Vandana Munishappa had a pink bandage across the left side of her jaw and a long line of stitches across her lower lip and her chin. The 14-year-old was petite for her age and her large, bright eyes made her seem much younger than she was. But she remained calm as she lay on the dental chair, awaiting her check-up, amid the bustle of the dentists, oral surgeons and medical students around her. Despite being unable to move her mouth fully, Munishappa forced a smile.

In June 2021, Munishappa, a class nine student, had noticed a swelling on her left cheek and felt some discomfort inside her mouth. But she ignored it.

She lived in a hostel in Bengaluru, away from her home in Karnataka’s Chikkaballapur district, and attended a government school in the city. In August, the swelling increased. Her teachers at the school took her to a dentist, who prescribed her painkillers and antibiotics. However, the swelling did not reduce. In a few weeks, Munishappa started to develop lesions on her chin and her cheek, and pus began to ooze out of them. Her teachers called up her mother, Shyamala V, and asked her to take the child back home and seek medical help.

Munishappa returned home to her small village, named Akalathimmanahalli, in Chikkaballapur. Shyamala, a daily wage earner, and the only breadwinner in her family of four, could not stay home and take care of her. So she left her daughter at her own mother’s house in another village.

Munishappa’s grandmother tried to find local village cures for the teenager. Nothing worked. Shyamala brought her back home and tried to get help from the village “doctors” – typically, unqualified practitioners who dispense basic medicines and treatment. “But that also did not help,” Shyamala said.

Finally, Shyamala decided to take her daughter to the government hospital in Chikkaballapur. “There were barely any facilities at the hospital,” Shyamala said. “The dentist we met there asked us to come to Bengaluru.”

When Munishappa arrived in Bengaluru, 70 kilometres from her home, and consulted with dentists, she was diagnosed with osteomyelitis of the jaw, a condition in which the bone cortex and marrow become inflamed, and which often occurs after a dental infection.

Dr Ashwin DP at Vokkaligara Sangha Dental College and Hospital, who is Munishappa’s surgeon, estimated that the first signs of the infection had appeared around a year, or a year and a half ago.

The infection had spread too deep and there was no way for the oral surgeons to conserve her jaw. It had to be removed and reconstructed. The signs of the surgery were unlikely to fade away, Ashwin noted.

The effects of the surgery were also likely to linger on for the rest of her life. Chewing would be difficult, which could put her at risk of malnutrition. In fact, Munishappa’s petite frame was likely a result of malnutrition, her doctor said.

It was a vicious cycle.

“The reason she got the infection in the first place was quite possibly because of malnutrition,” Ashwin said. “Her haemoglobin levels are low. Now, because of this infection, she may have to battle malnutrition in the future too.”

The economic burden of the treatment was also considerable. Shyamala earned about Rs 350 a day doing agricultural labour. She had another daughter, in high school. Her husband did not work. A trip to Bengaluru for her daughter’s treatment cost her a minimum of Rs 1,000. The days she made this trip, which took one-and-a-half hours each way, she lost a day’s wage. “We’ve been taking loans,” she said, with tears in her eyes. “There is no one else who can take her to the doctor. Only me.”

The morning of the day in March that we met, Shyamala had fought with her husband. He had demanded to know why their daughter needed to go to the doctor even after the surgery. She said that such fights were common and that her husband did not approve of these trips that she and her daughter had to make.

After the check-up was done, Shyamala lingered at Ashwin’s table for a while. “Can you suggest a hospital close by to our village?” she said. “It is difficult for us to keep coming here.”

Ashwin and two of his colleagues who were also in the exam room urged her to cope with the stress of the travel for just a little longer. “When the treatment has gone so well so far, why do you want to compromise in the last stages?” a doctor said.

As mother and daughter left the room, Munishappa waved goodbye to all the doctors and residents in the room.

Vandana Munishappa suffers from osteomyelitis of the jaw, a condition in which the bone cortex and marrow become inflamed, and which often occurs after a dental infection. Photo: Johanna Deeksha

Doctors at the hospital are not unused to patients like Munishappa, who come to them late. “Most patients who come to us, come at a very advanced stage when we cannot do anything to conserve the affected areas,” Ashwin said, as we sat in the exam room of the hospital. “Unless they go to a formally trained dentist, they don’t get referred on time. Because oral health is often neglected.”

