Introduction
In Turkey, one of the health care reforms recently is the establishment of a family doctor system giving priority to the primary health care of the population. The National Oral Health Policy followed the same priorities and suggested new strategies to promote the oral health of the population.

Background
As part of this process, in 2006, a new project involving fluoride gel tooth brushing under supervision, was started in Kirikkale city-center, and now this programme extends to many other cities, including Kütahya (Aegean region of Anatolia), Karaman (Middle Anatolia), Mardin (Southeastern Anatolia), and Denizli (Mediterranean Region Of Anatolia). This programme is called “brush-on fluoride gel application”. Second year dental students who will be the Supervisor in the programme, are trained during one month at the start of the calendar year at the Dental School in Kirikkale. There is close collaboration between the class teacher and the supervisor for this project to work successfully.

Fluoride gel on toothbrush

Table 1: Calendar for the Application Periods for the supervisors

Application Time
1st Application: November (1st semester)
2nd Application: December (1st semester)
3rd Application: March (2nd semester)
4th Application: R2CMay (2nd semester)

Dr Dulgergil demonstrating

Project Outline

• All procedures are performed in school premises with the support of the class teachers.
• Primary school class teachers are involved in the programme in getting the children's participation.
• Two to three days before the visit, the supervisor informs the class teacher of his/her visit. Usually there are two supervisors responsible for one school with around 4 -8 classes.
• The class teacher then informs the children to bring their toothbrush and a plastic cup on the appointed day.
• In Kirikkale, where this project was initiated in 2006, on the Friday of each week, dental students visit the primary schools and serve as a "supervisor" for this tooth brushing programme.
• Under the supervision of the dental student, a 2% neutral fluoride gel is used, and the children would brush their teeth with fluoride gel.
• Then they would spit into tooth glasses or disposable cups.
• This fluoride gel brushing procedure is repeated at least 4 times a year, for 3 years.

getting ready

Achievements

• In Kirikkale city, 9000 primary schoolchildren participated in brushing their teeth with fluoride gel, at each application period four times a year.
• A total of 114 classes in 38 primary schools were benefiting from this programme - 36 second year dental student supervisors covered all the 38 schools in 2 days, four times a year.
• See Table 2 for the estimated coverage in the different cities for 2011.

brushing and brushing*

Table 2 - Number of primary schoolchildren participating in the Programme according to cities in 2011 (These figures are for year 2011 estimates, and in reality can be more.)

City / Number of children
Adiyaman 10,000
Agri 6,000
Antalya 6,000
Corum 9,000
Denizli 12,000
Diyarbakir 1,500
Eskisehir 10,000
Istanbul 6,000 - 14,000 (new)
Karaman 8,000
Kayseri 14,000
Kirikkale 9,000
Kutahya 11,000
Malatya 12,000
Mardin 2,000
Ordu 5,000
Osmaniye 8,000
Sivas 10,000
Zonguldak 3,000
Total 142,500

spitting after 5 minutes

Notes on sustainability of the programme

Supervisor
When this programme was initiated in Kirikkale, dental students were trained to be the supervisors for the tooth brushing programme. However when the programme was extended to other cities, it was met with a problem, as dental schools were not situated in all the cities. In order to solve this, students involved in health related professions were trained as Supervisors for the programme. For instance, nursing school students in Agri city and in Adıyaman, students from the child development course in the University of Adıyaman were trained as Supervisors for these cities. In Malatya, on the other hand, supervisors were dental students and nursing school students serve as supervisors.

Materials for the programme
For each application (fluoride gel is applied at least 4-times in a year with toothbrush), fluoride gel, tooth brush and plastic cup to spit after application, is needed. During discussions with the class teachers, they suggested that each primary school child would bring their own toothbrush and cup. This can be done if the class teacher is informed two to three days BEFORE the supervisor plans to visit the class.

One bottle of 2% neutral fluoride gel was cheap and bought for the project by local medical managers for the school. This approach to the project is important to the sustainability of this programme.

Conclusion
Brush on fluoride gel application as a routine preventive protocol is now practiced in various city-centers and villages, including Zonguldak (Black-sea Region), Eskisehir, Mersin, Denizli, Şanlıurfa (southeastern Anatolia), Hakkari (southeastern Anatolia), Diyarbakir, Malatya, Şırnak, Muş, Kayseri, Mardin, Karaman, Kütahya, Çorum, Adiyaman and Ordu.

Source
http://www.sabancivakfi.org/page/coruh-turksel-dulgergil-3

by Dr Turksel Dulgergil, Department of Operative and Preventive Dentistry, Kirikkale University Dental School. (dulgergil@hotmail.com)