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Obstacles to Providing Oral Healthcare in Nepal

Many Nepalis, such as this man from the village of Kaskikot, expect their teeth to fall out with old age. Image by John Healey. Nepal, 2013.

Nepal is currently facing an oral healthcare crisis – 58 percent of children and 69 percent of adults in the country suffer from bacterial tooth decay. This can lead to infections, gum disease, and chronic pain as well as heart disease and diabetes. In April 2013, I met with Dr. Shaili Pradhan at Bir Hospital in Kathmandu to discuss the issue. Dr. Pradhan is a periodontist at Bir and the Chief of Oral Health Focal Point in Nepal’s Department of Health Services. She explained some of the challenges that Nepal is facing in terms of addressing oral health concerns.

  • The government does not advocate for institutions like WHO or UNICEF to provide the kind of support that they do for other medical issues because they do not prioritize oral health. “Losing a tooth won’t kill a person, but malaria can,” explains Dr. Pradhan. She says it’s quite possible that high rates of heart disease and diabetes in Nepal are linked to poor oral hygiene, but to date there have been no official studies to confirm this suspicion.
  • The culture does not prioritize dental hygiene. “People think, ‘I’m getting old, so my teeth should loosen and fall out,’” she explains. This is especially true in rural areas, where people may own—but rarely use—toothbrushes. The country’s water is not fluorinated, and people don’t know to look for fluorinated toothpastes. They often turn to harmful home remedies: brushing with a finger and ashes, salt, or sand. In lieu of toothpaste, some people use abrasive tooth powders that can strip enamel from teeth. In some places, people chew the end of datiwan, a stick with antiseptic properties.
  • A widely held conception in Nepal is that dental cleanings will lead to permanent tooth sensitivity and that extractions can cause people to go deaf and blind. “These myths are transferred through the generations,” says Dr. Pradhan. And the younger generation listens. “Even among educated people, there’s a belief that it’s bad to brush your teeth for two months after giving birth,” she says. “We train maternal health workers to tell women in villages that this won’t harm them, but I have no way to know whether people are actually following the instructions.”
  • The private dental care industry is rapidly growing. There are currently 1,200 dental surgeons registered with the Nepal medical counsel (though Dr. Pradhan says some of these people are likely abroad) and 800 to 1,000 certified dental hygienists in the country. Of the 12 private dental colleges five of which opened in the last year. Bir hospital offers two post-graduate dentistry programs.

But because the government offers little to no oversight in the oral health care industry, anyone with a modicum of training can open a clinic and offer procedures they are not trained to perform. “These are unethical practices,” says Dr. Pradhan. “You get people with two weeks of training doing work that requires four to five years of study. But people will go to whoever is cheaper.” In Nepal, it’s common to see a street of dental practices—one after the other—all advertising freedom from mouth pain. “Who knows which of these are qualified,” says Dr. Pradhan. In Kathmandu, on a street near these clinics, there’s even a shrine to a toothache god. People nail coins to the shrine in hopes that the offering will makes their pain go away.

In 2004, the Nepali government drafted a National Oral Health Policy focusing on the promotion of oral health care and prevention. Recommendations were made for the use of fluorinated toothpaste and currently, Dr. Pradhan says that 90 percent of the toothpastes available in Nepal are fluorinated. The policy also mandated community oral healthcare education, including school brushing programs. “But because of budget constraints for oral healthcare,” says Dr. Pradhan, “few of these educational programs have been implemented. There are 4,000 villages in Nepal and this program has reached only a few this year.”

She says that in the next six months, the National Oral Health Policy will be revised to specify exactly how many villages should have received education and prevention programs by 2020. But so far, the track record is not good: On the macro level, the government has been in the process of writing a new constitution since 2007. And in many villages, local elections haven’t been held for the last decade.