Several major organizations are calling for radical reforms to improve oral health. What’s holding them up?
Nature Outlook
Rob Beaglehole can pinpoint the moment he became a campaigner for oral health. It was in 2014, on his lunch break at Nelson Hospital in New Zealand.
Beaglehole had spent yet another morning removing decaying teeth from anaesthetized children and young adults. After extracting 54 teeth, he was tired. As he rested, peering through his surgery window, he watched a Coca-Cola truck arrive to make its delivery to the hospital cafeteria.
Suddenly, this truck and its cargo symbolized the Sisyphean nature of Beaglehole’s work. He became incensed, his anger catalysing a desire to do things differently.
Parents are often blamed for their kids’ rotten teeth, but Beaglehole — now the spokesperson for the New Zealand Dental Association — knew that unhealthy choices were often the easiest and cheapest option. He urged his hospital’s chief executive to ban the sale of sugary drinks in the medical centre.
Beaglehole’s arguments were twofold. First, excess sugar consumption is the main reason why tooth decay is the most common disease in both adults and children. Worldwide, some 2.3 billion people live with untreated caries of their permanent teeth and more than 500 million youngsters’ milk teeth are affected.
Second, surgical procedures are expensive. That year, about 7,500 children under the age of 8 had teeth removed under general anaesthesia in New Zealand, costing the government around NZ$32 million (US$22 million). “That’s an extremely expensive way of dealing with sugar,” Beaglehole says. Rather than prioritizing the prevention of oral disease, the focus was on drilling, filling and extracting teeth.
Beaglehole’s hospital soon banned artificially sweetened beverages, including juices, and today all hospitals in New Zealand have done the same. But Beaglehole wants to go further, campaigning to make them ‘water only’ — a policy that his advocacy has helped introduce into many New Zealand schools. He is also canvassing the national government to introduce taxes on sugary drinks and to restrict sponsorship and advertising by the manufacturers of such beverages.
“Tooth decay is basically 100% preventable,” he says. “You cannot treat your way out of the whole tooth-decay epidemic. Until we turn the sugar tap off, we’re just going to be mopping up the mess on the floor.”
A growing movement
Beaglehole is part of a growing global movement to improve oral health. Campaigning for policies that will reduce sugar consumption is a cornerstone of that endeavour — but there are also calls for major changes to how oral health care is delivered. In May, the World Health Organization (WHO) passed a resolution outlining several ways in which oral health care might be improved and made more equitable.
“Things like this do not fall from the sky,” says Habib Benzian, an oral-health advocate at New York University and a WHO consultant. It is, he explains, the culmination of more than a decade of “advocating, plotting and planning”. The resolution promises to push oral health up the global health agenda, but it also reflects an increasing drive to no longer consider it separately from general health.
In the same spirit as the WHO resolution, calls for reform and realignment are also being made by the Lancet Commission on Oral Health, which was formed in 2019, and in the Vision 2030 strategy document1 published this January by the FDI World Dental Federation. The bold proposals made by the federation — a professional association that represents more than one million dentists from 133 countries — are potentially significant given that the organization is often viewed as quite conservative.
“The advocacy of FDI has improved out of all recognition in the past decade,” says David Williams, a dentist at Barts and The London School of Medicine and Dentistry and one of Vision 2030’s lead authors. With the WHO, the Lancet commission and the FDI now sharing overlapping goals, Williams is encouraged that advocates with backgrounds in disease-focused dentistry and those from policy-centred public-health conventions are converging on the same objectives. “If different constituencies were coming forward with different messages,” he says, “our chances of being heard would be close to zero.”
Despite this unity, advocates acknowledge that change will not come easily. The current dentist-centred oral-health-care model is deeply entrenched and highly profitable for many practitioners. Global sugar consumption is promoted by a powerful industry and, despite efforts to curb it, continues to steadily climb. And meeting the distinct challenges present in different countries and socioeconomic settings will require carefully targeted strategies.
Accumulating advocacy
Oral-health advocates have witnessed a number of false dawns, Benzian says. The WHO declared 1994 World Oral Health Year, but little changed. A WHO resolution in 2007 had similarly disappointing results. But Benzian thinks this time is different.