India has the largest number of dental colleges in the world. According to the Dental Council of India, there are 322 dental colleges in the country, which can admit about 25,000 students each year. A total of 2.8 lakh dentists are registered with the Dental Council of India. These figures would suggest that there is one dentist for every 5,000 people in India. A report from the Indian Dental Association noted, “For a population of over 1.2 billion, there are currently over 1,80,000 dentists” – indicating that there is one dentist for approximately every 6,500 people.

Both these ratios are better than the World Health Organisation’s recommendation of one dentist for every 7,500 people. Yet, Vandana and her mother had to travel a long distance to get the medical support they needed.

There are two possible reasons for this. One, the number of registered dentists does not necessarily correspond with the number of practising dentists. “Not all dentists who register in India continue to work here,” said Dr Rajeev BR, a researcher in the field of oral health. “Some move abroad, some others drop out, some branch out into other fields like research.”

The other is that there is a huge disparity between the ratio of dentists to the general population in urban and rural areas. According to data from the Indian Dental Association, there is one dentist for every 9,000 people in urban areas, and one for every 2,00,000 people in rural areas.

A child with Vandana’s ailment in a different state might have faced even greater problems accessing care. Almost 62% of registered dental surgeons are concentrated in just six states. These states – Karnataka, Maharashtra, Tamil Nadu, Andhra Pradesh, Kerala, and the union territory of Puducherry – are all states with high “HRH” or human resources for health.

These skews have made oral healthcare difficult to access for many, a problem compounded by a broader tendency to treat the field as less important than general healthcare, dentists pointed out. “Then comes other social determinants – travel, distance, access, affordability. All this delays treatment,” said Dr Sushi Kadanakuppe from the department of public health dentistry at the Vokkaligara Sangha Dental College and Hospital,.

The biggest evidence of this neglect, Kadanakuppe added, “is the fact that we do not have sufficient data on oral health in this country. There is no enthusiasm to do a national oral health survey.”

Kadanakuppe said that the collection of oral-health data would be the first step to addressing the challenges in the field and improving accessibility. “To make any policy you need data,” she said. “And only with a good policy can we make any progress.”

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The last national oral health survey was conducted nearly 20 years ago, in 2003. Another survey was conducted in 2007, but focused only on seven states. Yet another survey was commissioned in 2008, but its results were never released because a review by the Dental Council of India found that it was filled with methodological errors.

The absence of recent data is mirrored in the fact that oral healthcare has received relatively little attention from the government.

“Remember the tobacco advertisement with Mukesh Harane?” said Dr Manu Mathur, a dental surgeon and senior research scientist at the Public Health Foundation of India, New Delhi. He was referring to a public-service advertisement that was commonly played in theatres before film screenings in the early 2010s. “That character is etched in our memory,” Mathur said.

The ubiquity of the advertisement was a sign “of how seriously the government took the tobacco problem in the country,” Mathur said. But, he added, the reason why tobacco control was given priority was that the government had the data to prove that there was a problem. “Even the mental health bill was passed after the data collected showed that there was a serious problem on our hands,” he said.

To date, however, no questions on oral health have figured in the five National Family Health Surveys conducted since 1992.

In the absence of data, efforts to craft an oral health policy for the country have also floundered.

The Indian Dental Association drafted a policy in 1985. This text remained a draft for many years, even after it found mention in the national health policy in 1995 – that year, the government formally acknowledged the need for an oral health policy, and launched a pilot project on oral health in five districts across five states, run by the All India Institute of Medical Sciences.

In 2014-’15, the government launched the National Oral Health Programme – but even this is still only implemented in 294 out of the country’s more than 700 districts. The programme “is in its very nascent stage,” Mathur said. “It is too early to say whether it has been successful or not.” He added that it could be “strengthened further with a strong policy statement”.

In February 2021, the Ministry of Health and Family Welfare released a second draft national oral health policy, and invited feedback from the public. Mathur himself was part of the committee constituted to draft this policy. He told that the policy was in its final stages.

