General characteristics of the participants
In total, 101 people (51 children and 50 parents or guardians) participated in the in-depth interviews. There were no participants who refused to participate or withdrew consent. The adult participants’ ages ranged from 24 to 63 years, and most adult participants were women (94%). The majority of participants were Buddhist (96%), and all belonged to the Karen ethnic group. In terms of education, 40% of the participants had finished secondary school or higher, 33% had finished primary school only, and 24% reported having no education. Most of the parents were farmers (61%), and 22% were housewives, traders, or casual laborers.
The age of the student participants ranged from 9 to 13 years, and they were in the fourth or fifth grade. Equal numbers of boys and girls were selected for participation in the study. Regarding the students’ schools, 11 of the students participating in the in-depth interviews attended Tung Tam School, and the remaining 10 students were from the other four schools.
Folk knowledge of teeth
In terms of oral health knowledge, most of the participants knew about two sets of teeth: baby teeth (Fun Nam Nom in Thai or Mae Nu Tee in Karen, both meaning “breast milk teeth”) and adult teeth or permanent teeth (Fun Tae in Thai or Mae Noh Kor Jar in Karen, both meaning “true teeth”). The majority of the participants perceived baby teeth to have low value because of their short-term utility and because they were only for chewing foods. They thought that permanent teeth were stronger and more effective in chewing foods, as adults ate a greater variety of foods, especially foods that were tougher to chew. Moreover, permanent teeth were seen as irreplaceable and needing to last many decades.
“After losing baby teeth, we simply throw them away. But adult teeth, we cannot lose them, as they are more important and necessary. We use them throughout our lives.” (30 to 40-year-old woman, Tung Tam Village)
Therefore, the participants reported paying less attention to protecting baby teeth, which contributed to the development of tooth decay and toothache. In fact, most participants had experienced dental caries in their baby teeth. They thought that baby teeth were weak and prone to tooth decay, which they saw as occurring spontaneously, regardless of oral hygiene or regular dental clinic visits.
Folk knowledge and perceptions about dental illnesses
Traditionally, Karen people believed that most general illnesses occur as a result of an attack by an offended spirit, the loss of the soul, or sorcery. However, among the participants in this study, dental problems were not generally perceived as having supernatural causes. The participants identified dental problems symptomatically, for example as toothaches, bleeding gums, sensitive teeth, or tooth mobility. Only dental caries was regarded as a disease. In the study villages, the most common dental health problems were dental caries and toothache.
Dental caries
Dental caries (Mae Ka Or in Karen) were described both in scientific terms (“tooth decay”) and using Thai phrases translating as, for example, “blackened teeth” or “dental hole/cavity” or Thai and Karen phrases meaning “tooth worms” or “worms eating the tooth.” The participants’ understanding of the etiology of dental caries came from a combination of local/traditional beliefs and scientific knowledge. However, most adult and child participants mentioned “tooth worms” as a local name for dental caries (Mang Kin Fun in Thai or Mae Ka Or in Karen), and these worms—tiny biological organisms that ate the tooth material—were seen as a main cause of dental caries. The participants thought dental caries resulted from being infected by this worm.
Consuming a large quantity of sweet foods or drinks and having food stick to the tooth surface were believed to be predisposing factors creating the worms. Because these worms liked to eat sweet food, consuming a large amount of sweet foods was seen as strengthening existing worms on the tooth surface. Holes/cavities in teeth were understood as resulting from the teeth being damaged by these worms.
Identification of dental caries was described as being based on people’s external appearance, such as having “black teeth”; however, this might not actually be applicable for this study population. Among adults, dental caries mostly occurs in the posterior teeth, where it is difficult to see without checking carefully in the mirror. In addition, most of the adult participants chewed betel quid, making it impossible to notice additional black staining on the tooth surface because of betel quid staining. Most participants mentioned that they did not actively check their teeth. They initially recognized oral diseases after experiencing an uncomfortable feeling, pain, or obvious swelling of the face.
