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Indian Journal of Community Medicine

Vol. 29, No. 1 (2004-01 - 2004-03)


National Oral Health Care Programme (NOHCP) Implementation Strategies

Dr. Sunder Lal, Dr. Dinesh Paul, Dr. Pankaj, Dr. Vikas, Dr. B.M. Vashisht

The most important resource of the country is its 1027 million population (2001 census), distributed in 28 States, 7 Union Territories, 5564, tehsils/talukas, 640,000 villages and 5161 towns and cities.1 India is predominantly rural, as over 72% of people continue to live in rural areas.2

Rural health infrastructure has been well designed to cover rural population through 136815 subcentres (SCs), 26952 Primary Health Centres (PHCs) and 3708 Community Health Centres (CHCs). Oral health care of necessity has to be delivered through primary health care infrastructure, because of limited resources and manpower of dentists. Though the country is producing 7000 dentists per annum, the dentist: population ratio is 1:30000, the distribution of dentist to population requirement is grossly uneven. More than 90% of doctors are available in urban settings and only 10% available to 72% of rural population.3,4 There are no dental surgeons posted at the level of CHC and PHC in most of the States. Besides this, there is acute shortage of equipment and material and other essential facilities to run the minimal curative services for vast population.

Nearly 30% of population lives in urban areas and half of this lives in urban slums. Tertiary level hospitals, district hospitals, nursing homes, private practitioners and non governmental organizations provide health services. Besides these, municipal corporations also provide services, however, these services are poorly organized. Urban ICDS projects provide services on geographical basis. Health policy 2002 envisages strengthening of urban health services. RCH urban projects have been launched to increase the coverage of health services for vulnerables. Variable dental health services in urban areas are available-through public and private set up.

WHO focussed its attention on oral health in 1994 and chose the theme "Oral Health for Healthy life" for World Health Day.5 National Oral Health Policy has been formulated by the "Dental Council of India", through the inputs of two national workshops organized way back in 1991 and 1994 at Delhi and Mysore respectively.6 These workshops considered the recommendations of national workshops on oral health goals for India, Bombay 1984 and a draft oral health policy prepared by Indian Dental Association in 1986. As a follow up measure of these efforts, the core committee appointed by Ministry of Health and Family Welfare, could succeed to move the resolution in fourth conference of Central Council of Health and Family Welfare in the year 1995. Ten points resolution has been brought out by the Council:4

1. There is an urgent need for an Oral Health Policy for the nation as an integral part of the National Health Policy.

2. Special, well coordinated, National Oral Health Programme be launched to provide Oral Health Care, both in the rural as well as in urban areas due to deteriorating oral health conditions in the country as revealed by various epidemiological studies. Dentist/population ratio in the rural areas is only 1:300,000. Whereas, 80% of the children and 60% of the adults suffer from dental caries, more than 90% of adult community after the age of 30 years suffer from periodontal diseases which also has its inception in childhood. In addition, 35% of all body cancers are oral cancers. Large segment of the adult population is toothless due to the crippling nature of the dental diseases and about 35% of the children suffer from malaligned teeth and jaws affecting proper functioning. In view of these facts, it is important to launch preventive, curative and educational oral health care programme integrated into the existing system utilizing the existing health and educational infrastructure in the rural, urban and deprived areas.

3. A post of full time Dental Advisor at appropriate level in the Dte.G.H.S. should be created as a first step towards strengthening the technical wing of the Dte.G.H.S.

4. Studies have revealed that dental diseases have been increasing both in prevalence and severity over the last few decades. There is, therefore, an urgent need to prevent the rising trend of dental diseases in India. The method used for primary prevention of dental diseases aims at achieving primary prevention of periodontal diseases and oral cancers.

5. The council, therefore, resolves that preventive and promotive Oral Health Services be introduced from the village level onwards and accordingly a pilot project on Oral Health Care may be launched by the Ministry of Health and Family Welfare during 1995-96 in five districts, one each in five States.

6. The Council further resolves that legislative measures be adopted to ensure a statutory warning on the wrappers and advertisement of sweets, chocolates and other retentive sugar eatables TOO MUCH EATING SWEETS MAY LEAD TO DECAY OF TOOTH. Similar measures are also called for tobacco and Pan Masala related products.

7. The Council recommends that a National Training Centre be established or the existing centres be strengthened for training of various categories of oral health care personnel.