In 2011, the United Nations convened a high-level meeting to address the growing impact of non-communicable diseases (NCD) on health systems and economies. The meeting focused on cancer, cardiovascular disease, diabetes and chronic respiratory disease. The resultant UN political declaration included a single brief mention of oral diseases, noting commonalities with other NCDs. “It looks like virtually nothing,” says Benzian, “but it’s a foundational justification to consider oral conditions as part of the chronic-disease family.”
Williams says that he and others started to think about oral disease in these terms in the mid-to-late 2000s. In part, this was simply good science. Oral disease is an NCD, and the methods commonly used to combat other major NCDs — reducing exposure to risk factors and developing strategies focused on health, early detection and management — offered a sound framework for attempting to reduce oral disease.
But aligning with the broader NCD agenda was also good advocacy. Catapulted to prominence by the 2011 UN meeting, the NCD movement has grown in size and influence. Now encompassing many more chronic conditions, it has reshaped the global health agenda. Health inequality, which is a big problem for those tackling oral conditions, has become a priority, with an emphasis on improving access to care. Policies aimed at reducing smoking, limiting alcohol consumption and significantly lowering sugar intake are gaining traction. They would all decrease oral disease, even if the strategies were not designed with the mouth in mind. And oral health continues to be highlighted in broader discussions of health care, including the UN’s 2019 political declaration on universal health coverage.
Two of the most important texts for the current wave of oral-health advocacy also arrived in 2019, published by The Lancet as the springboard for the launch of the journal’s oral-health commission.
The first is a paper2 that documented the global burden of oral disease, highlighting the profoundly uneven distribution of such disease and the equally steep disparities in access to oral health care (see ‘Unequal burden’ and ‘Dentists’ uneven distribution’). The second is a paper3 calling for radical action to end the neglect of global oral health. Written by 13 people in 10 countries, it called for many profound adjustments to oral health-care systems.
“Change needs to happen at many different levels,” says Carol Guarnizo-Herreño, a public-health dentist at the National University of Colombia in Bogota and co-chair of the Lancet commission, which is currently working to develop recommendations based on the studies.
Source: PHE
“We know how important oral health is for your general health,” Guarnizo-Herreño says. There is increasing evidence linking oral disease to other chronic illnesses, such as diabetes. But also, when the FDI proposed a unifying definition4 of oral health in 2016, it stated that a healthy mouth is not only free of disease but also functions well and causes no psychosocial issues. This definition emphasizes how oral health is a multifaceted contributor to quality of life. Guarnizo-Herreño considers oral health care to be a social-justice issue. “To eat without pain, without issues,” she says. “To speak to your kids; to express your feelings; to smile without being self-conscious or feeling ashamed of yourself; to tell someone you love them; to kiss — all that is part of the human experience. Everyone should enjoy that.”
The work of advocates, therefore, falls into three main interlinked streams: adopting prevention-based strategies, improving integration of oral health care with general health care, and addressing disparities.
Socioeconomic divisions
There are disparities in oral health both between and within countries. In low- and middle-income countries, there are generally very few dental practices, and they are typically located in urban centres. In rural areas, poor people often have almost no access to oral health care. In high-income countries, most oral health care is provided by dental practices that operate as small businesses and disproportionately serve affluent areas.
“Your mouth tells a story about your life and your living conditions,” says Guarnizo-Herreño, whose research has highlighted the social determinants of oral health. Part of the challenge, she explains, is that for the poorest people in society, oral health is often a secondary concern. “You don’t die of caries, you don’t die of periodontal disease, so it really goes down in your priorities.”
But by disrupting education and employment, poor oral health can also exacerbate existing inequality. One 2006 study5, for instance, showed that providing a cohort of unemployed people in the United States with oral-health treatment greatly increased their chances of finding work.
Source: WHO
Fixing health inequality is clearly a massive societal issue — and one that will require substantial investment. Miriam Muriithi, a dental surgeon and head of oral health services at the Kenyan Ministry of Health, hopes that the WHO resolution will be a spur for securing more funding at the national level. “When a statement is put out by the WHO, it is respected,” says Muriithi, who is on the Lancet commission and helped to formulate the WHO resolution. She explains that this global commitment to action on oral health provides powerful support to her and advocates when they petition their governments for greater investment and prioritization.
