Operational Guidelines

(National Oral Health Program)

NOHP

National Oral Health Cell

Directorate General Of Health Services

Ministry of Health and Family Welfare

Government of India

2012-17

Contents

  1. Preface I
  1. Foreword II
  1. Acknowledgement III
  1. Introduction1
  1. Burden of Oral Diseases in India1-2
  1. Rationale of Oral Health Program3
  1. Goal & Objectives3
  1. Strategies 3-5
  1. Organizational Structure of NOHP5
  1. Activities at various level5-6
  1. Financial Guidelines7
  1. Annexure
  2. Annexure I8-10
  3. Annexure II11
  4. Annexure III12
  5. Annexure IV13
  6. Annexure V14
  7. Annexure VI15
  8. Annexure VII16

Shri B P Sharma

Secretary(H&FW)

Ministry of Health & Family Welfare

Tel: +91 11 23061863 Nirman Bhawan

Email: New Delhi-110011

PREFACE

Oral health is essential for overall health of the individual in all aspects. Dental caries, Periodontitis are most common oral diseases affecting the population of India along with increasing incidence of oral cancer due to tobacco use. Though mortality due to oral diseases is negligible except for oral cancer, morbidity is quite high and treatment is mostly by out of pocket expenditure. To reduce the disease burden and expenses incurred towards treatment of these diseases country needs an efficient oral health care delivery system. Therefore, National Oral Health program (NOHP) is being launched to strengthen the public health facilities at each level up to the district.

The primary objective of the National Oral Health Program (NOHP) is to render promotive, preventive and curative services for common oral diseases in the rural and under served areas through the existing public health facilities and converge with relevant National Health programs for proficient service delivery.

I strongly believe that the operationalization of the guidelines given in this manual will ensure successful implementation of the program and reduction in burden of oral diseases of the country.

(Shri B.P. Sharma)

Prof. Jagdish Prasad MS, MCH Director General of Health Services

Department of Health & Family Welfare

Tel: +91 11 23061063 Nirman Bhawan

Email: New Delhi-110011

FOREWORD

Oral health is integral part of general health and better quality of life. Burden of oral diseases is one of the emerging public health problem of the country along with other Non Communicable Diseases(NCDs) like diabetes, hypertension, cardiovascular diseases and cancer.. Most of the dental diseases are life style related and are preventable in nature like other NCDs. But due to lack of awareness oral disease burden is increasing and the cost towards the treatment is escalating due to intervention at a very advanced stage. The crux of the problem is due to inequity in oral health service delivery in the public health facilities of the country, except few states.

National Oral Health Program(NOHP) is launched to support the States/UTs for strengthening the infrastructure up to district level, for a seamless basic oral health service delivery to the population. The guidelines given in this manual should be followed for proper implementation of the program in the States/UTs.

(Dr. Jagdish Prasad)

Ms Dharitri Panda,ICAS

Joint Secretary

Department of Health & Family Welfare

Tel: +91 11 23063585 Nirman Bhawan

Email: New Delhi-110011

ACKNOWLEDGEMENT

Oral health is themirror for the general health of an individual. Most of the common oral diseases like Dental caries, Periodontitis are preventable in nature if proper oral hygiene is maintained and mortality of many teeth can be prevented or delayed by routine dental check up and early intervention for the diseases. The burden of non communicable diseases is rising in the country and if oral diseases are included in true sense under the domain of non communicable diseases it is the most prevalent disease among the population. Therefore to improve the oral health indicators of the population and efficient oral health care delivery in the public health facilities of the country, the National Oral Health Program(NOHP) has been launched.

The conceptualization, formulation, technical contribution and compilation of the information given in this operational guidelines for NOHP has been a collective effort from experts from different fields. I would like to thank DDG Dr Mohd Shaukat Usta, CMO Dr Swasticharan for their technical inputs and guidance in preparation of this guidelines. I would like to appreciate the efforts from Mrs Valsamma K Daniel the erstwhile Deputy Secretary, Mr KK Jhell , Under Secretary, Dr Utkal Mohanty, Consultant for compilation of the guidelines.

(Ms Dharitri Panda)

1. Introduction:

Oral health is indispensable for overall health, well being and good quality of life for an individual. Poor oral health negatively affects growth, development, learning, nutrition, communication, self-esteem, and various general health conditions. Dental caries and periodontal disease are the two most prevalent dental diseases of Indian population. Both these diseases along with other conditions like oral cancer & precancerous conditions, edentulousness, malocclusion, have been neglected over the years especially in the underprivileged areas because of negligible mortality rate of these diseases.Lack of awareness about these diseases has contributed towards increase in the prevalence and severity of the problems. Oral diseases have been linked to bacterial endocarditis, atherosclerosis,chronic obstructive lung diseases, diabetes mellitus and preterm low birth weight. In addition, major impact on people’s daily lives in terms of pain and suffering, impairment of function and quality of life due to missing, discolored or damaged teeth must be considered.