8. The Council also resolves that all District Hospitals and Community Health Centres have dental clinics. All Dental Colleges should have courses on Dental Hygienists and Dental Technicians.

9. The Council further resolves that the Pilot Project may be extended to all the States at the rate of one District in every State.

10. The Council also resolves that there is an urgent need to have a National Institute for Dental Research to guide oral health research appropriate to the needs of the country.

Ministry of Health and Family Welfare, Govt. of India accepted in principle National Oral Health Policy in the year 1995 to be included in National Health Policy. In pursuance to National Oral Health Policy 'National Oral Health Care Programme' has been launched as "Pilot Project" to cover five States (Delhi, Punjab, Maharashtra, Kerala and North eastern States) for its implementation.7 To begin with, one district in each of these States has been chosen to test run the strategies evolved through 2 national and 4 regional workshops organized in the country, to achieve the following goals7:

  1. Oral Health for all by the year 2010.
  2. To bring down the incidence of oral and dental diseases to less than 40% from the existing prevalence of 90%.
  3. To bring down the DMFT in school children between 6-12 years of age to less than 2 which is approximately 4 at present.
  4. To reduce high prevalence of periodontal diseases to lower prevalence.
  5. At the age of 18 years, 85% should retain all their teeth.
  6. To achieve 50% reduction in edentulousness between the age of 35-44 years.
  7. To achieve 25% reduction in edentulousness at the age of 65 years and above.
  8. To achieve 50% reduction in the present level of malocclusion and dento-facial deformities.
  9. To reduce the number of new cases of Oral Cancers and precancerous lesions from the existing levels.

The proposed Oral Health Care Programme envisages three pronged implementation strategies of; Oral Health Education, Preventive Programme and Curative Service Programme at various levels of primary, secondary and tertiaryhealth care delivery services. Oral health has been recognized as an integral part of general health.

What people do with their lives and those of their children affects their health, including oral health, far more than anything that governments do. But what they can do is determined by their income and knowledge.8 Over the years evidence based "Information" on oral health has accumulated in the country but this is largely confined to dental clinics, hospitals and a few schools. The challenge is to put the available information into practice at every home/family and community. It is the information which can promote/improve the oral health of millions of young children, school children, adolescents and adults as also pregnant women and elderly people, provided it gets communicated. Therefore, the biggest challenge before us is to accept the challenge of communication of "facts for oral health" to all; in rural, urban and tribal and remote areas.9,10Hygiene is embedded in Indian culture and it is the way of life. Let us promote indigenous time tested practices, of rinsing mouth with plain water after each meal, massaging gums and teeth and cleaning mouth with finger after each meal, promoting traditional diets, brushing of teeth, avoiding smoking, chewing pans and tobacco in various forms.

Mass media (television, radio and news paper) should have regular programmes to beam messages focusing on most vulnerable target groups. Apart from mass media, interpersonal and group communication by health workers, anganwadi workers and school teachers can enhance the communication efforts. It is essential that these workers/functionaries are provided learning resource material in local languages apart from regular in-service orientation training programme on communication of oral health messages. One day in-service training programme under NOHCP for health workers and teachers has provided them the manuals and educational material in local languages.11,12 Oral health education has been given to them, by lectures with audio-visual aids and models. It is expected that they will be able to identify dental caries, periodontal, malocclusion, discoloured and fractured teeth and oral pre-cancer and cancer lesions. These workers will also be able to educate people/children on correct brushing, tongue cleaning and gum massaging techniques besides avoiding cariogenic foods. Teachers training programme for oral health promotion is welcome proposal under National Oral Health Programme (Project) and a guide book has been prepared in English and local languages.11 Much will depend upon local efforts, as to how the teachers are trained and what responsibilities they take up on regular and sustained basis? Students follow what the teachers do and say and the teachers are considered as good role models to transmit values of life and ways of life in the school as also outside the school. Regularly one hour is devoted in each school for socially useful and productive work and that hour can be used for learning correct brushing technique and rinsing the oral cavity with safe water, as also washing of hands and cutting of nails. In our experience, whenever teachers brushed their teeth, students followed and it became a routine exercise of daily brushing of teeth in guided manner. Teachers took up onerous responsibility of chlorination of water and promotion of hygienic practices apart from brushing. National education policy (1986) too has similar mandate and it encourages linkage between education and health and healthy habits. Shaping ways of life and personality development of school children during elementary education is the key responsibility of school teachers and parents as also the community. Mid day meal programme activities can be used as spring board to develop other behaviours such as washing of hands and rinsing of oral cavity after each meal apart from avoiding cariogenic foods, eating balanced diets, drinking clean water and eating clean food. School children can be used as ambassadors of health messages to their homes and neighbourhood and can act as change agents. Child to child programme in the school or out of school is yet another approach to build healthy life styles. Whatever chapters are contained in the school curriculum these need to be translated into visible actions through live demonstration. Students need to be demonstrated rinsing and mouth wash after meal, show them the content of mouth wash and let them react and participate in discussion and reach to conclusion.

