Oral diseases present a major global
public health burden, affecting 3.5 billion people worldwide, yet oral
health has been largely ignored by the global health community,
according to a new Lancet Series on Oral Health.
- Oral diseases present a major global public health
burden, affecting 3.5 billion people worldwide, yet oral health has been
largely ignored by the global health community, according to a new
Lancet Series on Oral Health.
- With a treat-over-prevent model, modern dentistry has
failed to combat the global challenge of oral diseases, giving rise to
calls for the radical reform of dental care
- The burden of oral diseases is on course to rise as
more people are exposed to the underlying risk factors of oral diseases,
including sugar, tobacco and alcohol
- Emerging evidence of the food, beverage, and sugar
industry's influence on dental research and professional bodies raises
fresh concern
Oral health has been isolated from traditional healthcare and health
policy for too long, despite the major global public health burden of
oral diseases, according to a Lancet Series on Oral Health, published
today in
The Lancet. Failure of the global health community to
prioritise the global burden of oral health has led to calls from Lancet
Series authors for the radical reform of dental care, tightened
regulation of the sugar industry, and greater transparency around
conflict of interests in dental research.
Oral diseases, including tooth decay, gum disease and oral cancers,
affect almost half of the global population, with untreated dental decay
the most common health condition worldwide. Lip and oral cavity cancers
are among the top 15 most common cancers in the world. In addition to
lower quality of life, oral diseases have a major economic impact on
both individuals and the wider health care system.
Accessing dental care continues to present the highest cost barrier
compared to any other healthcare service in the United States (U.S.) and
the highest dental expenditures globally were found for the U.S.
($129.1 billion). [1]
The Lancet Series on Oral Health led by University College London
(UCL) researchers brought together 13 academic and clinical experts from
10 countries, including the US, to better understand why oral diseases
have persisted globally over the last three decades, despite scientific
advancements in the field, and why prevalence has increased in low- and
middle- income countries (LMIC), and among socially disadvantaged and
vulnerable people, no matter where they live. [2]
A tipping point for global oral health
"Dentistry is in a state of crisis," said Professor Richard Watt,
Chair and Honorary Consultant in Dental Public Health at UCL and lead
author of the Series. "Current dental care and public health responses
have been largely inadequate, inequitable, and costly, leaving billions
of people without access to even basic oral health care. While this
breakdown in the delivery of oral healthcare is not the fault of
individual dental clinicians committed to caring for their patients, a
fundamentally different approach is required to effectively tackle to
the global burden of oral diseases." [3]
In high-income countries (HIC), dentistry is increasingly
technology-focused and trapped in a treatment-over-prevention cycle,
failing to tackle the underlying causes of oral diseases. Oral health
conditions share many of the same underlying risk factors as
non-communicable diseases, such as sugar consumption, tobacco use and
harmful alcohol consumption.
Professor Robert J. Weyant, DMD, DrPH Professor and Chair,
University of Pittsburgh, Department of Dental Public Health, said: "The
U.S. continues to struggle with how to best ensure access to affordable
dental care for many individuals. This has led to ongoing suffering for
many with oral disease and significant disparities in oral health for
vulnerable populations such as poor families, ethnic minorities, and the
elderly. The Affordable Care Act helped to expand access to dental care
for millions but many still remain unable receive needed care,
highlighting an urgent need for improvements in dental health policy."
[4]
In middle-income countries the burden of oral diseases is
considerable, but oral care systems are often underdeveloped and
unaffordable to the majority. In low-income countries the current
situation is most bleak, with even basic dental care unavailable and
most disease remaining untreated.
Coverage for oral health care in LMIC is vastly lower than in HIC
with median estimations ranging from 35% in low-, 60% in lower-middle,
75% in upper middle, and 82% in high income countries.
Sugar, alcohol and tobacco industries fuel global burden
The burden of oral diseases is on course to rise, as more people are
exposed to the main risk factors of oral diseases. Sugar consumption,
the underlying cause of tooth decay, is rising rapidly across many LMIC.
While sugary drinks consumption is highest in HIC, the growth in sales
of sugary drinks in many LMIC is substantial. By 2020, Coca-Cola intend
to spend US$12 billion on marketing their products across Africa [5] in
contrast to WHO's total annual budget of $4.4 billion (2017).
"The use of clinical preventive interventions such as topical
fluorides to control tooth decay is proven to be highly effective, yet
because it is seen as a 'panacea', it can lead to many losing sight of
the fact that sugar consumption remains the primary cause of disease
development." said Watt. "We need tighter regulation and legislation to
restrict marketing and influence of the sugar, tobacco and alcohol
industries, if we are to tackle the root causes of oral conditions."