The economic impact of oral disease is significant due to expensive treatment and frequent nature of the conditions. In developing countries, resources are primarily allocated to emergency oral care and pain relief; if treatment were available, the costs of dental caries in children alone would exceed the total health care budget for children. Furthermore, oral diseases restrict activities at school and work, causing millions of school and work hours to be lost each year throughout the world.

According to the World Oral Health Report-2003, oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world. The greatest burden of oral diseases is on disadvantaged and socially marginalized populations. Therefore to bridge the gap for oral healthGovt. of India envisaged the National Oral Health Program for an affordable, accessible and equitable oral health care delivery in a well coordinated manner.

2. Burden of Oral diseases in India:Oral disease burden in India is very high due to its multifactorial nature which also shares a common risk for other NCDs. Many oral health surveys have been done from time to time in different regions of the country.The comprehensive data on oral health was cited in the report by National Commission on Macro-economics and Health,and Oral Health in India: Report of multi-centric oral health survey (Shah et al, 2007). According to these reports, prevalence of various oral diseases in the population is as follows:

Table 1 Burden Of Oral Diseases( Multicentric survey 2007)

S.No. / Disease / Prevalence
1 / Dental Caries / 40-45%
2 / Periodontal diseases / >90% (Advanced disease in 40%)
3 / Malocclusion / 30% of children
4 / Cleft lip and palate / 1.7 per 1000 live births
5 / Oral cancer / 12.6 per lakh population
6 / Oral submucous fibrosis (pre-malignant and crippling condition of mouth) / 4 per 1000 adults in rural India
7 / Dental Fluorosis / Endemic in 230 districts of 19 States
8 / Edentulousness (tooth loss) / 19-32% of elderly population >65 years
9 / Oral lesions due to HIV/AIDS / 72% of HIV/AIDS patients
10 / Birth defects involving oro-facial complex / 0.82 to 3.36 per 1000 live births
11 / Others: Traumatic injuries,
  • Mucosal lesions associated with radiation and chemotherapy
  • Morbidity and deformity following oral cancer surgery.

Burden of Oral Diseases (National Oral Health Survey & Fluoride Mapping -2003)

3. Rationale for a National Oral Health Program:

Oral diseases are public health problem and have a great impact on systemic health. Poor oral health can cause poor aesthetics, affects mastication adversely, causes agonizing pain and can lead to loss of productivity due to loss of man-hours.

As per the recent data from Dental Council of India, there are 1,52,679 registered dentists for the population of about 121 million. The distribution of dental surgeons in different geographical locations is not uniform leading to a paradoxical situation pertaining to the urban rural population i.e 72% population remains in rural areas of India where as 70% of dentists render services in the urban areas.Provision of oral health care services through primary health care delivery has not yet been achieved uniformly across the country despite; many progressive states have made effort for oral health care delivery from their own budget or NHM flexipool.

4. Goals and Objectives of the NOHP

The Program objectives of NOHP are the following:

4.1Improvement in the determinants of oral health e.g. healthy diet, oral hygiene improvement etc and to reduce disparity in oral health accessibility in rural & urban population.

4.2Reduce morbidity from oral diseases by strengthening oral health services at Sub district/district hospital to start with.

4.3Integrate oral health promotion and preventive services with general health care system and other sectors that influence oral health; namely various National Health Programs (National Tobacco Control Program, School Health Program, National Program for Prevention & Control of Fluorosis, National Program for Prevention & Control of CVD, Diabetes & Stroke etc) education, social welfare, women and child development, etc.

4.4Promotion of Public Private Partnerships (PPP) for achieving public health goals

5. Strategies to achieve the Goal:

5.1 Core Strategies to achieve the Objectives of the program are:

5.1.1Human Resources: Dental Surgeons, Dental Hygienist & Dental Assistant will be recruited on contract basis to supplement the efforts of the State/UTs till the PHC/CHC level in a phase wise manner to improve the oral health care delivery service at each level of health care delivery system up to district level.

5.1.2Logistical Support: Program will support to establish dedicated dental clinics in the district and sub district hospitals according to the differential need of the states to strengthen the infrastructure for efficient oral health care delivery. States/UTs will be given grants to procure dental chair, x-ray machine and other supportive instruments to deliver basic oral health care services at the district and sub district hospitals.

5.1.3Training: General oral health training of all the health care staff will be done to increase the awareness about importance of oral health among the population with special focus on young children, expectant mothers and patients suffering from chronic diseases like diabetes, hypertension. Capacity building will be done by developing different training modules for different target groups, and adequate numbers of trainers in each stateto conduct the relevant training.

5.1.4IEC & BCC: Information, Education and Communication (IEC) materials/ Behavior Change Communication (BCC) materials will be designed and disseminated to the states which can be modified as per the local needs to create awareness among the population regarding importance of oral health. Interpersonal communication will be carried out for behavior change targeting

  • Proper Oral hygiene practice methods
  • Food habits for good oral health
  • Effect of tobacco and alcohol on oral health
  • Comprehensive Program Management: National Oral Health Cell (NOHC) will be established at the centre to coordinate the Oral Health Program in the state, district and sub district level with various stake holders.
  • Monitoring, & Evaluation: The NOHP shall be monitored at all levels utilizing the

existing HR support of NCD Cell under the program for continuous flow of the data from

peripheral level to the centre.