The modality of training programme persued by resource persons (under NOHCP) for dental surgeons' at district, CHC and PHC and subsequently training of health workers and volunteers will be judged on ground level actions by health teams in rural and urban settings. One time training for a day is for motivation and it must be followed up by continuing education, on the job training activities by local supervisors and doctors. Monitoring,- motivation and continuing education activities should be built in the programme. It is much better to build the NOHCP, into the basic/initial training of health workers male and female. Brushing habits have not been inculcated in rural areas. Barely 6% of children between age bracket 6-11 years brush their teeth regularly. Most share the tooth brush and cannot afford paste. Habit of brushing should begin at family level and parents should encourage this habit. Anganwadi is an extrafamilial institution which is heading for universalization to cover the entire rural and urban slums. System of ICDS anganwadis has played useful role for developing healthy habits like brushing teeth and hand washing in the anganwadis through non-formal education methods (learning by play way activities) focusing on pre-school children (under six years). This system can support parents and home to sustain the healthy habits acquired in the anganwadis. Further, Anganwadis have played effective role to enhance the school enrolment and provide continuity of services to school children in concert with school teachers. Proposal of having one exclusive dentist for 50000 school children is difficult to implement as also a risky proposition, as all others would withdraw and leave the school health activities for this designated school dentist who will soon be frustrated. It is not understood as to why the NOHCP has left the largest pool of Medical Doctors and only health workers have been picked up for training and orientation. Leadership of Medical Officer has been by-passed and, therefore, the workers will seldom obey the command of outsider. This is a weak point in the NOHCP; hence needs to be rectified. On all dietary interventions for prevention of caries the NOHCP has to integrate its activities with National Nutrition Policy of India, Policies of feeding of infants and young children, Breast feeding and many supplementary nutrition programmes. All unhealthy dietary practices have to be discouraged with strong health education programmes. Food adulteration act bans all textile colouring agents and allows only permissible colours in sweets and lozenges; however, enforcement of this act is tardy. Chocolates eating and chewing gums and use of soft drinks are invitation to caries and bad teeth. These habits should be curbed by parents who hold the primary responsibility of developing healthy life styles at home and teachers in school can play effective role in shaping and development of personality. Manufacturing of sugarless chewing gums have been recommended, let us not waste our times and energies on this front and we should convey universal message that extra-sugar and excessive sugars will decay your teeth in the long run. Avoiding chocolates, toffees, pasteries, cookies, cakes, breads, sandwiches, soft drinks, fast foods and other junk foods appear to be a big challenge for teachers in urban set up. Promote consumption of cheese, nuts, corn, fruits, carrots, salad and fibrous foods which have detergent effect and advantage of stimulating salivation. Both the IDA and Colgate, have been partnering for over 25 years for awareness generation programme. Latest in the series was "The Bright Smiles, Bright Future" has been mounted under the aegis of NOHCP from July 2003, targeting 45 lakhs school children across India. It has been ritual to distribute

"Colgate paste and brush" free to teachers and school children, shown as an activity of State or local IDA branch for teachers training and promotion of oral health, it is an easy escape and bad trap. It has seldom ensured follow up activities as to what happens to these "Colgate Pastes". Weather this activity has led to change in behaviour of cleaning teeth or not is questionable? Tracking of teachers and students exposed to such campaigns is seldom ensured and communication needs on oral health are seldom assessed for effective communication. Live situations of school children and school teachers were seldom used to communicate effective message and more reliance placed on imported charts and visuals and alien films. It appears to be advertisement gimmick to promote awareness about a product rather to inculcate a habit of brushing. It increases dependency and follow up actions are never ensured. The people and teachers retort back as to whenyou will organize next such Mela? School health services have not developed and remain a neglected area. It is totally a virgin soil; anything invested would certainly bear the fruits. Over the years we have done umpteen numbers of health check-ups and dental check-ups in the schools and have collected voluminous data, without any action. These all were perfunctory. School children are just being treated as objects and not subjects to collect voluminous data. Way back in 1995-96, Prime Minister's School Health Programme ensured country wide health check of all school children, but the follow-up actions were quite tardy, it was mere compliance of administrative orders. Only lesson learnt through these exercises was that, oro-dental health has remained a neglected area and it continues to be leading morbidity in primary school children. It is a reflection that nothing much has happened as trend of oro dental problems has not been arrested or declined from 1996 to 2003 (over seven years).

