Schools must integrate oral health education into their curriculum, coupled with a prophylaxis programme that requires annual screenings of all students. Through the students, awareness is also extended to their parents
Rural areas in Nepal are practically devoid of dental services. The overwhelming majority of qualified dentists work in Kathmandu and other larger cities, where they can find a sufficient number of patients willing to pay for their services and sustain a dental practice.
Over 80 per cent of Nepalis live in rural areas, where oral health care is near catastrophic. Although the need for dental treatment is enormous, there are hardly any dental practices available. It is common for a decayed tooth to be extracted, rather than repaired, once it causes excessive pain. This process decimates the natural set of teeth one by one over a lifetime. This situation is untenable and requires urgent improvement.
The government's primary interest is in providing medical services, as medical doctors can save lives, whereas dentists primarily alleviate pain and improve quality of life. Consequently, government funds are primarily invested in improving medical services rather than dental care, which must be paid for by patients.
To sustain a dental practice, income must be sufficient to cover high investments, running costs and the livelihood of the dentist and their family. This requires a sufficient number of paying patients, which is currently not the case in rural areas. Even when a dental clinic is established, it often fails due to low patient attendance, making it economically unfeasible for any dentist to operate there.
Most people in rural areas are poor farmers living hand-to-mouth. Their income is low, and traditionally, dental care has never been part of their family budget. An extraction is the cheapest treatment available, but even this small fee is often beyond the reach of common people in villages. Most of the time people wait until it is dire emergency or life threatening. I wonder how they can bear such huge pain, which is unlikely in my country.
Based on my 12 years of involvement in oral health sector in Nepal, the current oral health situation in Nepal is unacceptable and needs urgent change. Dentists seeking work in Kathmandu should be encouraged to move to rural areas. However, they must be made aware of the financial risks involved to avoid economic failure. These dentists need guidance on how to proceed, ideally by replicating the success of a sustainable dental clinic in a rural area. If any dentist wishes to move his practice to rural communities, there should be all the doors open to support him or her.
To demonstrate that this is possible, a School Dental Clinic (SDC) was planned and built in Sanghutar, Ramechap district, in the hills 160 km east of Kathmandu, guided by Dhulikhel Hospital. It was intended as a pilot project to show the path towards creating a successful, sustainable dental clinic in a rural area.
With the backing of the Village School Committee and the Rotary Club of Banepa, a small building was constructed on the grounds of Shree Himganga Secondary School, which has about 600 students. By Nepali standards, the clinic is well-equipped, adhering to the principle of redundancy with two dental chairs, two compressors and duplicates of all essential equipment. This is necessary due to the clinic's distance from technicians. All investments were funded through donations.
The dental office began treating patients in February 2020, initially employing a dental hygienist. A qualified dentist was hired two years later. The agreed policy with the village community was to provide free treatment to all students for prophylaxis and fissure sealing, though not for fillings. Fissure sealing is expected to reduce the number of extractions in later life.
Schools must integrate oral health education into their curriculum, coupled with a prophylaxis programme that requires annual screenings of all students. Through the students, awareness is also extended to their parents. In the last four years, root canal treatment (RCT) has gained popularity as it prevents painful extractions and preserves the full function of the tooth. RCT is currently the primary source of income for the clinic, and by now, it covers the salaries of the staff.
Since 2023, the SDC has been supported by two dentists from the German Rotary Volunteer Doctors (GRVD). They serve two neighbouring schools by conducting screenings, although students must walk the long distance to the SDC in Sanghutar for treatment.
This is a small example of how oral health can be taken care of if initiated at the grassroots level. School Dental clinic model has been successfully practised in many European countries and has reduced the burden of oral diseases. However, there needs a strong commitment from the government, the health ministry and Nepal Dental Association (NDA). Additionally at the policy level, there should be provision of school dental clinic in the secondary level schools.
A cost effective model of school dental clinic is the need for Nepal. It is recommended that oral health education be started in the rural areas of Nepal through schools. Stakeholders in such projects include the government, dental schools and dentists, represented by the NDA. Collaboration between these parties is crucial to address the problem effectively. Each must have clearly defined responsibilities. It is suggested that the government provide space in schools partnering with NDA to install all necessary tools and equipment, employ staff and manage the dental offices for long-term sustainability.
Dr Adderson is a retired German dentist. He has built a model School Dental Clinic in Sanghutar, Ramechhap. Dr Karmacharya is the Medical Director at Tamakoshi Hospital, Manthali