India has launched several successful health programmes since its Independence. Typically, the programmes were formulated in response to the most pressing health issues of the time.

One of the first programmes to be implemented after Independence focused on maternal and infant mortality. “The need of the hour at that point was to bring down mortality rates,” said Mathur. Thus, the government focused on improving nutrition and healthcare access for women and children. In the early 2000s, the focus expanded to life-threatening infectious diseases like malaria, tuberculosis and HIV.

Eventually, the country’s programmes expanded beyond those that targeted infectious diseases. In 2010, the government launched the national programme for the prevention and control of cancer, diabetes, cardiovascular diseases and stroke, otherwise referred to as the NPCDCS.

Mathur believes that the dental community should have worked towards ensuring that oral ailments and diseases, such as oral cancer and periodontal diseases, were classified as non-communicable diseases and included in the programme. “But we failed to do so,” he said.

Dentists point out that for too long, oral healthcare has been viewed as distinct from general healthcare. “By treating it as separate from general medicine, we’ve undermined its importance,” said Dr Chandrashekar Janakiram, the head of the department of public health dentistry, in Kerala’s Amrita Vishwavidyapeetham. “If we drew more awareness to the fact that a lot of oral health problems are connected to general health, then it would be taken more seriously.”

Mathur pointed out the oral cavity “is the gateway to one’s overall health”.

Several research papers have found that there is aconnection between oral health and chronic conditions like diabetes, heart diseases and stroke. “It is the canary in the coalmine effect,” Janakiram said, referring to the 19th-century practice of sending canaries into coal mines to test the air for toxic gases.

For example, if a dentist finds that a patient has a recurring problem of swollen or bleeding gums, they are trained to immediately ask about their drinking, smoking and eating habits. Next, the dentist will typically direct the patient to check their sugar levels, since these symptoms can indicate diabetes. Heart ailments such as bacterial endocarditis can also be detected through an examination of the oral cavity – dentists maintain that if patients visited them at least twice a year, they would have a high chance of finding the bacteria early, allowing patients to take measures to prevent serious heart ailments.

The article also noted that within hospitals and the healthcare system in general, dentists and physicians needed to coordinate more closely in devising preventive strategies against ailments such as diabetes and cardiovascular diseases.

Some general ailments, such as bacterial endocarditis, which affects the heart, can be detected through examination of the oral cavity, allowing for timely intervention. Photo: Fredericnoronha/Wikimedia Commons

There has been some progress on this front. In May 2021, the World Health Organisation passed a resolution on oral healthcare, in which it recommended that efforts to tackle oral health problems should be included within broader plans to combat non-communicable diseases. The organisation also recommended that health insurance programmes should be expanded to cover oral healthcare.

Sound oral healthcare is also key to tackling oral cancer, which is the most common cancer among men and the second most common among women in India. Some of the first symptoms of oral cancer are lesions, or small white patches in the oral cavity. Dentists are trained to scrape off these white patches. If they recur, they are termed “pre-cancerous lesions”.

Dentists are equipped to handle cases that are in the initial stages. Slightly advanced cases need to be handled by oral surgeons, specialists within the field of dentistry. It is only those patients who reach very advanced stages who need to consult oncologists.

Many dentists told that patients usually visit dentists at these advanced stages of this problem, when the dentists can only refer them to oncologists.

Among those who benefited from visiting a dentist at a relatively early stage was Sushil Kachhi, a 48-year-old agricultural labourer from a village near Sirora, Jabalpur district in Madhya Pradesh. Until this year, Kachhi had never felt the need to visit a dental clinic.

But in January this year, his gums began to hurt. He tolerated the pain for about 20 days, after which it grew unbearable. He traveled 50 kilometres to Jabalpur city to meet Dr Nishkarsh Jaiswal, an oral and maxillofacial surgeon. Jaiswal diagnosed Kachhi with oral cancer.

“He came at an early stage, so he’s had his first round of surgery already. He should be okay soon,” Jaiswal said, when I spoke to him and Kachhi over a video call in March. Many patients come to him when the cancer is far more advanced, Jaiswal added.

