IMPROVING CHILDREN’S DENTAL HEALTH

Training and Implementation of Preventive Dentistry In Bosnia and Herzegovina A Pilot Program

1. Introduction Dental Health is an integral part of the overall health of individuals; however, dental diseases remain a barely recognized problem in developing countries such as those in the Balkan’s area. Dental caries impact each aspect of children’s development and lead to malnutrition and illness. Besides that, non-treated dental diseases result in chronic pain of weak intensity which makes learning and daily functioning difficult. Children with oral health problems can have difficulty eating and sleeping or concentrating in school. Countless school hours are lost each year due to dental problems. Dental diseases could be significantly reduced by means of effective school-based preventive dentistry programs as well as education of health professionals in the techniques of dental prevention. Project HOPE will apply these proven, cost effective intreventions for improving dental health of children in selected schools to demonstrate the success and the effectiveness of these interventions in a resource poor setting.

2. Background In March 2001, an assessment trip to Bosnia, was made by Project HOPE’s expert in preventive dentistry 1 who examined 100 children from two primary schools in several distinct areas of Sarajevo. It was found that the decay incidence in children in the two schools was twice or sometimes three times as high as the average in the WHO Europe Region. Ministry of Health assessment reports from other areas of Bosnia indicate that 1

HOPE’s dental programs are planned and implemented under the leadership of Dr. Leon Dogon, Director of Education in Dental Health. Dr. Dogon has worked for 42 years at the Harvard School of Dental Medicine where he served as head of the Department of Operative Dentistry from 1970 to 1974 and is currently a Professor in Restorative Dentistry and Biomaterials Sciences. During his long career, he has educated a countless number of dentists, hygienists and other professionals in the techniques of Dental Health. This education was done at schools of Dental Health and Hygiene in the United States as well as schools and hospitals in China, Japan, Europe and South America.

the incidence of dental diseases nationwide is as bad as, if not worse than, that of the findings in Sarajevo primary schools. These results are alarming even in comparison with neighboring countries with similar heritage and similar level of health care as presented in table1. table 1. Caries for 12-Year-Olds by Country/Area by World Health Organization (WHO) DMFT describes the amount - the prevalence - of dental caries in an individual. DMFT numerically express the caries prevalence and are obtained by calculating the number of Decayed (D), Missing (M), Filled (F), Teeth (T). Country/Area Albania Austria Bosnia and Herzegovina Bulgaria Croatia Czech Republic

Year 2000 2002 1997 2000 1999 2002

DMFT 3.02 1 6.2 4.4 3.5 2.5

Estonia 1998 2.7 France 1998 1.9 Germany 2000 1.2 Hungary 1996 3.8 Japan 1999 2.4 Macedonia former Yugoslavia Rep. 1999 3.03 Poland 2000 3.8 Romania 1998 7.3 Russian Federation 1985-95 3.7 Serbia 1994 2.9-7.8 Switzerland 2000 0.97 Turkey 1988 2.7 Ukraine 1992 4.4 United Kingdom 2000-01 0.99 United States of America 1999-2002 1.75

Dental decay worldwide is most prevalent in the school age population which ultimately also accounts for dental problems in later life. In addition, the school attending population is where the most cost effective prevention can be achieved. The most effective preventive program for reducing dental disease is to develop a school-based program which includes oral health education, oral hygiene instruction, annual examination, fluorine therapy and sealant application.

Dental diseases are among the most prevalent health problems in Bosnia. There is a high need and an opportunity for establishing an effective school based preventive dentistry program to minimize oral disease and support a wholesome development of children at school age with relatively low yet cost effective interventions.

