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Logo of Phnom Penh Post newspaper Phnom Penh Post - Much to smile about? The agony of dentistry

Much to smile about? The agony of dentistry

OPEN WIDE: Dental surgery at Dr Hong Somethís clinic.

In 1997, Chamroeun Sok came down with bad toothache. He went to see a dentist, thinking

it would help ease the pain. It didn't - the traditional dentist removed four of

Sok's healthy teeth, leaving him with recurring pain that has plagued him since.

"They extracted my teeth and cut out the nerves without any anesthetic,"

he says. "Immediately after they put the crown in, I had pain and then swollen

gums a week later. They said it would get better very soon."

That was six years ago, and is why he is now sitting in the waiting room of another

dental clinic in Phnom Penh. Pristine staff clad in dazzling white outfits slip in

and out of the operating room. Customers sip iced water from plastic cups while waiting

for their turn in the chair.

The clinic belongs to qualified dentist and senior lecturer at the Faculty of Dentistry

Dr Hong Someth. He says the problems Sok has encountered are all too familiar.

"We have two types of dentist in Cambodia," he explains. "One is qualified,

the other is a traditional dentist. The traditional dentists do very dangerous things."

Traditional dentists, Dr Someth explains, are those who have learned their skills

from their parents. Despite their lack of formal schooling and the fact there are

few regulations, they are allowed to practice provided they are registered with the

Ministry of Health (MoH).

Poverty, a dearth of trained dentists, and generally poor education mean many people

still flock to the chairs of these untrained operators.

"People still believe in traditional dentistry," says Dr Someth. "The

reason is they are easily accessible, and cheaper than the qualified dentist. People

prefer the treatment methods of some dentists, and this is because of lack of knowledge."

Dr Someth sees the consequences of traditional dentistry daily. Holding up an X-ray

of a patient's jaw, he points to a large, egg-sized blotch that sits above the misshapen


"That is a cyst caused by the traditional dentist," he says, explaining

that incorrect filling of the roots caused this painful problem. The treatment is

also unpleasant.

"We lift up the gums and scrape out the cysts," he says. "Then we

cut out the tips of the roots so we can put more medication inside."

An examination of oral health here reveals a sorry picture: there are only 374 qualified

dentists, one for every 30,000 people. Partly as a result, the country's children

suffer one of the worst oral health rates in the developing world: a six-year-old

has an average of 9.7 teeth that are either decayed, missing or filled.

The reason has a familiar historical ring. Only 34 dentists remained alive after

the Khmer Rouge's attempted extermination of the educated class, leaving those in

rural areas with no access to dental care for years.

"After the Pol Pot regime, 90 percent of Cambodian people had oral disease,"

says Dr San Nyet, a dentist who trains medical workers in dental nursing. "They

were in rural areas and could not travel to the cities."

The first steps were taken in 1987, when the Faculty of Dentistry was set up at the

Royal University of Phnom Penh. In 1991, an NGO called International Cooperation

Cambodia helped the government to establish mobile training centers for dental nursing

in the provinces.

Traditional dentist Bun Than, who wants one of his children to go to dental school.

"The first unit was in Kandal province," says Dr San Nyet. "We selected

students from the health center and trained them. First we trained six students,

now we have 292 dental nurses in the whole of Cambodia. We do fillings, extraction,

clean the teeth, and give oral health education in schools."

But many qualified dentists still don't believe enough is being done to help improve

people's mouths. The government has other health priorities, dentistry experts say,

which means oral health problems are pushed aside.

"Other countries have an oral health budget," says Dr Oum Teng, president

of the Cambodian Dental Association (CDA). "I do not expect any money from the

government because ... in Cambodia we are not a priority like TB and HIV. We need

more support."

Dr Oum stresses that oral health is linked to many other problems, and consequently

should not be ignored.

"Poor oral health can cause HIV," he says. "It can be passed on through

bad sterilization. Traditional dentists ... do not update their knowledge. They do

not know about sterilization. Traditional dentists use the microwave, but there is

no research to show this is appropriate for sterilization."