5.2 Supplementary Strategies:

5.2.1Public Private Partnership (PPP): PPP will be undertaken with the Private Dental Colleges, Indian Dental Association, Community Based Organization to promote community based oral health awareness and service delivery.

5.2.2Reorienting dental education towards community based oral health care delivery:

There is an urgent need to sensitize the undergraduate students of dentistry about the health care delivery system of the country and expose them to the service delivery system at CHC/PHC level during the tenure of internship.

6 Organizational Structure of the NOHP:

6.1 National Oral Health Cell:

This consists of a national focal point,with a technical officer [CMO in charge of NOHP],who will report to DDG (NCD) in technical matters and also to the Joint Secretary(JS) /Director for other administrative matters. He will be supported by a oral health consultant. The team in the MoHFW consisting of an under-secretary and dealing assistant will support the JS (NOHP) and the CMO (NOHP). These two teams would liase with the main NCD team working in the Ministry and Dte GHS.

6.2State Oral Health Cell (SOHC)

The identified State Nodal Officer would be in charge of the NOHP cell at the State level. He may be the common CMO in charge of the NCDs in the State or a separate program officer as per the requirements of the individual states. This cell would work in liaison with the State NCD cell existing for other NCD program.

6.3 District Oral Health Cell

A similar structure would also exist in the district level led by the District Nodal Officer

identified by the district NCD cell.

7National Oral Health Program (NOHP) activities at various levels:

7.1National Level

  1. Preparation of TORs of manpower to be hired for the districts
  2. Preparation of the technical Specifications for equipments for the dental units
  3. IEC/BCC/ICT activities
  4. Training of trainers
  5. Monitoring and evaluation
  6. State Level
  1. Strengthening of dental units in the identified districts
  2. Monitoring and Evaluation
  3. Training of health care delivery personnel involved in district level & below regarding oral health.
  4. District Level
  1. Strengthening of dental units at identified districts
  2. Hiring of Manpower [dentists, dental hygienist, dental assistant]
  3. Training
  4. IECactivities

Table-2:Services to be made available at Different levels under NOHP

Health Facility / Package of Services
Sub centre / 1Oral Health Education to all target groups through the routine program
2Dedicated days in the monthly or fortnightly schedule for discussion on oral health topic
3Referral of patients having dental problems to the PHC or FRU depending on the availability of dental services
4Prescription of medication for pain relief and other routine dental problems
5Record keeping for reporting to the PHC
PHC /
  1. Daily OPD services by medical officer (Dental)
  2. Arrangement of dental camps in collaboration with other departments
  3. Maintenance of record in the provided format for reporting to CHC
  4. Delivering services to the children referred from school.

CHC / 1. First Referral Unit(FRU) for the PHCs and below
2. Arrangement of dental camps in collaboration with other departments
3.Maintenance of record in the provided format for reporting
4. Delivering services to the children referred from school.
District Hospitals /
  1. Management of cases referred from CHC and PHC, Provision of Denture, Fracture reduction , Appointing orthodontist on consultation basis weekly or Monthly,
  2. Collating the reports from PHC and CHCs
  3. Convergence with other programs under NHM and NCD
  4. Delivering services to the school children referred under RBSK

8. FINANCIAL GUIDEINES:

Financial Management Group(FMG) of program management support units at state and district level, which are established under NHM, will be responsible for maintenance of accounts books, release of funds, expenditure reports, utilization certificates and audit arrangements. The funds will be released to states/UTs through the treasury route to State Health Society (SHS), to carry out the activities at different levels as envisaged in operational guidelines and approved state PIP.

In the FY 2014-15, the funds were released to the states/UTs scheme wise. However, from FY 2015-16, it has been decided that in order to improve the operational flexibility of the states/UTs , funds will be released to under different flexi pools instead of scheme wise manner.

It has also been decided that National Oral Health Program (NOHP), would be a part of Health system strengthening under NRHM (also known as Mission Flexible pool) . Approvals will be given to the states in NOHP under Health system strengthening under NRHM, due to merger of schemes and accordingly expenditure will be captured in the FMR. Statement of Expenditure (SOE) and Utilization Certificate (UC) for FY 2014-15 is to be submitted as per GFR 19A, in the prescribed formats given at Annexure. From FY 2015-16 no separate UC needs to be submitted under NOHP. The UC under the pool of system strengthening will cover the utilization of NOHP.

Apart from the above it is to be noted that the flexibility has already been to the states at the time of sending PIP proposal and there is also provision of temporary loan from other pool for making expenditure, but in no case expenses should exceed the approvals given in the PIP.

ANNEXURE I: TORs for the manpower

  1. National Oral Health Cell

A.1 Oral Health Consultant: 1

Qualification:

Essential

i)MDS/ MD [Community Medicine, Community Health Administration, Community Dentistry]

or

ii)BDS with Masters in Public Health (MPH) with at least 2 years experience in related field

iii) Should be registered with either the Medical/Dental Council of India

Desirable:

Experience in Oral Health or any other Public Health Program