But using any such investment more efficiently is also important. In Kenya, there is a shortage of dentists and they are clustered in urban areas. Extra resources could allow more dentists to be trained and dental centres established, Muriithi says, although it might be more cost-effective to incorporate teams of oral-health-care workers in general health clinics as low- and middle-income countries seek to expand their health-care systems.
This view echoes the much wider assertion that dentistry in all settings would benefit from restructuring.
Aim for integration
“Globally, dentistry is still very much dominated by just the dentist and that’s crazy,” says Richard Watt, a public-health dentist at University College London and co-chair of the Lancet commission. “With dental treatment, there’s a lot of fairly routine, simple, basic care that can be provided by middle-level providers,” he says.
Such middle-level staff include hygienists, nurses and community health workers, who are faster and cheaper to train and employ. The models for providing oral health care that are now being discussed explore how such people could deliver essential basic services such as check-ups and advice on oral hygiene. The objective, Watt says, is “mixing some very high-skilled activities with some more general skills. So you’ve got wider coverage of the population with more appropriate personnel.”
Wider coverage should also facilitate the early detection of oral-health problems — allowing, in many cases, the use of cheaper, less-invasive treatments than drilling, filling and extraction. Greater integration with the wider health-care system, which the WHO, FDI and Lancet strategies all call for, could help to secure that wider coverage. In higher-income settings, the existing health infrastructure can help to maximize the provision of oral health care. Meanwhile, in lower-income settings, where health care needs to expand, advocates want to ensure that oral health care benefits from any changes that are made.
The expansion of dental services could help to reduce the incidence of other NCDs, because many of the risk factors are shared. Hiroshi Ogawa, a dentist at Niigata University in Japan who contributed to the FDI report, says initiatives aimed at promoting good oral health need to be integrated into existing health-care systems with their broadening emphasis on preventing NCDs. Ogawa also stresses the importance of such measures for elderly people, for whom tooth loss and other oral problems can cause difficulty eating, which then contributes to malnutrition and a wide variety of health issues.
The separation of dentistry from primary care, however, is so widespread that there are few existing models of how this integration might be achieved. In the United Kingdom, Williams is involved in a pilot study that will explore the feasibility of integrating dental and general health care. This takes inspiration from US work spearheaded by Jeff Hummel — a primary-care physician and medical director at the non-profit health-care consulting company Comagine Health in Seattle, Washington.
In 2016, Hummel reported on a four-year pilot scheme involving 19 health-care centres in five states. This was inspired by population-wide, prevention-focused approaches to chronic conditions such as diabetes and asthma. The organizers taught paediatricians and family doctors, along with their clinical teams, how to screen for oral disease and provide advice on oral hygiene and diet, as well as how and when to refer people to dentists.
The project led to an increase in the number of children receiving fluoride varnishes. However, Hummel says, the study encountered numerous barriers to full integration. One was simply difficulties in sharing electronic health records between physicians’ offices and dental practices. It was also difficult to give people access to dentists when required. The work was carried out in socioeconomically disadvantaged areas, where many people who needed dental care had neither dental insurance nor the disposable income to pay for oral health care.
Hummel does think that a shift is afoot, however. “You find very dedicated young dentists who are very interested in taking care of the whole population and preventing disease,” he says. But he is concerned that dental training continues to focus predominantly on invasive restorative treatments, rather than minimally invasive treatments, preventive interventions, patient engagement in oral health and promoting healthy environments.
Turning off the tap
Oral health has benefited from one of the world’s most successful preventive public-health interventions: the introduction of fluoride toothpaste and, in some countries, fluoridated water, for the purpose of preventing tooth decay.
Fluoride has unquestionably prevented countless caries but there is a downside — evidence is surfacing that fluoridated water supplies might have neurotoxic effects. Moreover, even with fluoridation, the global prevalence of tooth decay has continued to rise. This, says Williams, is because fluoride is “not dealing with the real villain of the piece, which is the sugar that’s causing decay in the first place.”
The role of dietary sugar in tooth decay is straightforward and well understood: oral bacteria ferment the sugar and produce acids that demineralize teeth and initiate the decay process. Fluoride slows the decay process by combining with calcium and phosphate in tooth enamel to promote re-mineralization. At the earliest stages of demineralization, fluoride can even reverse decay.