“I visited the dental clinic because I felt that something was stuck inside my tooth, very uncomfortable. It had been for some time, and I realized that I may have “Mang” eating up my tooth and there is cavity or hole in my tooth.” (30 to 40- year-old woman, Mae Tan Village)
Gingivitis
Of the participants who experienced bleeding gums, most noticed this during toothbrushing. They thought that bleeding gums resulted from brushing their teeth fast, for a long time, or too hard. None of the participants knew that inadequate oral hygiene and the presence of dental plaque between the teeth were the true causes of bleeding gums. Most of the interviewed children had heard about plaque in health education classes, but they were unable to relate plaque to gingivitis. Gum bleeding was generally regarded as a symptom rather than a disease, with some participants viewing bleeding gums as consequences of prolonged toothache or severe dental caries.
Some adult participants thought that irritation from chewing betel quid, which was a common practice among the adult population, was one of the causes of bleeding gums. None of the participants thought that gum bleeding was a problem, although some worried if they saw a large amount of bleeding during toothbrushing.
“Yes, I think it is normal about toothbrushing and bleeding gums. I notice bleeding when I rinse my mouth. But it only bleeds very little—not a problem. It is irritated from brushing too hard, I guess.” (30 to 40-year-old woman, Mae Tan Village)
Sweet food consumption as a risk factor for dental problems
Common sweet foods, snacks, and drinks in the study villages were chocolate, candy, cakes, cookies, ice creams, artificial fruit juice, and soft drinks (e.g., Fanta, Coca-Cola, and Pepsi). Most consumers of these products were children, who bought sweet foods and drinks from the local shops at costs ranging from US$ 0.03 (for a piece of candy) to US$ 0.3 (for a piece of cake). The most popular items were ice creams, Deedo sweet drinks (250 cc), and soft drinks (250 cc), each of which cost US$ 0.2.
Most participants knew about the association of the consumption of sweet foods and drinks with oral health problems. Some said that, according to health education classes, the consumption of sweet foods or drinks would not cause any problems if they brushed their teeth after consuming these products. Few of the student participants mentioned that milk and natural foods such as fruits and vegetables were good for dental health. Fruits and vegetables were easily accessed and mostly free of charge because the local people grew fruits and vegetables in their gardens for their own consumption.
“The teacher taught me how to brush my teeth after eating meals or snacks, but they’ve never taught [us] exactly about what food is good for the teeth.” (9 to 13- year-old male student, Khun Houy School)
“If we eat a lot of fruits, our teeth will be cleaned, and we will not have tooth decay.” (9 to 13-year-old female student, Uhu School)
According to the adult participants, when they were children, they were only able to access natural foods such as fruits and vegetables because sweet foods and drinks were not available in their villages at that time. However, sweet foods and drinks were widely available at the time of the research, and it was believed to be a main cause of the high prevalence of tooth decay among the children in this area.
“I had three siblings when I was young, and nobody had tooth decay. We did not eat sweet foods. Now, there are a lot of sweet foods and drinks available in this village. Children like those sweets. That is why most of the children have tooth decay.” (30 to 40-year-old woman, Mae Tan Village)
Oral hygiene practices
Most participants used their own oral hygiene methods, such as gargling with drinking water and swallowing after meals. Gargling was a common means of removing food remaining in the mouth or stuck between the teeth. However, this gargling normally happened while drinking water after a meal. Gargling with water was practiced inconsistently: people did not gargle after every meal, and they gargled more or less depending on the amount of food left in their mouths. For example, they reported that swishing one or two times was sufficient to remove a few pieces of food. Rinsing the mouth with water after consuming meals or snacks was not properly taught in health education classes. Using toothpicks was very common among the adult participants when gargling failed to remove food stuck between their teeth.
Toothbrushing was among the general oral hygiene practices reported. Traditionally, Karen people used a finger to rub their teeth with salt as a means of cleaning their teeth. Although toothbrushes were easily accessible during the research period, toothbrushing using a toothbrush and salt remained very common because toothpaste was unaffordable for some households.
“Brushing with salt is actually very good. It can increase the stability of the gums and teeth. It can also reduce bad smells in the mouth.” (30 to 40-year-old woman, Khun Houy Village)
“Now I brush my teeth with toothpaste. During my childhood, I didn’t have money to buy toothpaste, so I brushed my teeth with salt.” (20 to 30-year-old man, Uhu Village)
Most adult participants agreed that oral hygiene practices had changed since they were children. Toothbrushes were introduced in the study villages in the late 1980s, initially for primary school students. At the time of the research, children in the area learned how to brush their teeth for the first time in their first year kindergarten class when they were 5 years old. Although some children might learn about toothbrushing earlier at home, most of the students participating in this study reported learning how to brush their teeth correctly at school. Toothbrushes were given to all students in schools annually, in line with a national policy, and toothpaste was available in schools for use after eating lunch.
