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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 41-46

Providing dental services where there are no roads: Lessons from the field


1 Department of Public Health Dentistry, Century International Institute of Dental Sciences, Kasaragod, Kerala, India
2 Center for North East Studies, Jamia Milia Islamia, New Delhi; Center for North East Studies and Policy Research, Guwahati, Assam, India
3 Department of Oral Biology, Faculty of Dentistry, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Center for North East Studies and Policy Research, Guwahati, Assam, India

Date of Submission29-May-2019
Date of Decision30-Nov-2019
Date of Acceptance28-Jan-2020
Date of Web Publication2-Mar-2020

Correspondence Address:
Dr. Kuldeep Singh Shekhawat
Department of Public Health Dentistry, Century International Institute of Dental Sciences, Kasaragod - 671 541, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_65_19

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  Abstract 


Background: The riverine islanders of Brahmaputra (Assam, India) are among the most economically backward population group of Assam. Recurring floods results in eclectic damage affecting their everyday lives. Medical Relief is limited due to vast water body, which pose a challenge in providing and accessing health services with limited or no provision for oral health services. Objectives: Planning and implementing a program for delivery of dental services on an already existing model of 'Boat Clinics' in Assam, India. Setting and Design: Isolated riverine islands of Brahmaputra River in North eastern State of Assam, India. Materials and Methods: A service model was designed to implement and provide dental services on an already existing model of 'Boat Clinics' in Assam. Dentals services were provided via two dental units installed (in March 2016) in two different boats on a trial basis. Situation analysis of the setting was done prior to implementation. Challenges encountered were overcome using alternative strategy. Results: Situation analysis revealed dental caries affecting about 59.8 percent of the islanders (DMFT=3). The number of beneficiaries almost doubled from 2016. More than 750 islanders have been treated in 2017 from one 'boat dental clinic'. Women seem to utilize oral health services more than men and extraction was preferred over restoration. The main challenge had been the unavailability of full time dentists, auxillary dental personnel and management of complex dental cases. Discussion: Boat Dental Clinic Program is in accordance with objectives of National Oral Health Program. Corporate social Responsibility is excellent option that provide resources instrumental in initiating projects and more importantly sustaining them. Public Private Not for Profit Partnership (PPNP) is another way to bridge the disparity in the present setting having a downstream effect at the grass root level.

Keywords: Boat dental clinics, dental care, islands, oral health, riverine, social responsibility


How to cite this article:
Shekhawat KS, Hazarika S, Chauhan A, Rao A. Providing dental services where there are no roads: Lessons from the field. J Indian Assoc Public Health Dent 2020;18:41-6

How to cite this URL:
Shekhawat KS, Hazarika S, Chauhan A, Rao A. Providing dental services where there are no roads: Lessons from the field. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Oct 25];18:41-6. Available from: https://www.jiaphd.org/text.asp?2020/18/1/41/279824




  Introduction Top


Oral health is essential to general health and quality of life.[1] However, the global burden of disease, injury, and risk factors study estimated that about 3.9 billion people worldwide are affected by oral diseases. Oral diseases also significantly affect the quality of life. The most common morbidity associated was untreated dental caries in permanent teeth affecting 35% of the population. In addition, severe periodontitis, untreated dental caries in deciduous dentition, and tooth loss were listed as 6th, 10th, and 36th prevalent oral conditions, respectively.[2]


  Context Top


India currently has 312 dental colleges with an output of more than 30,000 dental graduates and postgraduates every year.[3] In spite of a vast dental workforce, the dentist-to-population ratio in India is at 1:10,000 as against 1:7500 recommended by the World Health Organization for developing countries.[4] This ratio has subsequently improved over the past several decades in India, however, with 68.84% of the population still residing in rural areas,[5] this improvement has not been equally distributed across the nation. The oral health of the urban population is better than their rural counterparts. A national oral health survey (2002–2003) revealed dental caries (which increased with age) (children aged 5 years was 50%; 52.5% in 12 year olds; 61.4% in 15 year olds; 79.2% in 35–44 year old; and 84.7% in 65–74 year old) and periodontal diseases as the two most common dental diseases (highest among 35–44 years of age group).[6] Fédération Dentaire Internationale World Dental Federation also estimated that seven of ten Indian children have untreated dental caries.[7] The lack of national centralized databank for oral diseases limits in estimating the current/periodic prevalence and trends of oral diseases in India.