Small act/action is much more important than lot of data collection. Unfortunately we are data driven than action. Children should be shown dental plaque the carious teeth of their peer groups, as also good teeth and bad teeth, good oral cavity and bad oral cavity and how to keep it healthy by daily action in home and at school. Children requiring dental treatment should be provided on the spot prophylactic and curative services in the school itself in the mobile dental clinic vans. Each district should have well equipped dental van or mobile clinic vans for school health services. In some progressive States the dental surgeons are posted at the level of Primary Health Centres and CHC, and these doctors do not have much work on machines or with limited dental material, their precious time, energies and talent is under utilized. They are seldom enthusiastic to undertake the work which they could easily undertake that is building capacities of school teachers, children and the parents on oral health promotion. They seldom consider it as their prime responsibility. Where we have gone wrong? We must look back to their basic training programmes during undergraduate (BDS) and PG (MDS) level as to how well we have prepared our young dental surgeon to shoulderthe preventive and promotive aspects of oral health programmes. The National Oral Health Programme has the onerous and primary responsibility to utilize the available manpower of dental surgeons in urban and rural settings for taking responsibility of geographical areas and schools to build the capacities of teachers and students. Monitoring reports of performance of these institutions must be made available on routine basis covering essential details and these should be used for mid course correction at various levels. Right now there is no built in monitoring system of performance on Oral Health Programme

Medical and Dental Colleges (142) are not evenly spread across various parts of the country. Apart from the uneven geographical distribution, the quality of education is highly uneven and in several institutions even sub-standard. It is common perception that syllabus is excessively theoretical, making it difficult for the fresh graduate to effectively meet even the primary health care needs of the population. Basic training imparted to dental graduates through present day curriculum (prescribed by DCI) in the area of preventive and promotive oral health seems to be inadequate. Preventive and Community dentistry departments in the country with few notable exceptions, tend to provide basic training mostly confined to hospitals and it is not based or rooted in the community and most of it is theoretical, emphasis remains on preparation of some charts, models, posters or visuals by students, which may have least relevance to the community needs and oral health problems. Material prepared by the undergraduate students is used as decorative material in the department and the information is not meant for community or children. Regular community contacts and contacts with school children on sustainable basis are missing. Institutions and students should take responsibility of a geographical area or community or schools and organize a meaningful programme to inculcate healthy oral habits by changing the harmful practices or undesirable behaviour. Students and teachers should plan and organize education programme, implement it and subsequently evaluate the success of that. It is imperative for community dentistry departments to develop a field practice area in urban slums or nearby rural area and take the responsibility of that area for sustainable oral health services with focus on promotive and preventive oral health programmes. Students do not have access to good oral health programme model, based and rooted, in the community and consequently they disbelieve in prevention and promotive activities. Resident internship training programme in community dentistry is essential to develop such models since very few places offer Postgraduate degree in community dentistry, the community based teaching of dentistry is lacking.

Community dentistry departments have been a neglected lot as they have inadequate manpower, resources and other facilities. Teaching of these departments is relegated/ delegated to some other department, which is least interestedto persue it seriously and it is more or less compliance of orders and ends up to complete the quota of assigned lectures in the class room. Sum total of learning experiences in preventive and promotive programmes of dentistry during undergraduate dental education, are quite distressing. Around 7000 dental graduates produced every year by various institutions, who have inadequately learnt the community dentistry or it has been variable learning mostly focusing on cognitive domain in class room settings.