All participants believed that toothbrushing once per day was sufficient. In the Karen villages in the study area, the bathroom was a separate building located approximately 5–20 meters away from the main house. Personal hygiene tools such as soap, toothbrushes, and toothpaste were kept in the bathroom. Toothbrushing while taking a bath was a common practice, and the participants reported taking a bath once a day in the evening. The purpose of toothbrushing for the participants was mostly cleanliness and hygiene, and they did not worry about the health risks of not brushing their teeth frequently enough.
“I take a shower once a day in the evening, and I also brush my teeth at the same time. It is convenient; everyone in my family does the same. Then I have dinner and go to bed. But to brush our teeth again after dinner, we would have to go to the bathroom to brush our teeth, and it is inconvenient. We rinse our mouths after dinner, and that is enough.” (30 to 40-year-old man, Khun Houy Village)
Most adult participants had not heard of mouthwash or dental floss. These oral hygiene products were covered in school, and they were commercially available in pharmacy shops and in a convenience store in town, but very few participants—mostly those living in the town—had used them.
With the recent introduction of dental floss in schools (14), the children were aware that toothbrushing and using dental floss resulted in more effective teeth cleaning compared with toothbrushing alone. Additionally, a few children used mouthwash, saying that using mouthwash after toothbrushing resulted in better oral hygiene.
Poor awareness regarding seeking dental care
Most adult participants thought that the condition of their teeth was good, even when they had a mild toothache or slight tooth mobility. Generally, they experienced suffering less frequently from dental diseases than from other health issues. Therefore, they considered seeking dental health care a lower priority, compared with general health care. Moreover, there were no oral health care facilities located near their villages, and most participants relied on their own methods to take care of their oral health problems between the annual visits of the mobile oral health clinic to their villages.
The participants knew that there was a dental clinic at the hospital and that its services were for treating dental illnesses, but they were not aware that the clinic also provided regular check-ups to prevent dental diseases. Some male participants visited the dental clinic for the first time when they had serious oral health problems, but most female participants first visited the dental clinic as part of a routine pregnancy check-up at the hospital. After their first oral health check-up during pregnancy, none of these women returned to the dental clinic for additional check-ups. They thought that this initial check-up during pregnancy was a health care requirement of pregnancy.
“I visited the dental clinic as a part of a check-up when I was pregnant. Now, I don’t go to the dental clinic, because I am not pregnant. So it has been 4 years since I last visited the dental clinic.” (30 to 40-year-old woman, Mae Tan Village)
Most children received their first oral health check-up when they enrolled in school. Oral check-ups were regularly conducted twice a year, at the beginning of each semester. The parents/caregivers participating in this study did not know that they should take their pre-school-aged children to the dental clinic for check-ups; therefore, they did not consider it a delay in care if their children received their first dental examination and services only after starting school.
The low priority these research participants placed on oral health care can be explained by their perceptions of their ability to deal with dental problems on their own and by their satisfaction with the existing mobile community oral health program implemented through Thasongyang Hospital.
Ability to self-treat dental illness
The adult participants mentioned that they had experienced a disadvantage during their childhood, which included a lack of professional dental care and oral hygiene tools, and they therefore had to rely on themselves to solve their oral health-related problems. Most of the dental pain they experienced was intermittent. Therefore, even when they suffered pain, some participants waited for the pain to resolve on its own because they believed that dental pain would disappear spontaneously without professional care. Most participants had confidence in treating these problems themselves by taking pain-relieving medications when they experienced toothache. If the pain was very severe and was not relieved by these drugs, they went to the dental clinic. Therefore, the decision to seek professional dental care was based on the outcome of the self-care rather than on their awareness of the need for dental treatment.
