Safaa Suliman sees dental care as an integral part of Public Health

Safaa Suliman sees dental care as an integral part of Public Health

As a pediatric dentist and epidemiologist, Safaa Suliman knows that working with children is not just about fixing their teeth. It also includes nutritional counseling and parent education about the importance of preventive dental services. In that capacity, dental health is closely related to public health, pointed out Suliman, a doctoral student in epidemiology at Columbia’s Mailman School of Public Health.

According to American Association of Pediatric DentistryAccording to its policy, pediatricians should refer parents to a pediatric dentist for an infant’s first dental checkup by six to 12 months of age. Partnerships like these can help reduce some of the barriers to getting dental care. In 2016, only approx 42% of US children aged 0 to 17 years had an annual dental visit. By 2020, the rate had risen to 80.9%. Suliman attributes some of this success to better coordination between pediatricians and dentists.

“Oral health should be integrated into public health because prevention should not be an individual issue,” Suliman argues. “Instead, dental disease prevention should be addressed at the state level.”

Leading the Earth Institute’s oral health and hygiene initiative Millennium Villages ProjectSuliman tried to implement a similar cooperation strategy in Ethiopia.

Originally from Sudan, Suliman first started in the field of public health after joining the Ministry of Health in Khartoum, the capital of Sudan. Using her expertise as a general dentist, she helped establish the first government school oral health program in Khartoum and also developed research guidelines for the ministry.

This experience sparked her interest in working with marginalized populations and implementing ambitious national oral health programs. 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, she was soon accepted as a Ph.D. student in the university’s epidemiology department. She then joined the Earth Institute (now Columbia Climate School) part-time in 2012 as director of the oral health and hygiene project in Koraro. Millennium Village Project location in Ethiopia.

We are joining forces with a farming community in Ethiopia

In rural Ethiopia, socioeconomics and lack of access to dental services are not the only causes of rampant oral disease among children and adults. Cultural beliefs and harmful traditional practices also play a role. Some of these practices include tattooing the gums, extracting baby teeth and subjecting children to a rhadiectomy (a surgical procedure where the gingiva – the 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 be cured by removing gingivitis or tooth buds during the teething phase,” Suliman explained.

Shortly after landing in Ethiopia in 2012, Suliman set out to explore how she could address such profound oral health problems in Koraro.

A remote village located in the Tigray region of northern Ethiopia, Koraro’s 55,000 residents speak the Tigrinya language. (The official language in Ethiopia is Amharic.) To overcome language barriers, Suliman recruited dental students from Addis Ababa University who spoke fluent English and Tigrinya. Under Suliman’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 noticed that most of the villagers did not have tooth decay. “I wasn’t shocked because they didn’t have access to sugar back then. The problem was that they didn’t brush their teeth regularly, which resulted in a lot of gum inflammation and bleeding,” Suliman said. “When sugar is introduced into their diet, which I assume is happening now thanks to better access to soft drinks and snacks, they will also develop cavities.”

As a foreign researcher, she knew that simply telling a community why their traditional practices are wrong and that they should develop new habits would be perceived as an attack. “Rather than just telling them what to do, it’s important to work with them by first gaining the trust of the community gatekeepers. If they can be convinced that traditional practices are harmful, they will also convince everyone else in their community,” Suliman added.

He first approached a number of local stakeholders in Koraro, including nurses, midwives, farmers, youth organizations and members of development groups. In particular, Suliman worked closely with community health workers known as the women’s development army. “They are mothers who are smart and active in their communities. Local decision makers hired them to spread health information to other mothers,” Suliman said. “So I started engaging with these already established women’s army development groups and trained them in 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 2019, Suliman and colleagues reported what they gleaned from initial focus groups involving 96 community members in Koraro. They found that lack of oral health awareness was more prevalent among older participants. Many believed that worms cause cavities. While younger adults were better informed, they were still unable to establish adequate oral hygiene programs because of how expensive it was to purchase a toothbrush and toothpaste.

Armed with data from the focus groups, Suliman launched a school oral health program where she trained teachers on how to educate their students about oral health and hygiene. The training also included requiring teachers to monitor the brushing habits of their young students after providing them with toothbrushes and toothpaste. The program lasted the entire school year.

To test the program’s effectiveness, Suliman and her team randomly assigned schools in Koraro to three interventions: In the first group, teachers trained their students using Suliman’s oral health and hygiene curriculum. In a second group, teachers not only trained their students but also gave them free oral hygiene tools and supervised their tooth brushing habits. The third group of students received neither the curriculum nor the tools.

Not surprisingly, the schools that had overseen tooth brushing and education did well. The children’s gum inflammation subsided and their oral health improved dramatically within a short period of time. However, the group of students who only had access to the curriculum – but did not receive toothbrushes and supervision – performed poorly, similar to the third group with no intervention. “Education alone does not work. There has to be practical application of the skills taught in a classroom,” Suliman said.

The long road to overcoming lack of access to dental care

In 2017, the project in Ethiopia was completed. Suliman then had the opportunity to pursue a three-year residency in pediatric dentistry at Boston University. At the end of 2021, she completed her residency and is now pursuing her Ph.D. program at Columbia.

From her extensive fieldwork in Ethiopia and Senegal, Suliman observed that although low-income countries have made great strides in providing medical care for the masses, dental treatment remains out of reach for the average person living in any rural area. During the project, only one dentist was available in rural Tigray — located in a health center in the largest nearby town, a 45-minute drive from Koraro. “By the end of the program, he informed me that he was leaving the health center,” Suliman said.

Village members have to walk for several hours to reach this health center. They only visit when there is a health emergency. In these rural areas, traditional practitioners in the villages continue to extract teeth unsanitarily, he added. “Although the villagers know this could be counterproductive to their health, their options are limited. Unfortunately, dentists cannot travel to such remote areas. The only way forward is to provide dentists with adequate resources to remain 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. This makes it vital for policy makers to subsidize these essential items so that marginalized communities can purchase them in their local shops.

“So soap became accessible to everyone. Sanitation workers provided cheap soap and educated communities about the importance of hygiene. Once it became affordable, village members started buying soap,” Suliman said. “Policymakers need to understand the importance of oral health and make it a priority.”

Over the years, Suliman has noticed that oral health trends are the same everywhere. In high-income countries like the United States, access to dental care depends on whether or not one has insurance. “For low-income communities, it doesn’t matter if they live in New York or the village of Koraro in Ethiopia – access to dental care is a global issue.”