As a pediatric dentist and epidemiologist, Safaa Suliman knows that working with children is not only about fixing their teeth. It also involves diet counseling and educating parents about the importance of preventive dental services. In this capacity, dental health is intimately connected to public health, pointed out Suliman, an epidemiology doctoral student at Columbia’s Mailman School of Public Health.
According to the American Association of Pediatric Dentistry’s policy, pediatricians should refer parents to a pediatric dentist for an infant’s first dental check-up by the age of six to 12 months. Collaborations such as these can help to reduce some barriers to receiving dental care. In 2016, only about 42% of U.S. children aged 0 to 17 years had an annual visit to the dentist’s office. By 2020, the percentage had risen to 80.9%. Suliman attributes part of this success to better coordination between pediatricians and dentists.
“Oral health needs to be integrated into public health because prevention should not be an individual issue,” Suliman argues. “Instead, prevention of dental diseases needs to be addressed at the state level.”
While leading the oral health and hygiene initiative at the Earth Institute’s Millennium Villages project, Suliman tried to implement a similar collaborative strategy in Ethiopia.
Originally from Sudan, Suliman first ventured into the public health field after joining the Ministry of Health in Khartoum, the capital of Sudan. Using her expertise as a general dental practitioner, she helped set up the first statewide oral health school program in Khartoum and also developed research guidelines for the ministry.
That experience piqued her interest in working with marginalized populations and implementing ambitious nation-wide oral health programs. In 2009, she moved to New York to join Columbia University’s Master of Public Health degree program to gain a deeper understanding of the field. After graduating in 2011, she soon got accepted as a Ph.D. student at the university’s epidemiology department. She then joined the Earth Institute (now Columbia Climate School) part-time in 2012 as the oral health and hygiene project director in Koraro, a Millennium Village project site in Ethiopia.
In rural Ethiopia, socioeconomics and lack of access to dental services are not the only causes of rampant oral conditions among children and adults. Cultural beliefs and harmful traditional practices also play a role. Some of these practices include gum tattooing, extracting baby teeth, and subjecting children to uvulectomy (a surgical procedure where the uvula — the small bell-shaped piece of flesh that hangs from the roof of the mouth — is removed). “Misinformation and myths have made the villagers believe that a sick child will get cured by removing the uvula or tooth buds during the teething phase,” explained Suliman.
Soon after landing in Ethiopia in 2012, Suliman set out to explore how she could address such deep-seated oral health issues in Koraro.
A remote village located in the northern Ethiopian Tigray region, Koraro’s 55,000 residents speak the Tigrinya language. (The official language in Ethiopia is Amharic.) To overcome the language barriers, Suliman recruited dentistry students from the University of Addis Ababa fluent in English and Tigrinya. Under Suliman’s guidance, the team carried out extensive research that included focus groups, surveys, and dental examinations in Koraro. These studies shed light on the causes of oral conditions.
She observed that most of the villagers did not have tooth decay. “I was not shocked because they did not have access to sugar back then. The problem was that they did not brush their teeth regularly, which resulted in a lot of gum inflammation and bleeding,” said Suliman. “When sugar gets introduced to their diets, which I assume is happening now thanks to better access to soda and snacks, they will also develop cavities.”
Being a foreign researcher, she was aware that merely telling a community why their traditional practices are wrong and that they need to develop new habits would be perceived as an attack. “Instead of just telling them what to do, it is 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,” added Suliman.
She first approached several local stakeholders in Koraro such as nurses, midwives, farmers, youth organizations, and development group members. In particular, Suliman worked closely with community health workers known as the women’s development army. “They are mothers who are smart and active within their communities. Their local decision makers hired them to disseminate health information among other mothers,” said Suliman. “So I piggybacked on these already formed women’s development army groups, and I trained them on how to discuss harmful traditional practices that are endemic to these areas. Also, the importance of nutrition and oral hygiene with other mothers.”
In a 2019 Lancet study, Suliman and colleagues detailed what they gleaned from the initial focus groups that included 96 community members in Koraro. They found that a lack of awareness about oral health was more prevalent among the older participants. Several believed that worms cause cavities. While younger adults were better informed, they were still unable to build adequate oral hygiene regimens due to how expensive it was to buy 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 involved making the teachers supervise their young students’ toothbrushing habits after supplying them with toothbrushes and toothpaste. The program ran throughout the 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 educated their students with the help of Suliman’s oral health and hygiene curriculum. In a second group, teachers not only educated 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 which had supervised toothbrushing and education fared well. The children’s gum inflammation subsided, and their oral health drastically improved within a short span. However, the group of students who only got access to the curriculum — but did not receive toothbrushes and supervision — displayed poor results, similar to the third group with no intervention. “Education alone does not work. There needs to be a practical application of the skills that are taught in a classroom,” said Suliman.
In 2017, the project in Ethiopia came to an end. Suliman then got the opportunity to pursue a three-year-long residency in pediatric dentistry at Boston University. In late 2021, she completed her residency and has now resumed her Ph.D. program at Columbia.
From her extensive fieldwork in Ethiopia and Senegal, Suliman observed that even though low-income countries have made great strides in providing medical treatment for the masses, dental treatment remains inaccessible for the average person living in any rural area. During the project, only one dental therapist was available in the rural Tigray region — located in a health center in the largest nearby town, 45 minutes away from Koraro by car. “By the end of the program, he informed me that he was leaving the health center,” said Suliman.
Village members have to walk for several hours to get to that health center. They visit only when there is a health emergency. In these rural areas, traditional practitioners in the villages continue to extract teeth unhygienically, she added. “Even though the villagers know that could be counterproductive for their health, their options are limited. Sadly, dentists cannot move to such remote areas. The only way forward is to provide dental therapists with adequate resources to stay in rural areas and serve communities.”
Another persisting issue is that toothbrushes and toothpaste continue to be far too expensive for Ethiopians living in rural areas. This makes it crucial for policymakers to subsidize these essential items so that marginalized communities can buy them in their local shops.
“That is how soap became accessible for everyone. Sanitation workers provided soap at cheap rates and trained communities on the importance of sanitation. Once it became affordable, the village members started buying soap,” said Suliman. “Policymakers need to understand the importance of oral health and prioritize it.”
Over the years, Suliman has observed that oral health trends are the same everywhere. In high-income countries like the United States, access to dental care depends on whether someone has insurance or not. “For low-income communities, it does not matter if they live in New York or Koraro village in Ethiopia — access to dental care is an issue worldwide.”