“Pain comes and goes, and it is normally relieved even if I don’t do anything. I have only visited the dental clinic when I suffered from severe pain. If I have a bad toothache, I cannot eat and even cannot sleep, that is the time I need to see the dentist.” (9 to 13-year-old male student, Mae Po School)
“Most of the time, toothache pain is mild, and I can endure it. If it is severe, I take paracetamol. I will wait for the dentist to come to my village to check. But if the pain is still severe, of course I will see the doctor at the hospital. My neighbor waited until he had an abscess in his gum—very bad, as we cannot treat abscess by ourselves.” (30 to 40-year-old man, Tung Tam Village)
When suffering with severe toothache or swelling in the oral cavity, the participants applied traditional remedies to relieve the pain. To remove mang, the traditional healer used oil to rub the swollen cheek and recited a Karen mantra. Salt, charcoal, and ashes were used as traditional remedies to relieve pain and remove black stains from teeth by rubbing the teeth with a piece of charcoal, rinsing with saline water, and then rubbing the teeth with ashes. When the toothache or swelling was not reduced by traditional medicine, the participants tried modern medications, using multiple medications at the same time or one after another, based on the improvement in the pain or the accessibility of the drugs.
“There are many herbs. My grandmother used some leaves, but I use red onion. When we have a toothache, we put red onion inside the dental holes/cavities. In this way, we can relieve the toothache.” (20 to 30-year-old woman, Khun Houy Village)
“He really can relieve pain. He has never visited the dental clinic. He just uses Burmese traditional medicine [Bain Daw Say].” (30 to 40-year-old woman, Uhu Village)
Some participants believed that brushing their teeth more frequently and limiting their consumption of sweet drinks would relieve dental pain. Some reported rinsing their mouths with normal water, warm water, or salt water to stop gum bleeding. Tooth mobility was caused by long-term betel quid chewing. This problem was found among adult participants, who reported avoiding discomfort or pain while eating by chewing food on the other side of the mouth or eating a soft diet.
“I have tooth decay, but it does not cause any pain. But mobility of the teeth is not good because my mother suffered pain while chewing food because of tooth mobility. She waited for some time and then decided to visit the dental clinic because she could not chew food properly anymore.” (30 to 40-year-old woman, Tung Tam Village)
Seeking professional dental care
More than half of the adult participants had never visited a dental clinic. Those who had visited a dental clinic did so because their self-care efforts failed to relieve their pain and because their dental diseases impacted their work-related activities or interfered with everyday life. There were two approaches to caring for children with dental problems: Their parents either brought these children to the hospital, or they sent their children to school and hoped that the teachers would take them to the hospital. Most parents and guardians had busy lifestyles; they had many work commitments in the fields or farms that were necessary for earning income, as well as housework that included taking care of young children. They normally worked 7 days a week; therefore, they did not have extra time to accompany their children to the dental clinic. The parents and guardians participating in this study thought the school did a better job than they could in terms of taking care of their children’s health, including their oral health.
“But I was very busy with my work. That is why I didn’t have time to bring my children to the dental clinic. They can get a check-up at school, and it is sufficiently good. If they are sick, I send them to school anyway; the teacher will take care of them and bring them to the hospital.” (20 to 30-year-old woman, Khun Houy Village)
“I have never sent my child to the dental clinic. The dentist and the team from the hospital regularly come to the school to examine my child for oral health problems and deliver dental health education to my child. They do a better job, and I am always very busy with work.” (30 to 40-year-old man, Tung Tam Village)
Instead of visiting the dental clinic, children with mild toothache preferred to take pain-relieving medication and wait for the hospital team to visit their school, which they did regularly every 2–3 months. Similarly, adult participants also preferred to wait for the mobile oral health service program to come to their village.
“I advise my child to wait for the doctor because I believe that the doctor will give better drugs when the hospital team comes to the school. Otherwise, the teacher will bring her to see the dentist at the hospital.” (30 to 40-year-old woman, Uhu Village)
After they had received treatment at the dental clinic and their pain was relieved, the participants did not pay attention to taking care of their treated teeth. For example, if they lost a filling, they did not return to the dental clinic to replace it.
Fear of dental care procedures
All children received oral health examinations in school. Most children participating in this study expressed fear of dental procedures and equipment. They were afraid of experiencing pain during dental procedures, and they also feared that their teeth would be removed. Some children had heard negative stories about their friends’ dental visits, and others had their own unpleasant experiences. Their experiences with local anesthesia injections using needles and with the removal of teeth using dental forceps resulted in a vicious circle of lack of timely care-seeking behavior and dental fear. Some participants pointed out that one reason for attempting self-care for dental problems was to avoid the dental clinic because of fear.