The growing cavities in India’s oral health

Bengaluru: Mid-week business is picking up pace at Bengaluru’s K R Market. On the sidelines of the core marketplace that sells everything from vegetables to machine tools, there is a section that comes with an all-season deal at attractive prices – here, they promise a good fix for teeth across stages of decay. 

Under the Balagangadhara Swamy Flyover near a bus stand are seated at least four quacks. They have mirrors, a few tools, chairs, and a large banner that has people showing off their smiles, all under a cloth roof.

Shaik Anwar has been doing this for at least 30 years. His business card advertises fixing of teeth and solutions for odour. Fixing one tooth costs about Rs 300. Even the pandemic did not slow Anwar down — he ran the business out of a room in a local lodge. “We do not do filling here. If customers ask for such procedures, we refer them to hospitals. Many of our customers are from other towns,” he said. On average, Anwar sees 15 to 20 of them every day.

A couple from Mysuru wait for their turn. Rajendra Kumar, a retired medical transcriptionist, started visiting Anwar after reading a feature on the street practitioner. His mother had saved the newspaper clipping from about eight years ago. When Kumar found that he had to get 28 teeth fixed, the clipping came in handy. He spent Rs 15,000 for his set, which, in Mysuru, would cost at least Rs 50,000. But what about the quality of the set? Is he not worried about the risks involved in what could be a quick-fix job? – “If I was, I would not be here.”

Kumar and Anwar signify the crux of India’s niggling oral health problem; they represent demand induced by a lack of awareness, insufficient access and economics, and a supply which is not always backed with evidence of effectiveness and is largely unregulated.

The World Health Organisation (WHO) estimates the prevalence of severe periodontal disease in Indians aged 15 years and above to be 21%. In its oral health country profile on India, WHO says the prevalence of untreated caries of deciduous teeth in children aged between one and nine years is 43.3 per cent and the prevalence of untreated caries of permanent teeth (5+ years) is 28.8 per cent.

The Indian Dental Association (IDA), addressing concerns over the acceptance of street dentists, refers to a key finding from a survey by the Indian Market Research Bureau – that only 47 per cent of the total treatments are performed by licensed dental professionals.

The government-run Dental Council of India (DCI) is betting on the upcoming National Dental Commission to bring wide-ranging reforms to India’s dental education and professional practice. Dr Dibyendu Mazumdar, President, DCI, said the Commission was “in the process” of being established.

The National Oral Health Programme, initiated by the Government of India, is aimed at improving the determinants of oral health, bringing down morbidity, integrating the oral stream with the general healthcare system and encouraging public-private partnerships in the sector.

Poorly understood

Experts pointed to the poor levels of awareness regarding oral health among the public – some of this is fed by the perception that oral diseases cannot be life-threatening – as a major contributor to the rise of the informal sector of dental health practitioners. They also noted that a large section of the population seeks oral healthcare only when teeth are affected. General guidelines recommend oral check-ups twice a year and periodic dental scaling.

Professor Naga Radhakrishna Ambati, who teaches at a private dental college in Andhra Pradesh, noted that a “culture of neglect” towards oral well-being has resulted in the deterioration of oral health, making the public increasingly tolerant of the problem.

Lifestyle changes that include a rise in tobacco consumption are aggravating the problem, said Dr Sanjay Pahwa, a senior practising dentist in Jaipur. “Most dental problems are taken lightly till they become unmanageable. Some of these dental diseases, if not attended on time, can have serious systemic implications like cancer, cardiac diseases, personality disorders and poor gut health,” he said.

Dr Santosh Thomas, state president of the Kerala Dental Council, highlighted the state’s impressive dentist-to-population ratio – about 1:1,000 – but called for government initiatives that promote oral hygiene in school curriculums to inculcate among the public a habit of regular check-ups. “Many wrong perceptions, like the myth that frequent cleaning of teeth can damage the enamel coating, should be dispelled,” he said.

Limited access, high costs

WHO prescribes a dentist population ratio of 1:7,500. In urban India, this ratio is at about 1:10,000. There are over 3.52 lakh dentists registered with DCI. Maharashtra (over 55,000), Karnataka (over 43,000), and Kerala (over 33,000) are the states with the highest number of registered dentists. The distribution of these dentists, especially in the urban-rural context, makes access a problem in many states.

Cheaper dentistry options could seem attractive to people without the means, or the access, to good-quality dental care, explained Dr Adarsh M S, professor, Vokkaligara Sangha Dental College and Hospital, Bengaluru.

“Private clinics are concentrated in urban areas. In government settings, dentists are appointed at Community Health Centres. Ideally, every Primary Health Centre should have a dentist but I do not think any PHC in Karnataka has one,” Dr Adarsh, who also runs a dental clinic, said. People availing dental care in CHCs have to pay a small fee for most of the procedures. “Only removable dentures are free for BPL card-holders if more than three teeth are missing,” he said.

It is important to make practice in rural areas more binding for dentists, argued Dr Mazumdar. “There have been concerted efforts to sensitise populations on oral health through camps and other outreach programmes. This is still not enough – the way things stand now, a large part of India’s rural population is going to miss out on good oral healthcare,” he said.