It is envisaged under NHP 2002 to set up Medical Grants Commission for funding new Govt. Medical and Dental Colleges in different parts of the country to upgrade the infrastructure of existing Government Medical and Dental Colleges of the country, so as to ensure an improved standard of medical education. The policy under 10th Plan further identifies a significant need to modify the existing curriculum. A need based skill oriented syllabus with more significant component of practical training will be introduced and problem of dental paraprofessionals, will be addressed to. The implementation strategies of NOHCP has to take these developments into consideration and dovetail its strategies in consonance with NHP 2002. The implementation of NOHCP can only be carried out through the State Governments, decentralized public health machinery, of necessity the programme has to be made flexible and each state formulates its local strategies to achieve the broad objectives. The NOHCP should continue to play the role of advocacy. The proposed infrastructure of placement of one Dentist (BDS) per PHC to cover 30000 population is feasible target, however, placement of a specialist (MDS) at the level of CHC by 2010 appears to be distant dream as the States are struggling to establish CHC s infrastructure and as many as 50% of CHCs are non functional for want of health specialists. The central budgetary allocation for health over the period, as an aggregate to total central budget has been stagnant at 1.3%. State's financial health is anaemic as the total public health allocation has gone down to 5.5% and it has to be progressively enhanced to the level of 7% and subsequently scaled up to the level of 8% by the year 2010 to establish meaningful infrastructure by 2010. Enhanced allocation of central Govt. funding from 15% to 25% has been proposed to meet out the deficiencies in the State. The NOHCP is silent on additional costs of placement of specialists at the level of district and CHCs. States have long inertia ".nd take substantial time to implement the strategies, whatever comes from the centre that is most welcome, States of their own are unwilling to spend additional costs. This raises basic question of mobilization of extra funds through user charges and privatization of services or developing insurance schemes for curative dental services as the treatment modalities of curative services are beyond the reach of many ordinary and poor citizens whose needs of dental care services are enormous. The norms of services as recommended by NOHCP at various levels are to be definitely strived, to establish primary and secondary dental health services. Since the health is a state subject the states should take the lead to establish these norms progressively. All the 142 Dental Colleges should take responsibility of a geographical area (say one district in which they are located) to implement the NOHCP and upgrade their training, research and services in the community.

Since dental equipment and machinery as also dental materials are quite costlier, only a few can afford dental treatment, it is imperative that cost should be contained and reduced by developing alternate indigenous material. Government should encourage to establish centres of excellence in dental material research, on regional basis in the country. Alternative models of dental treatment be explored through operational research studies. Dental insurance as part of health insurance should be encouraged. The aggregate expenditure on health sector is 5.2% of the GDP, out of this 17% of the aggregate expenditure is public health spending, the balance (83%) being out of pocket expenditure (Private Sector). Hence, it is imperative to promote Public-Private Partnership for curative services to reduce cost of treatment. NGOs can spearhead the movement of oral health promotion. Private practitioners should be given geographical area responsibility in urban set up to ensure regular school health services. Government should give liberal incentives to private practitioners as charity work is something very rare.

Interventions through Legislations:

National Oral Health Programme recommends several interventions andstrategies related to policy and legislations. Primary and pivotal strategy identified by the programme is legislation against smoking and chewing tobaccos. 16% of adults smoke in India. The picture is variable in rural areas as many children, adults and old people continue to smoke and most used type of tobacco is smoking bidis, chewing tobacco through Pan Masala etc. 50% of young people who continue smoking will die from smoking and smoking is attributed to development of cancer of lips, mouth, throat and larynx as also sub mucus fibrosis of oral cavity and it is responsible for 90% of lung cancers, 75% of bronchitis and emphysema and 25% of ischemic heart diseases.13

Evidence suggests that comprehensive ban on all forms of tobacco promotion can be effective in reducing tobacco use while partial restrictions have limited or no effect. Partial restrictions are notorious for leading to other forms of marketing supplanting the restrictions. Curbing smoking is a matter of policy. Anti-tobacco campaign and policy of the Govt. is welcome in the direction of Primordial Prevention of oral cancers apart from many other systematic diseases.

Oral cancers account for one third of all body cancers: Smoking at public places has been banned and so is the advertisement on tobacco. Statutory warning appears on each pack. But it requires behavioural change. Parents at home and school teachers in schools, peer groups at schools, in colleges and work place have strong influence on behaviour of initiation, perpetuation and quitting smoking. Recently advertisement on Pan Masalas have been banned, it is again a positive step. Legislations are legislations, the implementation lies with people themselves. Many legislations will not be effective if there is no public understanding, support and demand for such change. Over 87% of respondents in India favoured curbing tobacco use; a good sign indeed.13 (on World No Tobacco Day 31st May 2002). Every year on 31st May, we observe world No Tobacco Day to disseminate message of quitting smoking. Statutory warning on the wrappers and advertisement of sweets, chocolate and other retentive sugar should be given as "Too Much of Eating Sweets May lead to Decay of Teeth". Chewing indigenous material like datum, coconuts, fruits, vegetables and fibrous foods should be encouraged for development and strong teeth and flow of saliva (salivation).