Kachhi and his family are still anxious for his health. “The doctors are saying I will be okay, but until they tell me the cancer is completely gone, I won’t stop feeling afraid,” he said. For now, he travels 50 kilometres each way to make it to all his appointments.

Kachhi, the only earning member of his family, is the father of two children, one in school and the other in college. He is struggling to meet his expenses, since he has been unable to go to work since his diagnosis – he still has stitches and bandages across his face.

Kachhi borrowed money from relatives and friends to pay a part of his treatment expenses. The financial burden was somewhat reduced by the assistance he received through the government’s universal health insurance scheme, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana.

But the scheme’s coverage of oral health has reduced over the years.

When it was launched, it had a significant focus on “oral disease prevention and health promotion”, Mathur said. “But post-2019, it was only limited to treatment of facial fractures and oral cancer.”

Meanwhile, many dentists told that most private insurance companies exclude oral health from their coverage, viewing them as “cosmetic” procedures, and not potentially serious diseases.

Unsurprisingly, then, many in India still visit street “dentists”, who thrive to this day, even in large cities like Bengaluru. At the city’s KR Market, one of its most populated areas, pillars are adorned with posters of big smiles and shining white teeth. Next to it are a series of “before” and “after” pictures of patients who had sought the help of street “dentists” with dentures.

When I visited the area on a Wednesday morning in March, Mustafa, one such worker, who asked to be identified by a pseudonym, pulled out his phone and showed me another set of before and after pictures. “They come from all parts of the state. Even from other states, like Mumbai,” he said. “But we are not doctors. If patients come in with pain, we ask them to go to a dentist. We only fix dentures.”

This kind of intervention can lead to other oral health issues, Kadanakuppe said. “Patients come later and tell us they went to a street dentist and have developed problems.”

Street dentists still thrive in India today, typically frequented by those from poorer backgrounds. Treatment by these unqualified practitioners can lead to serious complications later. Photo: Reuters/Jitendra Prakash

But for many, the idea of visiting a qualified dentist remains a daunting one. “Patients, especially from poorer backgrounds, usually come only when the pain is absolutely unbearable,” Kadanakuppe said. “By then, there is no other option except to remove the tooth.” Though doctors view this as a last-ditch measure, many patients prefer it, “because that would mean they don’t need to keep visiting the doctor for treatment,” Kadanakuppe said.

What patients don’t realise is that such treatments have other health consequences. “Patients don’t realise that just resorting to pulling out teeth can have adverse effects on the body,” Janakiram said. “It affects the body nutritionally since it affects their ability to chew properly, and also affects them physiologically and psychologically.”

But dentists don’t blame patients for their neglect of oral healthcare. “It is up to the dental fraternity and the government to spread awareness,” Kadanakuppe said.

Any policies to improve oral healthcare in the country will prove ineffective as long as large swathes of the country have no access to dentists. Mathur believes that a major problem with the profession is that most dental graduates open up private practices rather than join the public workforce. Currently, of the 2.5 lakh dentists enrolled with the Dental Council of India, only about 2.7% are enrolled in government service.

But this was understandable, Mathur said, since after spending large sums of money on their education “they need to have some returns”.

The fee for the first year of a Bachelors degree in Dental Surgery starts at around Rs 50,000 in government colleges, and runs into lakhs of rupees in private colleges.

But even entering private practice after training is expensive. Those who choose to do so incur further costs, to purchase the equipment they need for a clinic. This investment runs into a few more lakhs.

“All that a general physician needs are a table and a stethoscope,” Janakiraman said. “But a dentist needs special equipment to perform even the most basic examination.”

Effectively, in order to recoup the investment in their training, many students spend more money, and then limit themselves to high-paying patients.

Sitting in his office in the Government Dental College and Research Institute, in Bengaluru, Dr Manjunath Puranik pointed to the dental chairs set up in his department of community medicine. “Each of those dental chairs costs one to two lakhs, just the chairs,” he said. “The other equipment also is very expensive. So after somebody invests in this, they want to ensure they make the money back. This is why the treatment charges at private clinics are so high.”