3. Project Objectives Primary Goal: The primary goal is to improve the oral health of children in Bosnia, aged six to thirteen years, by establishing a well-organized school-based preventive dentistry program. To achieve this primary goal, a pilot program will be implemented which will include primary schools in ten cantons in FBiH to demonstrate the effectiveness of the schoolbased concept. Objectives of the Pilot Program: • To improve the knowledge and skills of school health personnel on the importance of recognizing and treating early signs of poor oral health • To improve the knowledge skills and practice of dentists and dental assistants in providing preventive dental care for school aged children • To implement proven cost effective methods for preventive and conservative dentistry in the participating institutions • To improve school children’s and their family’s knowledge and awareness of the importance of proper oral health • To change children’ and their parents beliefs and behavior re nutrition and oral hygiene • To demonstrate the effectiveness of internationally accepted current guidelines and practices in objectively measurable terms in the piloted target group

4. Program plan Step One A baseline assessment will be carried out re the condition of children’s teeth as the first step of the implementation of the program in all participating school by trained personnel. Baseline data will be recorded and continuously monitored over the course of the project. Step Two A step by step protocol for the follow up and the algorithm of required preventive and curative dentistry interventions will be established for the personnel of all participating institutions to ensure consistency with prevailing international practices and guidelines. Step Three All school health personnel along with selected teachers peer educators and caregivers will be trained in the latest approaches to promoting oral health for school age children, and will be tasked to maintain regular health promotion activities in their territory.

Step Four All school dentists and assistances will be trained in latest methods and approaches to continuous dental care Step Five Regular follow up courses will be made available at the Dental faculty of the Sarajevo University Clinic to maintain Continuing Professional Development programs in the field of preventive dentistry made available for all dental health personnel throughout the country. Project HOPE will assist the faculty with developing their curriculum. Step Six Project HOPE will evaluate the effectiveness of the school based preventive dentistry program in the pilot sites so that the evidence obtained via the pilot study could be used as a blueprint for a nation-wide program

Baseline dental health assessment M&E data

Guidelines and protocols for preventive dentistry interventions established/introduced

Number of school dentists and assistances will be trained to continuous dental care in latest methods

Number of health/ educational personnel will be trained to promote oral health for school age children and promote regular health promotion activities

Regular follow up courses at Dental faculty of the Sarajevo University Clinic

Evaluation of the effectiveness of the program

Assistance for national curriculum development

Continuing Professional Development programs offered to practitioners country-wide

Nation wide program

The program will replicate the model which was found very effective in many countries worldwide, including U.S.A., China, Indonesia, Europe, and numerous other countries. If necessary, minor modifications will be introduced to accommodate varying circumstances, geographical requirements, and different cultures and beliefs in order to achieve maximum benefit in the given cultural and socioeconomic context.

5. Impact and Expected Results By the end of the pilot program all school sites will be able to demonstrate clear and objectively measurable improvements in the status of their children’s oral health. A cadre of well trained health and dental health professional will be available for health promotion and preventive dental care. Guidelines for good preventive dental care will be adopted and implemented in all sites. A curriculum for preventive dentistry will be developed for training of all health professionals in the essentials of preventive dental care. A core of trained dentists, dental nurses and oral health promoters will become a nucleus to assist in the training of others when the program is able to expand.

6. Project HOPE in Bosnia Project HOPE is one of the leading health education organizations in Bosnia and Herzegovina. It has been involved in the emergency phase of the crisis delivering humanitarian assistance in response to the war in 1992. As the situation in Bosnia normalized, Project HOPE’s developmental activities have taken shape. Today, Project HOPE is assisting Bosnia in developing long-term, sustainable health education/capacity building projects supporting the country’s ongoing health care reform in close partnership with Bosnian MOH. Project HOPE is currently implementing health education programs in family medicine, pediatric physical rehabilitation and HIV/AIDS.

7. Budget Appendix 1 Distribution of dental health care staff in Bosnia and Herzegovina

No. VI

name of canton

SREDNJE BOSANSKI KANTON ZAPADNO VIII HERCEGOVAČKI KANTON IX SARAJEVSKI KANTON

total population

children 7-14

dentists

dental nurses

no. of visits per year

no. of dental units

240958

25542

34

47

73057

44

81412

8630

20

35

18049

13

401274

42535

189

261

260465

64

No. VI VIII IX

name of canton SREDNJE BOSANSKI KANTON ZAPADNO HERCEGOVAČKI KANTON SARAJEVSKI KANTON

no. of primary school 134

no. of pupils 29153

72

10000

78

36855