Fluorosis is endemic in 17 states in India on account of excess of fluoride in ground water. Around 70-100 % of districts are affected in Andhra Pradesh, Gujarat and Rajasthan. 40-70% districts are affected in Bihar, National Capital Territory of Delhi, Haryana, Jharkhand,Karnataka, Maharashtra, Madhya Pardesh, Orissa, Tamil Nadu and Uttar Pardesh. 1-40% of districts are affected in Assam, Jammu and Kashmir, Kerala, Chattisgarh and West Bengal while endemicity in rest of the states is unknown. Since in India 80% of population is dependent on ground water for drinking purposes, the prevalence of dental fluorosis and skeletal fluorosis tends to be a significant problem.14,15 WHO guidelines for value of fluoride has set 1.5 mg/liter in drinking water and further favour lower limits of 0.5 mg/liter (Nov. 2000 International Workshop on Fluoride). Rajiv Gandhi NationalDrinking Water Mission (RGNDWM) has set up a sub-mission on control of Fluorosis by provision of alternate sources of water and defluoridation techniques at community and domestic level. In the light of this information the NOHCP has to coordinate its activities with RGNDWM; however, the NOHCP favours promotion of fluoride toothpaste and topical application of fluoride in persons above 6 years of age and it recommends community water fluoridation which is contrary to the national-submission on control of fluorosis. The prescription of sodium fluoride tablets or mouthwashes to prevent dental caries is questionable. WHO recognizes that dental fluorosis and dental caries co-exist in a population drinking water contaminated with fluoride at concentration above 0.5 mg. (WHO 1986 appropriate use of fluorides for human health; ed. Murray JJ, WHO Geneva). Following a ruling by the US Federal Drugs Administration,American toothpaste now comes with warning which states that if more than a pea-sized amount is swallowed, a poison control centre must be contacted immediately (WHO (1994). Fluoride andoral health, WHO, technical report series 846, WHO Geneva). In essence fluoride has no beneficial effect, rather fluoride destroys the teeth. Fluoride has no role in prevention of dental caries, which is basically a bacterial dental disorder.15 Most toothpastes may have natural contaminant fluoride.

Life expectancy in India has risen to 64.6 years. Dental health of the aged will be a substantial challenge in coming years. In our settings community based survey of elderly revealed that 17% were endentulous, in 78.3% some teeth were missing and only 1.5% were using denture and around 3.2% had intact teeth. Smoking was almost universal habit.16 Challenge was to provide low cost denture and preserving teeth by adopting healthy practices during adulthood and advancing years of life.

Monitoring and Evaluation system has not been built in under NOHCP, this deficiency needs to rectified at the earliest. A minimum agreed upon performance report with fixed periodicity must be designed and regular feed back given to all the participating units to sustain their interest besides mid course correction. In the long run it can serve as evaluation tool.

The progress of implementation of NOHCP has been very slow and variable in different regions and states of the country. The implementation strategies were published in the year 2001, indeed it was quite a laudable exercise. AIIMS was used as launching pad for NOHCP in Feb. 2002 where the first training workshop for Delhi's health workers was organized and training manual on oral health for field workers was released alongwith film titled "Kripaya Muskaraiye" onus of implementation of these strategies lies with State Government. The sustainability of programme poses various challenges

Goals set for the programme have wider ramifications. These goals set by oral health policy remain on paper, without action/activities these are unlikely to be achieved. Time frame for these goals cannot be uniform because of diversities and pace of development of oral health infrastructure and services apart from health services. Exclusive "Oral Health Policy" is not a viable, it has to be integral part of "health policy" in principle. Training of health workers and the school teachers has been the only activity persued so far and that too with variable coverage. Training of anganwadi workers has not yet commenced. There are no follow up activities as to what has been accompolished by the health workers and teachers. The work reporting units have not been identified and no body has been made responsible to render regular reports and provide supportive supervision. It would have been much better if the Pilot Project activities were started in that area where the infrastructure of dental surgeons, dental specialists were already in position at the level of PHC and CHC and district level or upto the level of PHC/CHC with minimum input of curative services.

