Journal of Advanced Clinical and Research Insights

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Hebbar:

Role of oral physician in Indian public health system

Pragati B. Hebbar

Advocacy Officer, Institute of Public Health, Bengaluru, Karnataka, India

Correspondence Dr. Pragati B. Hebbar, Advocacy Officer, Institute of Public Health, No. 250, Master’s Cottage, 2 ‘C’ Main, 2 ‘C; Cross, Girinagar 1st Phase, Bengaluru - 560 085, Karnataka, India. E-mail: pragati.hebbar@gmail.com
Received 05 May 2015;
Accepted 20 June 2015
doi: 10.15713/ins.jcri.71

Abstract

The Indian public health scenario is gradually receiving the due attention it deserved at least in the academic front. Oral medicine and radiology in itself is a very vast branch concerned with the diagnosis and non-surgical management of diseases of oral and paraoral structures. The specialty of oral medicine and radiology being in this crucial position as a link between medicine and dentistry can contribute much more to strengthen public health efforts than it is currently contributing. This branch covers diseases not only related to the teeth, surrounding jaws, joints, and salivary glands but also systemic diseases, their inter-relation to oral health and their manifestations in the oral cavity. This vast bank of knowledge can be exploited with integrated oral and general health programs. With the growing burden of non-communicable diseases globally as well as nationally a greater role for the oral physician needs to be carved out. In a three-tier health care delivery system the oral physicians could be taken up into the secondary care facilities to diagnose oral cancer, precancers, indications of systemic diseases and management of their oral manifestations, counsel on tobacco cessation, etc. Academics, health care delivery and research are viewed as distinct fragmented structures. Breaking these silos to achieve integrated people-centered care should be our long-term vision. This article delves into each of the silos to examine the gaps and propose some solutions to delineate the optimal role of an oral physician in the complex health care landscape of India.

Keywords: Dentistry, non-communicable diseases, oral health, oral medicine, public health

Introduction

The oral physician or in the Indian context the oral medicine and radiology specialist is the one who diagnoses and non-surgically manages a variety of oral lesions, orofacial pain as well as medical disorders affecting the oral mucosa, salivary gland diseases and temporomandibular disorders. On one hand the increased incidences of oral lesions, and the diagnoses and management of several stomatological disorders that fall in the gray area between medicine and dentistry requires the oral physician. However on the other hand in India, the specialty of oral medicine and radiology is one of the least sought after. In such a scenario, it becomes important to define the boundaries of this specialization and understand the contribution of this cadre.[1]

Dentists are trained to recognize approximately 100 manifestations of systemic and lifestyle diseases as well as genetic disorders; they are also equipped to provide some basic preventive care such as recording vital signs and administering vaccines.[2] With the in-depth knowledge of oral manifestation of systemic diseases, oral physicians are in an unique position for early identification of diabetes, substance abuse, eating disorders, child abuse as well as some other systemic diseases. This preventive role is rarely recognized except for in college settings where a detailed history, referral for medical care and follow-up of patients is practiced. Non-communicable diseases (NCDs) accounted for nearly 60% of all deaths in 2014 in India.[3] With such a significant burden of chronic NCDs, the role of oral physicians needs to be revisited to expand the scope to include certain preventive, monitoring and management aspects.

Indian Public Health System and Workforce

The Indian public health system is divided into primary health care – sub-center (which is the first point of contact to a basic health facility, serves about 3000-5000 population) and primary health center (first point of contact with qualified doctor, serves about 20,000-30,0000 population), secondary care – community health center (CHC) (first referral unit for specialist care and serves about 80,000-120,000 population) district hospital (provides curative, preventive and promotive health care to the population of a district) and tertiary care.[4]

The health workforce in India is very diverse and spread out over public and private sectors. As per the National Occupation Classification allopathic providers include - Doctors, dentists, nurses, midwives, pharmacists, technicians, optometrists, physiotherapists, nutritionists, sanitarians and administrative, and support staff. The Indian health systems include - Ayurveda, Yoga, Unani, Siddha and Homeopathy. Apart from these formally recognized cadres there are several others such as community health workers, registered medical practitioners (no formal training in medicine), and other traditional and faith healers.[5] However, as per the census data the situation of Indian health workforce is quite dismal owing to a severe shortage of trained professionals, rural-urban misdistribution, lack of reliable documentation of number of these varied practitioners, under-representation of women amongst this workforce etc.[5] In such circumstances optimizing available resources such as oral physician’s skills seems a logical step forward.

