Many Americans fondly remember “Tommy the Tooth” – the ever so familiar image of a clean and sparkling white molar reminding children to brush their teeth every day. However, most refugees seldom receive the appropriate education, screening, and care to maintain healthy oral hygiene. This is true not only of the regions refugees flee from, but also of refugee camps, where healthcare generally focuses on addressing acute illness. Bhutanese refugee camps in Nepal were no stranger to this tendency, despite hosting refugees for, sometimes, decades. Between the years of 2009 and 2012, 87% of Bhutanese refugees in Madison County, Wisconsin, who had oral health screenings were referred to a dentist for early caries, urgent dental care, or prevention. In light of such data, this article will seek to further explore the etiology, prevalence, and significance of oral health challenges amongst Bhutanese refugees in North America
Bhutan, like many other developing nations, has had a great need for dental health and hygiene services, but has only recently begun working towards filling that need for its citizens. By 2007, when Bhutan created its National Professional Dental Health Services Standard, nearly all of the Nepali-speaking Bhutanese had been expelled from the nation and forced into refugee camps, which lacked oral health education and services. More importantly, these refugees, including the many children who grew up in the camps, did not have access to dentally protective fluoridated water. Now elderly Bhutanese refugees also commonly chewed betel nuts in camps, placing them at a higher risk for oral cancers. These factors compounded with the effects of anxiety, including bruxism and acid reflux, fostered an environment ideal for oral and dental disease.
A study exploring immigrant and refugee oral health in Nova Scotia, Canada, found that 85% of recent refugees had untreated decay, with most having gingivitis and a majority having developed its more severe cousin, periodontitis. If left untreated, this condition can lead to tooth loss and bleeding gums, among other complications. Ultimately, this end state has severe implications on a person’s quality of life and nutritional status. While I will discuss nutritional concerns in this population in a later article, it is important to appreciate the effects of oral health and hygiene on a person’s overall ability to eat the foods necessary to derive recommended nutrition. Malnutrition, consequently, can lead to more severe oral health concerns.
In Philadelphia, a survey conducted through the Center for Urban Health at Thomas Jefferson University (Jefferson) found that a lack of dental health care was identified as a barrier to better health for Bhutanese refugees. As a student at Jefferson, I have had the pleasure of working with individuals from this population. However, in my observation, patients who come into clinic with tooth pain owing to severe dental decay require a tooth extraction, which cannot easily be provided in free clinic settings. These patients must then overcome language barriers in resource-poor areas in order to travel to free or low-cost dental clinics to have a tooth pulled. When taking into consideration additional challenges with insurance coverage, these individuals may find it easier to simply take an increased strength or quantity of pain medication to address their acute symptom of tooth pain. This, of course, does not address the root cause of the pain and allows the initial decay to spread to other teeth or areas of gum, ultimately causing more pain and irritation.
Hence, the best way of addressing the lack of oral hygiene in this population may lie in prevention, which can be implemented in both free clinic and public health settings. In a free clinic, this can be as simple as offering to apply dental fluoride varnish to patients’ teeth and explaining to them its benefits. In my experience, this intervention was well-received in the population when recommended by a physician. The process is also fairly quick and straightforward for the healthcare provider, and explanation regarding temporary restriction on food and drink for a few hours following topical application of the varnish is simple for the patient to understand. In the realm of public health, ensuring that refugees, many of whom live in resource-poor settings, have access to fluoridated water is important in decreasing the overall number of cavities in the population. This absolutely includes the undeniably important aspect of education, especially regarding the importance of drinking fluoridated water and maintaining oral hygiene. To accomplish this with children and adults in these communities, it may indeed prove useful to ask for help once again from our beloved friend, Tommy the Tooth.
A study exploring immigrant and refugee oral health in Nova Scotia, Canada, found that 85% of recent refugees had untreated decay, with most having gingivitis and a majority having developed its more severe cousin, periodontitis. If left untreated, this condition can lead to tooth loss and bleeding gums, among other complications. Ultimately, this end state has severe implications on a person’s quality of life and nutritional status. While I will discuss nutritional concerns in this population in a later article, it is important to appreciate the effects of oral health and hygiene on a person’s overall ability to eat the foods necessary to derive recommended nutrition. Malnutrition, consequently, can lead to more severe oral health concerns.
In Philadelphia, a survey conducted through the Center for Urban Health at Thomas Jefferson University (Jefferson) found that a lack of dental health care was identified as a barrier to better health for Bhutanese refugees. As a student at Jefferson, I have had the pleasure of working with individuals from this population. However, in my observation, patients who come into clinic with tooth pain owing to severe dental decay require a tooth extraction, which cannot easily be provided in free clinic settings. These patients must then overcome language barriers in resource-poor areas in order to travel to free or low-cost dental clinics to have a tooth pulled. When taking into consideration additional challenges with insurance coverage, these individuals may find it easier to simply take an increased strength or quantity of pain medication to address their acute symptom of tooth pain. This, of course, does not address the root cause of the pain and allows the initial decay to spread to other teeth or areas of gum, ultimately causing more pain and irritation.
Hence, the best way of addressing the lack of oral hygiene in this population may lie in prevention, which can be implemented in both free clinic and public health settings. In a free clinic, this can be as simple as offering to apply dental fluoride varnish to patients’ teeth and explaining to them its benefits. In my experience, this intervention was well-received in the population when recommended by a physician. The process is also fairly quick and straightforward for the healthcare provider, and explanation regarding temporary restriction on food and drink for a few hours following topical application of the varnish is simple for the patient to understand. In the realm of public health, ensuring that refugees, many of whom live in resource-poor settings, have access to fluoridated water is important in decreasing the overall number of cavities in the population. This absolutely includes the undeniably important aspect of education, especially regarding the importance of drinking fluoridated water and maintaining oral hygiene. To accomplish this with children and adults in these communities, it may indeed prove useful to ask for help once again from our beloved friend, Tommy the Tooth.