Orientation and training of health workers and teachers and anganwadi workers should have been done locally by Dental Surgeon and inputs of district specialist, along with local Medical Officer and SMO of CHC to prepare oral and health teams for community oral health activities at the village subcentre, PHC and CHC level. The focus should have been to integrate oral health activities with school health activities, ICDS activities and cancer control activities and geriatric health activities.

Improving oral health means improving general health and well being of the community and in essence it is improving the quality of life and developing healthy life styles (brushing, eating protective foods, avoiding smoking and Pan chewing etc.) in children, adolescents, adults and senior citizens. NOHCP is a multi sector endeavour, leadership of dentists is essential to sustain the activities. The leadership is required to effectively coordinate the functions of school health activities, non formal educators, ICDS anganwadis, water and sanitation programme, Nutrition Policy, health workers Primary Health Care Sector, food adulteration, popular mass media, and national cancer control programme, and above all the communities, homes and parents as also Panchayati Raj Institutions (PRI) to achieve the desired goals. Convergence of services of different sectors is essential to mitigate the dental problems (dental decay, periodontal disease, oral cancers and malocclusion). Results of the Pilot Project are awaited eagerly to expand the programme in other areas. These results must be shared with various stake holders/sectors on regular basis and more so with the school children, teachers and parents whose quality of life and oral health, these results affect most.


  1. Ashish Bose. Health for the millions, Population Scan, First results of census of India, 2001, March-April 2001.
  2. Bulletin on Rural Health Statistics in India March-2003.Issued by infrastructure division, Deptt. of Family Welfare, MOH&FW Nirman Bhavan New Delhi.
  3. National Oral Health Policy: Prepared by core committee, appointed by the Ministry of Health and Family Welfare, 1995.
  4. Fourth conference of Central Council of Health and Family Welfare - Proceedings and resolutions. October 11-13,1995 New Delhi. Bureau of planning, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, New Delhi.
  5. Oral Health: ICMR Bulletin, Volume 24, April, 1994 ICMR, New Delhi.
  6. Bali RK, Mathur VB, Tewari A, Jayna P. National oral health policy for India formulated by Dental Council of India, 1994.
  7. National oral health care programme implementation strategies, DGHS, MOH&FW. Govt. of India. Prepared by Dr. Hari Parkash, Project Director, Dr. Naseem Shah, Addl. Project Director, Department of Dental Surgery. AIIMS, Ansari Nagar, New Delhi.
  8. World Development Report 1993. Investing in Health World development Indicators.
  9. Facts for Life. A communication challenge. Indian Edition, Published by UNICEF India country office, New Delhi-India. Jan. 1990.
  10. Intensive health education for primary school children, School Health Education Division, Central Health Education Bureau DGHS, MOH&FW, Kotla Road, New Delhi, April 1992.
  11. Oral health training manual for school teachers. NOHCP, DGHS, MOH&FW, Govt. of India, Dr. HariParkash and Dr. Naseem Shah, AIIMS New Delhi 2001.
  12. Oral health training manual for health workers. NOHCP, DGHS, MOH&FW, Govt. of India Dr. Hari Parkash and Dr. Naseem Ahmed, Deptt. of Dental Surgery, AIIMS New Delhi 2001.
  13. The Tobacco Atlas. Dr. Judith Macky and Dr. Michel Eriksen, World Health Organization 2002.
  14. Prevention and control of fluorosis in India - Health aspects. Rajiv Gandhi National Drinking Water Mission New Delhi. Ministry of Rural Development Paryavaran Bhavan CGO Complex New Delhi Vol I, 1993.
  15. Fluorosis prevention and control. CD Alert: May-June, Volume 6, 5: 2002, NICD New Delhi.
  16. Lal S, Singh BM, Punia MS: Health and social status of senior citizens in rural areas. Indian Journal of Community Health Vol. 9, NO. 3 September-December 1997, 10-7.

Dr. Sunder Lal - Prof. & Head, SPM Deptt. PGIMS Rohtak.
Dr. Dinesh Paul - Joint Director (CD) NIPCCD New Delhi.
Dr. Pankaj - MDS (St.) K.L.E. Society's Institute of Dental Sciences & Dental Hospital & Research Centre, Belgaum.
Dr. Vikas - MDS (St.) College of Dental Surgery Mangalore (Manipal Academy of Higher Education - A Deemed University).
Dr. B.M. Vashisht - Assoc. Prof., SPM Deptt., PGIMS Rohtak.

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