Nearly 3.5 billion people suffer from some form of oral disease – half the global population – 2.5 billion of this due to tooth decay alone. Oral disease is part of the group of non-communicable diseases, yet their case rate is higher than that of all the other NCDs combined. Over the last 30 years there have been 1 billion additional cases. Three quarters of the global burden is found in low- and middle-income countries. Despite these striking numbers, oral disease remains almost completely overlooked according to STIAS fellow Habib Benzian, Research Professor at the Department of Epidemiology & Health Promotion, College of Dentistry, New York University, Co-Director of the WHO Collaborating Center for Quality Improvement & Evidence-based Dentistry; and member of the Lancet Commission on Oral Health.
During his seminar at STIAS, he described the situation as a world of dramatic inequalities that divide humanity into parallel oral health realities. “One half of the world has relatively good oral health. They know where to get care, have health insurance and can navigate the health system,” explained Benzian. “The other half have oral problems that deeply impact their lives, wellbeing and productivity. They have very limited or no access to prevention and care, huge difficulty in navigating healthcare systems, are at high risk of being pushed further into poverty by catastrophic expenditures for expensive dental care, and have greater exposure to risks with no access to prevention or, even, self-care, despite the fact that oral disease can be effectively prevented with simple measures.”
Although oral disease occurs across the lifespan the situation is particularly bad for children. In some settings children are exposed early to risk factors like prolonged bottle nursing with sweetened beverages. Pain from oral disease is one of the leading causes of school absences and has a systemic effect on children with long-term growth impacts unless treated.
“The situation of oral health is particularly alarming in sub-Saharan African countries, where about 480 million people suffer from preventable oral disease like tooth decay, gum disease or tooth loss,” continued Benzian. “Most African countries the expenditure on oral health is less than $1 per person per year. Overall only 1,5% of all dentists worldwide work in low-income countries. The number of dentists per 100 000 population is lowest in sub-Saharan Africa. 80% of the global dental expenditure benefits only 20% of the world population with high-income countries spending 800 times more than low- and middle-income countries (LMIC).”
And it was in Africa that this divided world first became apparent to Benzian when he worked after graduating for a non-governmental organisation at the Albert Schweitzer Hospital in Gabon and found himself as the only dentist in an area with a population of 500 000 doing non-stop extractions. “It was a deep dive into another reality. I realised I couldn’t be a clinical dentist in a high-income country but instead needed to find another career purpose. A public-health degree and a second PhD in global health gave me opportunities to work towards addressing the neglect of global oral health at very different levels of science, policy and academia.”
But the situation is not only about differences between countries. There are huge within-country divisions. Like other diseases, oral disease has social determinants and risk factors. “Publicly funded health systems are often not providing any appropriate services for the majority of populations, while at the same time state-of-the-art private oral healthcare is available for well-off, middle-class populations or elites able to afford it. There is a distinct social gradient with ethnic minorities, the elderly, children living in poverty, marginalised populations and refugees at higher risk.”
“Even in the US an estimated 77 million citizens have no dental coverage” making ‘dental tourism’ a reality for many.
A crisis requiring attention
A World Health Organization (WHO) report released in November 2022 described the situation as “a global oral health crisis” and as “alarming and requiring urgent attention”. The report highlights that 4 billion people have no sustained access to oral healthcare, that street dental care is all that is available to a large proportion of the global population, and that in some countries there are even more illegal quacks than regular dentists. The consequences are huge for individuals, communities and societies, affecting health and wellbeing, social participation, productivity and economies.
But it’s a problem that can largely be prevented in the first place, so why aren’t we?
“Most oral disease can be effectively prevented with simple measures at individual and population level,” explained Benzian. “But these measures are not prioritised or widely used as they contravene the current setup of oral healthcare, the intrinsic interests of its key actors, and the structure of health systems that have evolved around a curative – ‘biodental’ – rather than preventative model of care.”
Too many ‘isms’
In the context of the Lancet Commission on Oral Health, which was formed in 2020 following the publication of an Oral Health Series in the journal in 2019, Benzian and colleagues have worked on a critique of the current state of dentistry and oral healthcare, describing the current approach in terms of 12 ‘isms’ – behaviouralism, normativism, scientism/clinicalism, solutionism, corporatism/protectionism, lobbyism, elitism, entrepreneurism, commercialism, consumerism, separatism/isolationism, over-professionalism.
Focusing on some of these, Benzian pointed to behavouralism which blames the patient for becoming ill due to wrong behaviour choices; clinicalism/scientism which focuses on the clinical ignoring the broader social aspects; consumerism which pushes the money-making cosmetic aspects of dentistry; and, over-professionalisation of the field with an ever-increasing breakdown into specialities. He also pointed out that dentistry is a profession with highly powerful associations and the ability to lobby to legislators and forge alliances with corporate interests.
“The causes for these parallel oral health realities are rooted in a complex blend of historic, colonial, scientific, professional and political factors: lack of evidence-informed decision-making, political priority setting, dominance of professional interests, false economic incentives within oral healthcare systems, negative and subversive corporate influences on public policy and people, but also misguided narratives and social beliefs related to oral health.”
The Lancet Commission has created significant momentum. It has focused on strategic recommendations and advocated for oral health as part of the global thrust towards universal healthcare. Subsequently, the WHO has put a set of policies in place, including a global strategy and a global action plan on oral health which includes actions, targets and indicators to monitor implementation progress until 2030. The framework includes an aspirational vision of 80% of the world population having access to oral healthcare by 2030. “Oral healthcare has been recognised as part of fundamental human rights to health – which has never been so explicitly acknowledged before,” said Benzian. Despite this positive progress, there is also the need for a more critical interdisciplinary analysis of the current situation of global inequalities and its underlying causes.
Digging deeper
“We can’t solve the problem with the solutions that caused the problem in the first place,” continued Benzian. “We need more critical thinking and to dig deeper into the root causes. We need innovative, new approaches.”
One of the areas that Benzian and his colleagues are exploring further is around decolonising global oral health – a research area in which there is currently zero literature – “unpacking issues like lack of diversity, white supremacy, coloniality, racism, patriarchy and profit interests in the field as well as looking at traditional medicine and the reframing of normative ideas of health and beauty”.
For example, he pointed out that the main risk for tooth decay is sugar consumption something intimately linked to the colonial legacy (and the subject of another workshop which Benzian and colleagues will hold while at STIAS).
It’s also about understanding the environment, power structures, the causes of government and public-sector disengagement, the risks and disease burden, as well as reconceptualising dental care and education with a more preventative, public-health focus.
Benzian pointed out that governments need to take responsibility at the population level to turn off the tap on new oral disease. This includes involving more health professionals including community health workers, the expansion of oral health into school health programmes, and the integration of inexpensive, low-tech, prevention solutions – e.g. fluoride varnish and similar approaches.
Benzian highlighted the need “for a model of oral healthcare that provides the basic needs for everyone at an affordable cost. We also need to learn how to frame the problem in a better way, we need to challenge the paradigms that dominate the current models of prevention and care at a population level, and we need to translate available solutions into effective policies. We also have to create momentum for change. New policies won’t solve anything if not implemented. We need change leaders and champions.”
“Uncovering and understanding the co-existing realities in oral health and analysing their different enabling and driving factors is at the core of my work at STIAS”, Benzian said. Shedding light on the processes around political priority setting in health that have led to the neglect of oral disease, is an important entry point to conceptualise new, more captivating and impactful narratives and approaches around oral disease to precipitate the shift needed to merge the two realities for the better.”
Michelle Galloway: Part-time media officer at STIAS
Photograph: Noloyiso Mtembu