  Background Top


Setting

The Brahmaputra (river in the state of Assam, India) is a classic example of a braided river, which has resulted in the formation of about 2500 small riverine islands. These islands are inhabited by approximately 2.5 million people (roughly about 8% of the total state population of Assam [India]). Unfortunately, these islands are among the most economically backward areas of Assam with no access to communication and people are badly hit by recurring floods. Most islands totally lack basic infrastructure and services, from health to schools from power and roads to drinking water and sanitation.[8] Due to recurrent floods, people are forced to shift from one island to another due to massive erosion. The houses are built about 4–5 feet above the ground on thick logs which help them to sustain during floods. Transportation is via boat at specific timings only. Health care in the form of medical relief is often provided by Primary Health Center (PHC) and/or Community Health Center (CHC) situated on few islands such as Majuli (World's largest riverine island and has to be ferried via boats), which has an area of 421.65 sq. km.[8] Oral health services are very poor with no private practitioners among the islands.


  Planning and Implementing the Dental Program Top


Determination of dental needs

This was done as a part of the situational analysis for the precise and optimal usage of resources available.

  • There was no provision for dental services on boat clinics
  • Nonavailability (except on the main island) of oral health-care providers for more than 2.5 million riverine islanders. Dental officers are deputed at 30-bedded CHC, Kamalabari (Majuli) and at civil hospital, Garmur (Majuli). There was only one Regional Dental College in Assam (at Guwahati) addressing the unmet dental needs for the population (located about 340 km from Majuli). Even to reach Majuli, one has to ferry across the Brahmaputra for a variable duration of time to reach PHC and/or CHC or the mainland, which at times is fatal (due to other systemic conditions). These ferry boats are available only at a specified time during the day
  • A search on the Internet for any biomedical literature relating to the burden of oral diseases in the setting (for islanders) did not provide us with any relevant and satisfactory results
  • A pilot study was conducted on 102 patients living in islands since there were no data on oral health diseases among the islanders. The results revealed that the overall prevalence of dental caries was 59.8% and overall prevalence of dental caries was 59.8 percent and (decayed-missing-filled tooth for deciduous dentition) dmft and DMFT (for permanenet dentition) scores was 2.3 ± 2.9 and 3.0 ± 2.9 respectively.[9]



  Resource Identification and Development Top


To bridge these gaps in accessibility among the riverine islanders of Assam, a nonprofit trust in Guwahati, Assam, India, initiated an innovative rural health program for the vulnerable and marginalized communities and introduced “Boat Clinics” which was named AKHA, (Assamese meaning – hope) [Figure 1]. The details of the boat are provided in [Box 1].[10] At present, there are about 15 boat clinics operating across 13 districts along the course of Brahmaputra in Assam. These boat clinics commute from island to island providing basic medical care facilities, maternal and child health care, and immunization. These are dedicated to improving the general health care of marginalized population residing in remote areas without any access to health-care services.
Figure 1: Boat Clinics of Brahmaputra

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A written request was made to the nonprofit trust (Guwahati) in 2015 to plan and implement oral health services on boat clinics. Following their approval, stakeholders from the private sector were contacted to be a part of this program. The project involved initiating and implementing oral health-care services on Public–private Not-for-profit Partnerships (PPNPs) on an already existing model of boat clinics that can both be utilized and availed by marginalized and vulnerable communities of riverine islands.


  Establishing the Goals and Objectives of the Dental Program Top


Given that accessibility was a major challenge with no provisions for oral health services, we strongly felt the need for the same, which can be easily accessed by islanders. The objective was to plan, initiate, and implement provisions for oral health services on an already existing model of boat clinic. The secondary objective was to integrate oral health services with the general health-care system for increased utilization by patients. In addition, this would reduce the burden of oral diseases among the islanders.


  Program Implementation Top


Initiating and implementing the program following situation analysis [Table 1] was conducted in the following phases: (i) design of a model, (ii) funding and implementation of the model, and (iii) impact of the program [Box 2].
Table 1: Prevalence and extent of dental caries among a section of islanders

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  Program Outcome Top


After the Dental unit was implemented on Boat clinics in March 2016 (henceforth Boat Dental Clinic Program [BDCP]), dental services such as extraction (of a decayed tooth) were delivered on board the dental unit of boat clinic. The statistics provided are for dental treatment rendered on only one of the two boat dental clinics (Jorhat Boat Clinic). Overall, the number of beneficiaries receiving dental care almost doubled from 268 in 2016 to 508 in 2017. There was a three-fold increase in the number of child patients receiving dental care in 2017 as against 2016 [Graph 1], [Graph 2], [Graph 3], [Graph 4]. Women utilized these services more than men, with dental extractions more often opted than restorations. Preventive procedures such as the application of sealants and fluorides were not performed since patients focused more on their felt need than normative need. Proper brushing techniques were demonstrated to all the patients. In addition, they were made aware of the adverse effects of consuming tobacco that was found to be on the higher side.