Although no research has been undertaken locally into links between bad dentistry

and HIV infection, Dr Someth has encountered patients who believe it transmitted

the disease.

"One patient said her son died of AIDS at 16," he says. "He had never

been to any brothels, he was a good student, and a few years after the extraction

he died of HIV."

For Dr Oum, the solution to the problem is clear.

"The government should create a board of directors for oral health," he

says. "Their role would be controlling public and private sector clinics. If

you are not a dentist, then you cannot open a clinic."

MoH officials insist oral health is seen as a priority, and say a law passed last

year will put an end to cowboy clinics.

"If they do not have a certificate from the university of dentistry they are

illegal and they are not allowed to operate," says Ung Phirun, secretary of

state at the MoH.

The law covers the spectrum of illegal medical practitioners, including dentists,

doctors, pharmacists and plastic surgeons. Phirun says letters are currently being

sent to all involved.

"We will inform them that we have made it illegal, and if they continue to operate

we will take them to court," he says.

However he was unable to comment on how long it would take to close down the country's

numerous traditional dental clinics, or what would replace them.

One man who may be forced to shut up shop as a result of the new law is traditional

dentist Bun Than. His clinic is at the back of his house near Psar O'Russey, where

the roads are packed with similar clinics, often nestled inside a pharmacy or a money

exchange booth. Hand-painted signs of wide-open jaws or a smiling set of falsies

entice potential patients.

Although it does not match the immaculate standards of Dr Someth's clinic, Than's

operating room is clean, and the smiling dentist has 17 years' experience.

3,000 children at 225 schools are involved in a daily teeth-brushing program that has reduced dental problems by two-thirds.

"I practiced with my father," he says. "I never learned by the rules,

just by my ancestors - my father and my grandfather. This is my family business.

We don't have any other skills but dentistry."

Bun Than carries out a range of work, such as cutting teeth and replacing them with

false ones, putting on gold caps, and performing fillings. He says he adheres to

strict sterilization of his equipment, and maintains his patients have faith in his


Also, he says, the government has visited to grant him a license.

"We replace teeth, but we do not extract because the doctors asked us not to

pull them since we are just traditional dentists," he explains. "In the

late 1990s they came and asked me to apply for a license, which I did."

Bun Than got his license without much in the way of scrutiny. The MoH officials,

he says, told him they had other traditional dentists to see, so did not have time

to watch him perform surgery.

Although this lack of regulation worries many, most agree the solution is not a clear

cut matter of ditching traditional dentists, especially when there is nothing else

to fill the gap.

"The MoH wants to reduce traditional dentists," says trainer Dr San Nyet,

"but there are not enough dentists and dental nurses."

But things may be looking up. Enrollment in the Faculty of Dentistry has increased

in recent years. Lecturer Dr Someth says the number of first-year students has more

than doubled to 50 in the past year alone.

Another positive step is that some traditional dentists such as Bun Than are now

sending their children to study at the faculty.

"I have four children, and I want one of them to be an official dentist,"

he says. "I want to send him to the Faculty of Dentistry. They have no time

to learn from me because they go to school every day."

Another innovation is a prevention program funded by the government and NGOs. It

aims to increase awareness of good oral health in primary schoolchildren, thereby

preventing disease.

The CDA's Dr Oum heads the program. He says 225 primary schools take part in the

scheme. It involves 3,000 children brushing their teeth twice a day, rinsing once

a week, and a host of educational activities. He is encouraged with the results.

"If we compare to a school in Phnom Penh without the preventative program, they

have 4.7 decayed, missing or filled teeth. In the preventative program, it is 1.6,"

he explains. "If we look at the difference, that is three teeth."

Despite the good results, Dr Oum is skeptical it can be expanded nationwide. There

are 5,875 primary schools teaching 2.3 million children, and the money simply isn't


"I do not expect [the program will expand] because it is not sustainable,"

he says. "We need support from communities and from the national budget."

Dr Oum says root problems, such as poverty and lack of education, need to be tackled

before real progress in oral health will be made.

"My main goal would be to hold Cambodia's oral health up to other developing

countries," he says. "[But] if you have no food, how can you be concerned

about your mouth?"



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