Safa Suleiman considers dental care to be an integral part of public health
As a pediatric dentist and epidemiologist, Safa Suleiman knows that working with children is not just about fixing their teeth. It also includes dietary counseling and parent education about the importance of preventive dental services. In this capacity, dental health is closely related to public health, noted Suleiman, a doctoral student in epidemiology at Columbia’s Millman School of Public Health.
Based on American Pediatric Dental AssociationAccording to this policy, pediatricians must refer parents to a pediatric dentist for the first dental examination of a baby between six and 12 months of age. Collaborations like this can help reduce some of the barriers to getting dental care. In 2016, only approx 42% Children aged 0 to 17 in the United States visited the dentist’s office annually. By 2020, this percentage had increased 80.9%. Suleiman attributes part of this success to better coordination between pediatricians and dentists.
“Oral health should be integrated with public health, because prevention should not be an individual issue,” Solomon argues. Instead, dental disease prevention should be addressed at the state level.”
while leading the Oral Health and Hygiene Initiative at the Earth Institute Millennium Villages ProjectSuleiman tried to implement a similar joint strategy in Ethiopia.
Originally from Sudan, Suleiman first entered the field of public health after joining the Ministry of Health in Khartoum, the capital of Sudan. Using his expertise as a general dental practitioner, he helped launch the first state-level oral health school program in Khartoum and also developed research guidelines for the ministry.
This experience sparked his interest in working with marginalized populations and implementing ambitious oral health programs across the country. In 2009, he moved to New York to join Columbia University Master’s program in public health To gain a deeper understanding of the field. After graduating in 2011, he was soon accepted as a Ph.D. student in the university’s epidemiology department, then joined the Earth Institute (now Columbia’s Climate School) part-time in 2012 as director of the Oral Health Project in Curaro. Millennium Village Project Site in Ethiopia
Joining forces with the rural community of Ethiopia
In rural Ethiopia, socioeconomics and lack of access to dental services are not the only causes of oral diseases among children and adults. Cultural beliefs and harmful traditional customs also play a role. Some of these procedures include gum tattooing, pulling baby teeth, and subjecting children to uvulectomy (a surgical procedure in which the uvula—a small bell-shaped piece of flesh that hangs from the roof of the mouth) is removed. “Misinformation and myths have led villagers to believe that a sick child will get better by removing the tooth buds during the teething stage,” Suleiman explained.
Soon after landing in Ethiopia in 2012, Suleiman decided to investigate how he could address such profound oral health issues in Koraro.
A remote village located in the northern Tigray region of Ethiopia, Koraro’s 55,000 inhabitants speak the Tigrinya language. (The official language in Ethiopia is Amharic.) To overcome language barriers, Suleiman recruited dental students from Addis Ababa University who were fluent in English and Tigrinya. Under Suleiman’s guidance, the team conducted extensive research that included focus groups, surveys, and dental examinations in Koraro. These studies shed light on the causes of oral diseases.
He observed that most people in the village do not have tooth decay. I wasn’t shocked because they didn’t have access to sugar back then. The problem was that they did not brush their teeth regularly, which led to gingivitis and excessive bleeding. “Once sugar enters their diet, which I think is happening now thanks to better access to soft drinks and snacks, cavities will also occur.”
Being an outside researcher, he knew that simply telling them why their traditional ways were wrong and that they needed to develop new habits would be seen as an attack. Instead of just telling them what to do, it’s important to work with the gatekeepers of the community first by gaining their trust. Suleiman added: “If they can be convinced that traditional practices are harmful, they will convince other members of their community as well.”
He first contacted several local stakeholders in Koraro, such as nurses, midwives, farmers, youth organizations and development group members. In particular, Suleiman worked closely with community health workers known as the Women’s Development Army. They are mothers who are smart and active in their communities. Their local decision makers hired them to spread health information to other mothers.” “So I used these women’s development army groups that were already formed and taught them how to discuss harmful traditional practices that are endemic in these areas. Also, the importance of nutrition and oral hygiene with other mothers.
In a Lancet study 2019Suleiman and his colleagues gathered what they could from initial focus groups involving 96 community members in Koraro. They found that lack of knowledge about oral hygiene was more common among older participants. Some believed that worms caused cavities. While younger adults were more knowledgeable, they were still unable to establish adequate oral hygiene regimens due to the high cost of purchasing toothbrushes and toothpaste.
Using data from focus groups, Solomon launched a school oral health program where she taught teachers how to teach their students about oral hygiene. The training also included making the teachers follow the brushing habits of their young students after providing them with toothbrushes and toothpaste. This program was implemented during the academic year.
To test the effectiveness of the program, Suleiman and his team randomly assigned schools in Koraro to three interventions: In the first group, teachers trained their students with Suleiman’s oral health curriculum. In the second group, teachers not only taught their students, but also gave them free oral hygiene tools and monitored their brushing habits. The third group of students received neither curriculum nor tools.
Not surprisingly, schools that monitored brushing and teaching performed well. The children’s gingivitis subsided and their oral and dental health improved drastically in a short period of time. However, a group of students who only had access to the curriculum—but not toothbrushes and supervision—showed as poor results as a third group without the intervention. “Education alone does not work. Suleiman said: The skills taught in the classroom should have practical application.
A long way to overcome lack of access to dental care
In 2017, the project in Ethiopia was completed. Suleiman then had the opportunity to pursue a three-year residency in pediatric dentistry at Boston University. In late 2021, he completed his residency and is now resuming his Ph.D. Program in Colombia
From his extensive fieldwork in Ethiopia and Senegal, Suleiman observed that even though low-income countries have made great strides in providing medical treatment to the masses, dental treatment remains inaccessible to ordinary people living in every rural area. During the project, only one dentist was available in the rural area of Tigray – located in a health center in the largest nearby town, 45 minutes by car from Koraro. “At the end of the program, he informed me that he was leaving the health center,” Suleiman said.
Village members have to walk for several hours to reach that health center. They only visit if there is a health emergency. He added: In these rural areas, traditional doctors in the villages continue to pull teeth in an unhygienic manner. Although the villagers know that this can be harmful to their health, their options are limited. Unfortunately, dentists cannot relocate to such remote areas. The only way forward is to provide adequate resources for dental therapists to reside in rural areas and serve the communities.
Another persistent issue is that toothbrushes and toothpaste are still too expensive for Ethiopians living in rural areas. It is imperative for policy makers to subsidize these essential items so that marginalized communities can purchase them in their local shops.
This is how soap became available to everyone. Sanitation workers provided cheap soap and educated communities about the importance of hygiene. Suleiman said: When the price became affordable, the village members started buying soap. Policymakers should understand the importance of oral health and make it a priority.
Over the years, Suleiman has observed that oral health trends are the same everywhere. In high-income countries like the United States, access to dental services depends on whether one has insurance. For low-income communities, whether they live in New York or the village of Koraro in Ethiopia, access to dental care is a worldwide issue.