  Discussion Top


This report is an attempt to describe the establishment and impact of BDCP for the riverine islanders of Brahmaputra. To the best our knowledge, this is the first of its kind and unique dental program initiated in India and perhaps the world. The imperative for this service arose from concerns of unavailability and limited accessibility (if available) of oral health service in the present setting. The present model has its emphasis on providing oral health services at their doorstep, thereby reducing the disparity of accessibility. These boat clinics have established themselves as the “ships of hope in the valley of floods,” thus providing a medium/platform for providing dental services. Therefore, the project area (geographical area already having access to boat clinics) was provided by the not-for profit trust, the armamentarium (with portable dental chair and compressor) with other dental materials was funded by private stakeholder, and the dental workforce (qualified dentist) was provided by the public sector (National Rural Health Mission) as a part of Public–private Partnership (PPP) framework with nonprofit trust managing the boat clinics. The BDCP model is at par with the objectives of the National Oral Health Program which was implemented as a part of the 12th 5-year plan in 2014–2015.[11] The present model focused on reducing disparity in accessibility in rural areas and promoted PPPs/PPNPs, integrating oral health services with the general health-care system.


  Success Factors Top


The success of BDCP is demonstrated by the increase in the number of beneficiaries from 268 in 2016 to 508 in 2017. The project has entered in its 3rd year and this success can be attributed to a number of likely characteristics. Arguably, the key factor responsible for the success so far is the fact that it is incorporated on an existing concept of “boat clinics,” which has made a huge impact on the everyday lives of islanders and is also culturally accepted. The nonprofit trust is symbolic of the voluntary sector, though its overall presence is limited to islanders of Brahmaputra, it is playing a significant role in providing innovative and quality health services to the needy in remote areas. There is a need to create an enabling climate for them to grow further, especially in those pockets of the country where the overall health and development situation remains grim.

The enthusiasm and commitment of the staff (auxiliary nurse-midwife, general nurse-midwife, and community health worker) was crucial in the implementation of the program. Having a health worker from the same community enabled them to approach the dental unit and avail oral health services. They are also to be credited for creating awareness and promoting good oral hygiene practices among the islanders.


  Challenges and Lessons Learned Top


The BDCP was initiated and implemented to reduce the burden of oral disease and improve the quality of life of those staying away from the mainland or away from PHCs by bringing oral health services to their doorstep. Within a year, the BDCP has had to face several constraints and alternative arrangements had to be made with limited resources, which are enumerated in [Table 2]. The biggest challenge we faced was the lack of dental workforce to assist the dentist and perhaps in future the sustainability of the program [Box 3]. This implied that the dentist has to examine the patient followed by arranging the required instruments, for example, mixing the dental cement and then placing it in a prepared cavity, which consumes extra time. This is merely the tip of iceberg since BDCP is still in its infancy and it might take some time before the project (BDCP) is accepted and settles down among the islanders. The project was stalled due to the unavailability of the dentist and again restarted in March 2017 with a deputation of another dentist under the Rashtriya Bal Swasthya Karyakram (RBSK) scheme of National Rural Health Mission, Government of Assam. The dentist was deputed for 3 days a week and this curriculum is still maintained. The program has entered in its 3rd year, and by October 2017, more than 700 patients were treated for various dental diseases (one of the two boats).
Table 2: Constraints faced and alternative strategies implemented with limited resources

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Limitations

It is crucial to identify the limitations of this project. First, the BDCP is implemented only on two boat clinics; this means, there remains a huge population that is still devoid of oral health services. Second, few factors such as heavy monsoons and overhauling of boats were beyond our control. Third, those cases requiring complex treatment (fabrication of dentures, removable, and fixed partial dentures) and multiple sittings (root canal treatment) are not possible. We need to formulate a plan that can take care of the services mentioned above.


  Conclusion Top


BDCP is the first of its kind initiative and currently provides dental services for riverine islanders of Brahmaputra. This model provides an ideal platform to infiltrate the marginalized and vulnerable sections of islands (about 2500 islands) where basic medical, especially “dental facilities,” is a distant dream.

Future concerns

Sustainability of the program is an important aspect to be considered. From the available data, the utilization of oral health services is clearly visible. Nevertheless, unless, otherwise, the program is supported in every aspect, the longevity of this initiative is questionable. There is a need to create awareness among stakeholders regarding the importance of oral health. The program has to be assessed for formative and process evaluation at regular intervals to rectify and improve any shortcomings. Informal and formal interviews need to be conducted to identify key challenges in utilizing oral health services, strengthening community participation in oral health services.