Most of the district government hospitals in Assam do not have dedicated dental care wings, official sources confirmed. These hospitals also run short on doctors and infrastructure. "At the government dental colleges, most of the time, junior doctors or interns attend to the patients," said Neelkamal Kalita, a resident of Guwahati who struggled with dental health issues. In Tripura, most of the district and sub-division level government hospitals work with sub-par facilities.

Dr Pahwa underlined the lack of coverage for dental healthcare under insurance schemes. “Unfortunately, our governments, over the years, paid no heed either to the preventive aspect of oral diseases or financial aid to the patients in the form of insurance,” he said.

As limitations in access to licensed dentists further embolden unauthorised practitioners, stringent curbs on quackery become imperative. Dr Deepak V, a Bengaluru-based forensic odontology expert, said most of these practitioners had no formal training and worked with the experience they had as support staff in dental clinics. They also tend to use carcinogenic materials, do not follow sterilising protocols, and use acrylic resin and teeth sets procured from stores near Victoria Hospital in the city that do not require buyers to furnish a medical licence and registration.

“Resin is used for specific reasons, to obtain tooth impressions and jaw measurements, and not inside the mouth. The dentures we give are personalised and safe because they are tested for heat in laboratory conditions but quacks do not do any of that. They shave the tooth to fit the ridge without any science behind it,” Dr Deepak said.

There are serious implications in the form of cross-contamination and infections as well. Over time, the tissue below the fixed tooth loses blood and oxygen supply and cells begins to die. Slowly, the nerve supply to the bone gets compromised and the nerves become numb, leading to a loss of sensation.

The problem with access is also about distribution, Dr Mazumdar contended. “Colleges and healthcare facilities need to be on an even spread. There is no point in having three or four institutes within a limited area when entire regions go without any of these facilities. They have to be established based on local needs,” he said.

Public sector 

Dental education has remained a contentious area in India. A shortage in public educational institutions has necessitated extensive privatisation, setting off concerns about the quality of education.

In August 2023, the National Dental Commission Act came into force, in what the government stated as a move to address the failings in dental education and to improve healthcare standards. The Act envisions a “complete overhaul” of the dental education and professional landscape, in line with international benchmarks.

Dr George Paul, a consultant oral and maxillofacial surgeon based in Salem, Tamil Nadu, pointed out that dental healthcare in India is still inaccessible to a large section of the population. Noting that “too many” dentists are graduating in Tamil Nadu, he argued that the state did not need more dental colleges in the government or private sector. As per DCI records, there are 329 registered dental colleges in the country.

Tamil Nadu has only three government-run dental colleges, while the remaining 25 are in the private sector. In Kerala, there are 29 dental colleges and only six of them are in the government sector. Karnataka has 35 private dental institutes and two government oral health colleges. The state produces one of the highest numbers of dentists in the country according to Dr Sharan Prakash Patil, Karnataka Minister of Medical Education. "Every year, we are producing many dentists. There is no shortage, so there is no need for people to go to quacks. More awareness among people is required," he said.

Rajasthan has 35 medical colleges: 25 government colleges, one All India Institute Of Medical Sciences, and nine private colleges. In contrast, it has only five government-run dental colleges but is home to 18 private dental colleges. The course fee ranges from Rs 8 lakh to about Rs 21 lakh. The state policy requires that before starting a dental college, the applicant will have to set up a hospital and the supporting infrastructure, as per the regulations of DCI.

Dr Paul questioned permissions being granted to set up new dental colleges in states like Tamil Nadu and Kerala where the decadal population is decreasing. NEET was expected to ensure merit but has failed miserably due to low cut-off marks, making dental admission “a low-hanging fruit”, he said.

In Andhra Pradesh, the standards in education have been falling over the past decade, as academic corruption continues unchecked. A dental doctor, who wished to remain anonymous, said, despite “rampant proliferation” of shadow staff and plagiarism in research, corrective action has been minimal. 

A Kerala-based doctor who preferred anonymity said the increasing number of dentists in the state was leading to unemployment, forcing many to leave the profession. It requires Rs 20 lakh to Rs 40 lakh to set up a dental clinic in Kerala but the returns are meagre for many practitioners.

“Many PHCs have dentists on their payroll, but they may not have the required equipment and filling materials. Merely employing dentists does not make dental healthcare accessible. They should be able to provide proper dental care,” Dr Paul said.

A public health expert, who did not want to be named, emphasised the need for exclusive public sector dental hospitals in the districts. “It looks like we have sold off dental and eye care to the private sector. Dental care should be made affordable to the masses and that can be done only if the government steps in,” the expert said.

(With inputs from Arjun Raghunath in Thiruvananthapuram, E T B Sivapriyan in Chennai, Rakhee Roytalukdar in Jaipur, S N V Sudhir in Hyderabad, Sumir Karmakar in Guwahati, and Udbhavi Balakrishna in Bengaluru) 

A doctor works at his advanced dental care clinic; Street