Cities are the only places that dentists in private practice can charge the high prices that they need to charge to pay back their investments and loans. “If they set up in rural areas, there would be no way that they can charge the same kind of prices. Nobody would be able to afford them,” Mathur said. He worried that this had led to those in the field being largely motivated by profits.

But Dr AL Gopinath, Professor of Oral and Maxillofacial Surgery at Vokkaligara Sangha Dental College and Hospital, argued that graduates’ reluctance to set up private practice in rural areas stemmed from a mental block, and that the scarcity of dentists in rural areas meant that each dentist was assured of a steady stream of patients. Some students of his had gone on to set up clinics in rural areas and were doing well, he noted. “If a dentist can treat a few patients in the cities and make money, patients in rural areas can treat dozens and make the same kind of money,” he said. “Dentists just needed to be assured that they would be able to have a good practice in rural areas too.”

When it came to government service in rural areas, Mathur argued that many dentists hesitated to take up jobs in rural areas because hospitals in these areas often lack proper equipment. “Treating dental diseases is extensive and expensive,” Mathur said. “The materials are required to be kept at a certain temperature and there are strict sterilisation norms to be followed. This becomes difficult at primary healthcare centres.”

“It is a problem that plagues dental clinics in primary health care centres across the country,” he added.

But Kadanakuppe argued that dentists weren’t reluctant to take up government postings. In fact, she said, students were scrambling for government jobs. “Students who come from poorer backgrounds can in no way afford to set up their own clinics,” she said. “Also, you need experience before you set up your own clinic, and that can take up to five years.”

She added, “The reality is that they are desperately looking for jobs with the government. The problem is there are no jobs available.”

According to Kadanakuppe and other dentists spoke to, there are simply not enough dentists posts available at government hospitals – only Community Health Centres and Primary Healthcare Centres in big cities had posts open for dentists, they pointed out. “In fact, the draft national oral health policy was criticised by many for not making this crucial recommendation to the government. The government must increase the number of postings,” Kadanakuppe said.

Even these centres do not have enough posts for dentists. According to health ministry data from 2018-’19, the number of dental surgeons “required” at community health centres nationwide was 10,670, but only 2,307 posts had been sanctioned.

Dr Rajeev BR noted that the power to allocate money in a district usually rested with the district health officer, and not the heads of different programmes. “If the directorate of the health programme devoted to oral healthcare is given financial authority, then they would ensure that the money was utilised fairly,” Rajeev said, adding that in the aftermath of Covid-19, oral ailments, like many other diseases, had been receiving even less attention than before.

For now, most patients in rural areas have to travel to cities to access well-equipped facilities.

On a bright and sunny Wednesday in March, Virupakshappa, a 46-year-old driver from Kunigal, Karnataka, walked hurriedly to the dentist’s office at the Government Dental College and Research Institute, Bengaluru, situated just a few kilometres from the hospital where Vandana was treated.

For six months, Virupakshappa had felt an intense pain in two of his teeth. He had visited the doctor at the primary healthcare centre in his hometown. He was given a prescription for painkillers and sent back. The pain subsided for a few days and then returned. He returned to the health care centre and was given the same medication.

“At the government hospital in my hometown, there are very few dentists and infrastructure is poor,” he said.

Virupakshappa struggled with pain again after a few days of the medication. Finally, six months later, he decided that he had had enough, and that he needed to see a dentist who would prescribe him more effective medication.

This meant he had to wake up early, walk to the bus stop, to catch an 8 am bus to Bengaluru city, more than 70 km away. “I just could not bear the pain anymore,” he said. “So I decided that I would rather miss a day’s work and travel to Bengaluru.”

He added, hopefully, “It will save me time off in the future,” then rushed towards the dentist’s office for his appointment.

Kadanakuppe argued that it was unacceptable that people should face such hurdles in accessing oral healthcare. “Only if we begin to recognise oral health as a human right will the government take steps to ensure that it is given the significance it deserves,” she said. “People should be aware that they deserve to have good oral health. Visiting the dentist cannot be considered a privilege, it is a basic fundamental right.”

This reporting is made possible with support from Report for the World, an initiative of The GroundTruth Project.