Recommendations

  1. The implementation of Compulsory Rotating Resident Internship for at least 2 months on board these boat dental clinics with remunerations, by Regional Dental College, Guwahati
  2. Incorporation of a permanent dental surgeon and/or pedodontist (pediatric dentist) in mobile health teams exclusively under the ambit of RBSK
  3. The implementation of a separate boat clinic, especially for a dental specialty where complex cases can be treated with multiple sittings
  4. We request the state government of Assam, India, and Central Government of India to promote and reinforce the existing program so that this unique BDCP reaches the unreached among the underprivileged sections of riverine island of Brahmaputra
  5. Compulsory incorporation of dental services for the rural and urban poor by any corporate and/or industrial group in India, under its Corporate Social Responsibility ([CSR activity] if any).


CSR is a management concept whereby companies integrate social and environmental concerns in their business model. Corporate houses are among the effective constituents of society which can be further explored since giving back to the society is their core framework. Social, health, and environmental issues falling in their core principles are taken seriously. Resources in the form of finances can be utilized from these private sectors, and with provisions, subsidies provided by the state/central governments and nongovernmental organizations; effective projects focusing on PPP can be initiated.

Types of dental services provided

Preventive

a. Patient oral health education

  • Proper brushing techniques were demonstrated to all the patients. In addition, patients were made aware of the adverse effects of consuming tobacco.


b. Distribution of toothbrushes and toothpaste (chairside and at educational sessions)

  • Toothbrushes and toothpaste were distributed as and when there was any opportunity to do so. Since the project is still in its infancy, and due to limited funds, the focus is more on strengthening the efforts toward sustenance.


Dental health education

c. Educational sessions were given importance for the entire team of health-care providers on the boat clinic. They were sensitized about the importance of oral health and simple measures to maintain the same. However, there is a need to reinforce the same for more effective results.

Treatment

Grossly decayed tooth was extracted. Amalgam and glass ionomer cement was used for restoration. Teeth with pulpal involvement (and requiring root canal treatment) and other complex treatments were referred to CHC.

Financial support and sponsorship

The entire project was funded by the Mahindra Financial Services Limited, Mumbai, as a part of their Corporate Social Responsibility. However, there is no funding for the publication of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Oral Health. Information Sheet. World Health Organization Website; 2012. Available from: http://www.who.int/oral_health/publications/factsheet/en/. [Last accessed on 2018 May 03].  Back to cited text no. 1
    
2.
Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, Lopez A, et al. Global burden of oral conditions in 1990-2010: A systematic analysis. J Dent Res 2013;92:592-7.  Back to cited text no. 2
    
3.
College List. Dental Council of India Website. Available from: http://www.dciindia.org.in/CollegeSearch.aspx?ColName=dental%20college&CourseId=&SplId=0&StateId=AND&Hospital=&Type=0& Status=--Select. [Last accessed on 2018 May 04].  Back to cited text no. 3
    
4.
Global Health Observatory. World Health Organization Website. Available from: http://www.who.int/gho/publications/world_health_statistics/EN_WHS2014_Part 3.pdf. [Last accessed on 2018 May 04].  Back to cited text no. 4
    
5.
Census of India. Ministry of Home Affairs; 2011. Available from: http://censusindia.gov.in/2011-provresults/paper2/data_files/india/Rural_Urban_2011.pdf. [Last accessed on 2018 May 04].  Back to cited text no. 5
    
6.
Bali RK, Mathur VB, Talwar PP, Chanana HP. National Oral Health Survey and Fluoride Mapping, 2002-2003, India. Delhi: Dental Council of India; 2004. Available from: http://www.dciindia.org.in/Download/Books/NOHSBOOK.pdf. [Last accessed on 2018 May 05].  Back to cited text no. 6
    
7.
FDI World Dental Federation. The challenge of oral disease – A call for global action. In: The Oral Health Atlas. 2nd ed. Geneva: FDI World Dental Federation; 2015.  Back to cited text no. 7
    
8.
Goswami BK, Hazarika S. The river. In: Hope Floats: The Boat Clinics of Brahmaputra. New Delhi: Academic Publications; 2016. p. 20-3.  Back to cited text no. 8
    
9.
Shekhawat KS, Chauhan A, Ahmed F, Das D, Hazarika D, Sarma B, et al. Prevalence of dental caries dental pain and oral hygiene practices among riverine islanders of Brahmaputra in North Eastern state of Assam India. Online J Health Allied Sci 2019;18:3.  Back to cited text no. 9
    
10.
Goswami BK, Hazarika S. The ships of hope. In: Hope Floats: The Boat Clinics of Brahmaputra. New Delhi: Academic Publications; 2016. p. 30-2.  Back to cited text no. 10
    
11.
National Oral Health Program. Director General of Health Services, Ministry of Health and Family Welfare, Government of India. Available from: http://dghs.gov.in/content/1352_3_NationalOralHealthProgramme.aspx. [Last accessed on 2018 May 17].  Back to cited text no. 11
    


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    Tables

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Abstract
Introduction
Context
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