessment of tobacco dependency, informing about possible support and pharmacotherapy, if appropriate. This stage should be coded as preventive intervention similar to an oral hygiene instruction. Stage 4: Advanced care. Treatment codes should be created for advanced interventions by oral health professionals with adequate qualification. Interventions should follow established guidelines and use the most cost-effective approaches.

ISSUES: To contribute towards reversing the tobacco pandemic, professional organisational alliances must reduce the wide international variability in the smoking rates among health-care professionals and students, and also address the gaps in tobacco cessation training and services. APPROACH: Ongoing international surveys for monitoring smoking rates could provide the impetus for these alliances to develop programs that reduce smoking rates among professional and lay populations. KEY FINDINGS: Health professional organisations must advocate for systematically implementing comprehensive tobacco cessation training programs. IMPLICATIONS: These programs can include both evidence-based interventions and experience-based learning innovations. These innovations can help individuals address the limitations of evidence-based guidelines. This shift from teaching individuals about changing-specific risk behaviours to engaging individuals to learn how to change any risk behaviour expands the reach and impact of behaviour change programs. CONCLUSIONS: Practitioners and staff need first-hand experience of these learning innovations before guiding patients through the same process. Using both evidence-based guidelines and experience-based learning methods, organisational leaders can develop professional alliances to create social movements that promote healthy habits in general. For example, they can develop voluntary learning programs in primary care and community settings that are led by patients and that are for patients. Such bottom-up approaches have greater potential yield in addressing gaps in health promotion and disease prevention, and particularly for tobacco cessation services. This strategy is a more feasible option for resource-limited, developing countries that cannot afford costly tobacco cessation programs.

OBJECTIVE: Dental caries remains the most common disease worldwide and the use of fluoride toothpaste is a most effective preventive public health measure to prevent it. Changes in diets following globalization contribute to the development of dental caries in emerging economies. The aim of this paper is to compare the cost and relative affordability of fluoride toothpaste in high-, middle- and low-income countries. The hypothesis is that fluoride toothpaste is not equally affordable in high-, middle- and low-income countries. METHODS: Data on consumer prices of fluoride toothpastes were obtained from a self-completion questionnaire from 48 countries. The cost of fluoride toothpaste in high-, middle- and low-income countries was compared and related to annual household expenditure as well as to days of work needed to purchase the average annual usage of toothpaste per head. RESULTS: The general trend seems to be that the proportion of household expenditure required to purchase the annual dosage of toothpaste increases as the country's per capita household expenditure decreases. While in the UK for the poorest 30% of the population only 0.037 days of household expenditure is needed to purchase the annual average dosage (182.5 g) of the lowest cost toothpaste, 10.75 days are needed in Kenya. The proportion of annual household expenditure ranged from 0.02% in the UK to 4% in Zambia to buy the annual average amount of lowest cost toothpaste per head. CONCLUSION: Significant inequalities in the affordability of this essential preventive care product indicate the necessity for action to make it more affordable. Various measures to improve affordability based on experiences from essential pharmaceuticals are proposed.

Dental NGOs and volunteers working in disadvantaged communities around the world do so with the best of intentions and with high motivation. Regrettably, the impact of this engagement on oral health at the population level remains rather low. This is mainly due to the choice of inappropriate approaches, the failure to integrate their projects within existing health care systems and the lack of sustainability. This paper proposes the concept of the Basic Package of Oral Care (BPOC) as a guiding framework for dental NGO and volunteer activities. The main components of the BPOC (Oral Urgent Treatment, Affordable Fluoride Toothpaste, Atraumatic Restorative Treatment) offer many opportunities for effective, affordable and sustainable activities that aim to improve oral health on the community and population level. Only through a reorientation of dental volunteer services and NGOs towards new roles and activities can a sustained impact on global oral health be possible. Recommendations are given that could help dental NGOs and volunteers in this process of change.

Tobacco use is a significant public health problem across Europe. Each year over half a million Europeans die prematurely due to a smoking-related disease. Tobacco use is a primary cause of many oral diseases and adverse oral conditions. The prevalence of tobacco use varies considerably across Europe, although in many countries overall rates of use have declined in recent years. However, tobacco use among women and young people is rising in several European countries. Tobacco behaviour is influenced by an array of factors, and quitting is a major challenge for many tobacco users. Tobacco use is now considered a chronic progressive relapsing condition requiring very specific support and assistance. To reduce tobacco use across Europe, a range of complementary actions and policies are required at an international, national and local level. The WHO Framework Convention on Tobacco Control (FCTC) outlines an array of evidence-based policies that can be implemented to prevent tobacco use and promote cessation. National dental associations and professional groups across Europe have an important role to play in supporting the ratification and implementation of the FCTC. The aim of this paper is to outline the public health aspects of tobacco control and highlight how the oral health professions across Europe can become actively engaged in this important and relevant area of prevention.

AIM: To collect basic data about non-governmental dental aid organisations on a global scale and thus contribute to a better understanding of their diversity, activities and limitations. METHODS: Data was collected through a mailed questionnaire to all organisations listed by the FDI World Dental Federation. A second questionnaire was e-mailed to those organisations identified as non-governmental organisations (NGO) by the first questionnaire. FINDINGS: The response rate to the first questionnaire to detect NGOs was 36.2%, to the second e-mailed form 84.4%. About two thirds of NGOs originated in developed countries, one third responded from developing countries. The majority had been established after 1980. Developed countries dental NGOs tended to have larger membership and disposed of greater budgets. In general, income was generated predominantly from donations and own resources. The workforce was primarily based on volunteers. High priority activities: service provision, education and training, technical assistance, community development. Measures for quality assurance showed low complexity. Frequent areas of problems were associated with funding and staff. Collaborative links with other stakeholders in development were weak and focussed on information exchange. CONCLUSIONS: Recommendations for NGOs, donors, FDI and future research are developed.