Academics, Health Care Delivery and Research as Separate Silos

In India, public health is now garnering some attention and interest and a modest rise in number of institutions providing public health teaching, compared to the phenomenal rise in number of institutes providing undergraduate and post-graduate medical education. However, there is an absence of a Central Public Health Council/accreditation body leading to non-uniformity of curricula and lack of coordination/dialogue amongst the different academic stakeholders.[6] The health care delivery landscape in India much like the academic profile is very diverse ranging from untrained informal providers to the high-end state of the art tertiary care facilities. A lot depends on the affordability of the patients owing to the burden of out of pocket expenditure pushing families into poverty. Third the research scenario is also fairly unorganized with the lack of a central agency setting research agendas, monitoring quality of research and ensuring a uniform minimum standard. Hence, often these three interconnected components of academics, research and health care delivery appear as fragmented and separate from each other with minimal dialog and cross learning.

Way forward

With increasing focus and anticipation about the 17 sustainable development goals, it can be realized that health is no longer confined only to the health sector rather it should become a purview of several other sectors.[7] The health department needs to play a key stewardship role to reach out to these other sectors and ensure convergent multisectoral action for better population health.[8] Being engaged in both the fields of oral medicine and radiology and public health I would like to put forth some plausible solutions without being prescriptive.

  • The fields of medicine, dentistry and nursing have shown to have independently evolved similar and comparable basic competencies and learning objectives.[9] Given the severe shortage and misdistribution of human resource in Indian public health systems an interprofessional education and collaborative practice model as proposed by the World Health Organization could be considered[10]

  • The National Oral Health Policy of India was drafted 20 years ago in 1995 and piloted in 1999 in five Indian districts. The initial focus was on primary prevention through health education. The 11th five-year plan strategies were slightly broadened to include manpower and infrastructure development along with implementation of a basic oral health package.[11] The lack of political will is evident as in spite of a policy being drafted 20 years ago in the 12th five-year plan (2012-2017) oral health still features as a pilot project independent of the National Rural Health Mission ambit.[12] Stronger advocacy by the dental fraternity is much needed to make an integrated national oral and general health policy a reality

  • The Indian standards for public health revised guidelines mentions dental care such as root canal, filling, extraction, and oral health education with nutritional and adolescent health education as essential at the secondary care level of a CHC.[4] With increasing burden of NCDs it is high time to expand this scope and include early detection of oral precancer and cancer, substance abuse counseling, early detection of diabetes and other systemic diseases via oral manifestations at the CHC level

  • The specialty of oral medicine and radiology needs to claim its rightful position by utilizing the skills to integrate with medical and dental practice and provide better health care for the vast unmet population needs. This role clarity of an Indian oral physician should be reflected in the academic as well as health care delivery set ups.

References

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2. Giddon DB, Swann B, Donoff RB, Hertzman-Miller R, Dentists as oral physicians: The overlooked primary health care resourceJ Prim Prev 2013; 34: 279-91.

3. World Health Organization (WHO). Noncommunicable Diseases (NCD) Country Profile2014; India: WHO; 1.

4. Ministry of Health and Family Welfare, India. Indian Public Health Standards (IPHS) Revised Guidelines2012; New Delhi: Ministry of Health and Family Welfare;

5. Rao KD, Bhatnagar A, Berman P, So many, yet few: Human resources for health in IndiaHum Resour Health 2012; 10: 19.

6. Zodpey SP, Negandhi H, Yeravdekar R, Future directions for public health education reforms in IndiaFront Public Health 2014; 2: 68.

7. World Health Organization (WHO). Open Working Group Proposal for Sustainable Development Goals2014; Geneva: WHO;

8. Lakshminarayanan S, Role of government in public health: Current scenario in India and future scopeJ Family Community Med 2011; 18: 26-30.

9. Spielman AI, Fulmer T, Eisenberg ES, Alfano MC, Dentistry, nursing, and medicine: A comparison of core competenciesJ Dent Educ 2005; 69: 1257-71.

10. World Health Organization (WHO). Interprofessional collaborative practice in primary health care: Nursing and midwifery perspectives: Six case studiesHum Resour Health Obs 2013; 13: 1-18.

11. Ministry of Health and Family Welfare, Government of India. Report –Working Group on Communicable and Non-Communicable Diseases for the 11th Five Year Plan2006; September

12. Planning Commission of India, Health Division. Report of the Steering Committee on Health for the 12th Five Year Plan2012; February