Bridging the dental divide in Nepal

As anyone who has suffered a bad toothache will attest, it is a singular kind of debilitating pain. But often, people do not feel any pain from infection until it is too late. 

In Nepal, there is a wide dental divide between those with access to dental care and the majority who are without. In remoter parts of the country, complications from a simple untreated abscess in the oral cavity can even be fatal. 

However, up to 90% of dental conditions like tooth decay and gum diseases in Nepal can be prevented through awareness of oral hygiene. This is not rocket science (or even a root canal) but knowing how to brush teeth correctly, avoiding junk food and eating meals that have to be chewed properly can save people from expensive and painful trips to the dentist.

In the old days the people of Kathmandu would visit Kilagal to nail coins into the stump of a tree in the belief that it would stop excruciating toothaches. Today, most dental clinics in Nepal are concentrated in Kathmandu Valley, and even these are mostly located inside the Ring Road. They have expensive state-of-the-art dental equipment which drives up the cost of care.

Public health experts suggest that instead of planning to invest in expensive dental clinics all over the country, the focus should be on dental hygiene awareness, simple prevention and telemedicine for more complicated cases.

“We have two drastically different groups in Nepal: those who need the latest cosmetic dentistry and others who have never ever seen a dentist in their lives. The way to bridge this gap is through technology,” says dental surgeon Sushil Koirala. “We have to digitise the system itself so that the poorest communities in the remotest parts of Nepal have access to dental care.”

There are 13 dental colleges in Nepal which produce some 500 dentists a year on average. Nepal’s dentist-patient ratio is 1:12,000 (WHO recommends 1:5,000). But most of these clinics are in the cities, and in remote districts like Jumla the dentist patient ratio can be more than 1:200,000.

There are some Nepal government scholarship students who mandatorily serve in the districts for two years, but most return to the city to set up clinics in an already saturated market. The government has dental surgeries in district and provincial hospitals, but the infrastructure is outdated and the staff insufficient.

The way to compensate for the shortage of dentists in rural Nepal could be to prioritise dental hygienists. Ideally, hygienists work under the supervision of dentists helping out with simpler procedures for gum diseases or atraumatic restorative treatment (ART) which involves removing decayed tissue. 

Because of the lack of regulation, hygienists have become ‘pseudo-dentists’ in the village, doing everything from filling to extraction.

“Dental treatment is actually the last resort. The initial phase should always focus on prevention and proper care. But remote places of Nepal lack education and training,” says another dental surgeon Parakram Parajuli. 

To plug the gap, National Dental Hospital, the non-profit Punyaarjan Foundation and MiCD Global Academy have jointly established the Dental Innovation Centre which aims to develop and implement accessible to all in Nepal (box). The team is currently working on an app that allows tele-dental care with use of AI. The initiative also plans a vigorous prevention campaign for oral hygiene among school children.

Dental complications are linked to lifestyle, and this means maintaining teeth and gums. Reducing the intake of junk food and sweets can also reduce prevalence of obesity, diabetes, hypertension and cardiovascular diseases in the population. There is also growing evidence pointing to a correlation between oral health and mental well-being.

Some 90% of the world’s population suffers from oral illnesses at some point in their lives with caries and periodontal (gum) disease being the most common and painful conditions. Nearly all adults and up to 90% of schoolchildren worldwide suffer from caries, and up to 50% from gum disease. In fact, severe periodontitis is the sixth most prevalent disease in the world.

All of this makes prevention critical, but in Nepal dental care is largely limited to filling cavities or tooth extraction when in fact the focus should be on comprehensive care which includes prevention, treatment, follow-up and monitoring. This would also reduce visits to dentists, and timely diagnosis would make interventions cheaper. 

Says Koirala: “The most cost-effective approach in a country like Nepal to prevent dental diseases is raising awareness about oral hygiene among school children, because through them we reach the communities. Dental hygienists as well as school nurses should be trained and mobilised in schools to achieve this.” 

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Leapfrogging with tele-dentistry

Set up only three months ago, the Dental Innovation Centre-Nepal (DIC-N) is working with post-grad students from the Institute of Engineering in Pulchok to develop an app that will connect dental hygienists in rural Nepal with dentists in Kathmandu for tele-dental consultations. 

Students are also working on a software which will be the standard treatment protocol for minimally invasive comprehensive dental treatment for professionals as well as record keeping with the patients' oral history.

Explains Sushil Koirala, who is leading the Centre: “On one hand, dentists won’t need to be everywhere anymore. Paramedics and hygienists will be able to provide correct and cheap treatment. It also addresses over-treatment, which is another major issue with dental care.” 

This is also a platform to encourage young innovative IT minds. The Centre will organise an open competition every two years so they get a chance to pilot project for real-life scenarios.

The Centre will also host professionals who want to volunteer so that they adopt some children and provide them with general consultation free of cost. This will serve to motivate young dentists interested in philanthropy.

While dentistry itself is a lucrative profession, many of the 500 graduates every year in Nepal do not have enough resources to start their own clinics and are underpaid elsewhere. And while some migrate to work overseas, dental licensing abroad is harder to get and even then Nepali dentists are mostly restricted to the role of hygienists.

In the meantime, the dental studies curriculum in Nepal is largely outdated with students not able to practice much of the latest surgical methodologies. The Centre is led by a team of Nepal’s foremost dental surgeons to share expertise. 

“Most developed countries have problem-based learning and practice approach, where creativity and research are encouraged early in their dentistry course but this is sorely lacking in our part of the world,” adds dental surgeon Parakram Parajuli.

At Dental Innovation Centre, the team is in the designing phase of the app which they want to test through remote area hospitals like Bayalpata in Achham which already has an electronic health record of all its patients.

Says Koirala: “It is a business model in that institutions and hospitals have to pay for technology while the patients get the benefit without additional cost. We want to become a model for others to learn from and replicate while also leading the reforms in the field.”

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