Writing in a linked commentary, Cristin E Kearns of the University
of California and Lisa A Bero of the University of Sydney raise
additional concerns with the financial links between dental research
organisations and the industries responsible for many of these risk
factors.
"Emerging evidence of industry influence on research agendas
contributes to the plausibility that major food and beverage brands
could view financial relationships with dental research organisations as
an opportunity to ensure a focus on commercial applications for dental
caries interventions--eg, xylitol, oral hygiene instruction, fluoridated
toothpaste, and sugar-free chewing gum--while deflecting attention from
harm caused by their sugary products."
Lancet Series authors argue a pressing need exists to develop
clearer and more transparent conflict of interest policies and
procedures, and to restrict and clarify the influence of the sugar
industry on dental research and oral health policy.
Radical reform of dentistry needed
Lancet Series authors have called for wholesale reform of the dental care model in five key areas:
1. Close the divide between dental and general healthcare
2. Educate and train the future dental workforce with an emphasis on prevention
3. Tackle oral health inequalities through a focus on inclusivity and accessibility
4. Take a stronger policy approach to address the underlying causes of oral diseases
5. Redefine the oral health research agenda to address gaps in LMIC knowledge
Dr Jocalyn Clark, an Executive Editor at
The Lancet, said:
"Dentistry is rarely thought of as a mainstream part of healthcare
practice and policy, despite the centrality of the mouth and oral cavity
to people's well-being and identity. A clear need exists for broader
accessibility and integration of dental services into healthcare
systems, especially primary care, and for oral health to have more
prominence within universal health coverage commitments. Everyone who
cares about global health should advocate to end the neglect of oral
health."
APPENDIX OF KEY FACTS & STATISTICS
Oral disease: types and causes
- The key oral health conditions include: dental
caries (tooth decay) [localised destruction of dental hard tissues
(enamel and dentine) by acidic by-products from the bacterial
fermentation of free sugars]; periodontal (gum) disease [chronic
inflammatory conditions that affect the tissues surrounding and
supporting the teeth]; and oral cancer [squamous cell carcinoma is the
most common type of oral cancer].
- The main cause of periodontal disease is poor oral
hygiene leading to an accumulation of pathogenic microbial biofilm
(plaque) at and below the gingival margin. Tobacco use is also an
important independent risk factor for periodontal disease.
- The major risk factors for oral cancers are tobacco
use, alcohol consumption, and areca nut (betel quid) chewing. In many
high-income countries (HIC), human papilloma virus (HPV) infection is
responsible for a steep rise in the incidence of oropharyngeal cancers
among young people.
- Oral diseases can lower quality of life in many ways,
including pain, infections, problems with eating and speaking,
diminished confidence, and disruption to social, work, and school
activities.
The global burden of oral disease
- The most recent data from 2015 confirm that
untreated caries in the permanent dentition remain the most common
health condition globally (34·1%).
- A 4% decrease in the number of prevalent cases of
untreated dental caries occurred globally from 1990 (31,407 cases per
100 000) to 2017 (30,129 cases per 100 000).
- The global burden of untreated dental caries for
primary and permanent dentition has remained relatively unchanged over
the past 30 years.
- Epidemiological evidence indicates that lifetime
prevalence of dental caries has decreased in the past four decades, but
this is mainly in HIC, with the most substantial decrease seen in
12-year-old children.
- Data from 2018 show that oral cancer has the highest
incidence among all cancers in Melanesia and south Asia among males, and
is the leading cause of cancer-related mortality among males in India
and Sri Lanka.
Inequalities in oral disease
- Case-control studies showed a consistent
association between low socioeconomic status and oral cancer in both
LMIC and HIC, even after adjustment for behavioural confounders.
- Extreme oral health inequalities exist for the most
marginalised and socially excluded groups in societies, such as homeless
people, prisoners, those with long term disabilities, refugees, and
indigenous groups, which serves as a classic example of a so-called
cliff edge of inequality
- Indigenous children, even in HIC (Australia, Canada,
New Zealand, and USA), are particularly vulnerable, with the prevalence
of early childhood caries ranging from 68% to 90%.
Prevention
- WHO recommends that free sugars intake should be
restricted to less than 10% of total energy highlighting that for
further benefits, restriction in sugar consumption should be now more
than 5% of total energy; however, many countries do not meet these
guidelines.
- While topical fluorides are proven clinical preventive
agents, caries will still develop in the presence of free sugars above
10% of total energy intake. Even where exposure to fluoride is optimal,
evidence suggests that free sugars exposure as low as of total energy
may still carry a risk of caries.
Commentary: Sugar industry ties to professional dental organizations must be addressed
Oral diseases, such as tooth decay, gum disease and oral cancers,
are a major health burden affecting 3.5 billion people worldwide, but
are largely ignored by the global health community, according to a
series on oral health in