Consequently, regular brushing with fluoride toothpaste will remain central to oral health — and increasing access to, and education about, good oral hygiene is a vital part of prevention-focused dentistry. But when sugar consumption is high, fluoride cannot hold back the tide. Putting an end to tooth decay will require people to reduce their sugar intake.
Oral-health-care providers can help by educating their patients about the adverse effects of excess sugar consumption. But, in many ways, Beaglehole’s work to create healthier environments in New Zealand serves as a template for what oral-health campaigners — and NCD advocates more broadly — want to see happen worldwide.
Advocates want governments and other institutions to implement measures that will reduce the sales of such products — especially for consumption by children. Options include taxation, reduced access or restricted advertising of high-sugar products. The rationale is simple: these measures take the onus away from individuals to reject unhealthy options.
Policies of this kind are gradually becoming more common in high-income countries, but there is an unfortunate consequence. In a shift that parallels the tobacco industry’s response to restrictive legislation in high-income settings, ‘Big Sugar’ is increasingly targeting markets in low- and middle-income countries. Guarnizo-Herreño and Muriithi are witnessing this first hand in Colombia and Kenya. They say these companies bring economic benefits that are hard for poorer countries to resist, and that this influence gives them undue power to quash attempts to legislate against their products.
And yet, says Guarnizo-Herreño, the need to quell the rising consumption of high-sugar products is even higher in such settings. Many people in poor regions have little access to fluoride toothpaste or fluoridated drinking water. “Toothpaste can be expensive for many families,” she says. “If you have to choose between food and toothpaste for your children, what would you choose?”
The Phelophepa Healthcare Train provides access to health care, including dentistry, for people in rural areas of South Africa.Credit: Papi Morake/Gallo Images via Getty
The road ahead
The ambitions of oral-health advocates range from addressing large structural issues in society to more practical concerns about how dentists operate. The immediate task is to develop and implement strategies that will bring about real-world change.
“Vision 2030 articulates broad strategic principles,” says Williams. To create more concrete plans, the FDI is now gathering feedback on its strategy document from member organizations in low-, middle- and high-income countries, with the aim of generating recommendations for each setting. “Thus, a report that begins at a strategic level,” Williams says, “will lead to the development of regionally appropriate ‘this is how we’ll do it’ plans that can be used in achieving our goal.”
Meanwhile, the WHO is preparing a global strategy document for publication in 2022, to be followed by an action plan in 2023. And the Lancet commission hopes to deliver its own recommendations in the next year or two.
As these next stages evolve, Benzian highlights two achievements of the broader NCD work that he thinks oral-health workers need to emulate. First, there is the development of a menu of ‘best buy’ policy options — from which national governments can select — that have been shown to have high cost-effectiveness.
Second, there needs to be better monitoring and surveillance. For conditions such as cancer and diabetes, there is now a mandatory global system for closely tracking the burden of disease. “If you don’t know about something,” Benzian says, “how can you expect that you will see any action on it?”
Ogawa agrees. He has worked to develop methods with which the WHO could effectively track rates of oral disease. In his opinion, tooth decay is currently monitored reasonably well, especially in children, but the surveillance of gum disease needs to be improved.
Such data are essential for determining whether interventions work. The importance of robustly evaluating outcomes was something Ogawa stressed to the rest of the FDI report’s team. “Always the problem is everybody giving guidance, guidance, guidance,” Ogawa says, “but no one is implementing.”
Now that oral health has risen up the global health agenda, advocates say, this passivity must come to an end. The community has laid bare the shortcomings of oral health care. Now is the time for action. “We have a WHO resolution,” says Muriithi, “but we have to really get a lot out of the resolution.”
doi: https://doi.org/10.1038/d41586-021-02926-4
This article is part of Nature Outlook: Oral health, an editorially independent supplement produced with the financial support of third parties. About this content.
References
Glick, M. et al. Vision 2030: Delivering Optimal Oral Health For All (FDI World Dental Federation, 2021).
Peres, M. A. et al. Lancet 394, 249–260 (2019).
Watt, R. G. et al. Lancet 394, 261–272 (2019).
Glick, M. et al. J. Am. Dent. Assoc. 147, 915–917 (2016).
Hyde, S., Satariano, W. A. & Weintraub, J. A. J. Dent. Res. 85, 79–84 (2006).