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The neglect of global oral health: symptoms and solutions
Benzian, H.
Publication date
2014
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Citation for published version (APA):
Benzian, H. (2014). The neglect of global oral health: symptoms and solutions.
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CHAPTER 1
Introduction
1
A global diagnosis: the neglect of oral health
The world of oral health is a world of stark contrasts. Oral diseases, in particular dental decay, are among the most common maladies on the planet, affecting more than 90% of the world’s population. Yet, the wider international health community is not aware about the pandemic character of dental caries1,2 and of oral cancer for some of the world’s regions and
population groups.37 There is a global oral health workforce of more than 1 million dentists,
about 3 million supporting oral health professionals and a wellfunctioning dental industry with an annual 16billionUSD global market just for dental supplies.8,9 The WHO states that
oral diseases are the 4th most expensive disease group to treat; and the United States alone
are projected to spend $115 billion USD on oral health care in 2013.10,11 Contrasting to this, an
estimated 2/3rds of people worldwide have no or very limited access to even basic and safe oral care, leaving most of the oral diseases untreated. While highincome countries spend between 510% of their health budgets on oral health services, it can be estimated that 2/3 of countries worldwide spend less than 2% of their health budget on oral health care, and some do not even have a dedicated oral health care budget at all, let alone a national policy to address oral diseases.12,13
Oral diseases have a significant impact on quality of life, are closely related to socio economic status and determinants of health and show great inequalities.14 Affluent popula
tions, even in low and middle income countries, enjoy access to good oral care, while the poor and marginalised suffer from a high burden of oral disease and at the same time have limited or no access to appropriate quality oral care or preventive measures.1518 All countries
are facing demographic changes, lifestyle as well as nutrition transitions with increasing sugar consumption that will affect disease burdens in the near future. If oral disease burdens are to be reduced or preferably prevented, significant changes in approaches, concepts and policies are required.1921
The starting point for this thesis is the diagnosis of neglect: Oral health is a generally neglected area in international, regional and national health contexts, and, consequently, suffers from low priority on political and health agendas. The principal reasons underlying the diagnosis are manifold.
Inability to attract political attention
Public health priorities and political priorities are not necessarily aligned. An example is po liomyelitis with a rather limited impact on morbidity and mortality (polio eradication) and
1 on the other hand, major killer diseases such as diarrhoea and infectious causes of childhood
deaths, which do not receive adequate political and donor attention.2224 Knowledge about
the processes and underlying reasons for such mismatches is limited and virtually absent for oral diseases and their political priority status.
All major international stakeholders in oral health e.g., the World Health Organization’s (WHO) Global Oral Health Programme, the FDI World Dental Federation, the International Association for Dental Research (IADR), and the International Federation of Dental Educa tors and Associations (IFDEA) suffer from limited resources, both financially and in terms of manpower. These organisations deplore the neglected state of oral health worldwide,25
but their approaches, philosophies, and inherent values are very different and at times even competing, resulting in a fragmentation of the sector with little tendency to form strategic alliances or causerelated partnerships. Stakeholders in oral health on all levels are unable to raise political priority of oral diseases on the basis of an agreed global agenda. The broader international health community in general is unaware of this critical situation and the strik ing disparities in global oral disease burden and access to care.9,26
Misleading focus on dentists for service provision
Although the absolute number of oral health professionals, is not directly related to access or quality of care27 many countries misleadingly attempt to address oral health only through in
creasing the number of dentists.28 Increasing the number of dentists alone creates inequities
in terms of access to and affordability of oral care. The deregulated mushrooming of private dental education institutions seen in many countries, particularly in Brazil and countries of South Asia, has not shown to improve access.12,2935 Because of this problem of access, many
patients in low and middleincome countries have to rely on a range of illegal oral care providers who are often socially accepted and part of the cultural context. Although filling a gap in service provision for poor populations, illegal provision of oral care is a serious public health problem, resulting in situations of lowquality care and risks for patients. It is a complex phenomenon going far beyond the legal context. It should be seen as a symptom of underlying health system and society deficits, due to low prioritization for service provi sion and related governance and lawenforcement. Illegal providers and quacks are often the only ones available for providing pain relief or simple emergency treatment. This informal health care sector in general, and the sector of illegal dentistry in particular, has not yet been subject to extensive research, despite the importance of informal care for entire population
1
groups in low and middleincome countries.36 In the context of global efforts for Health
Systems Strengthening and improving patient safety the problem of illegal oral care merits a closer examination.37,38
A hidden burden of oral diseases
Oral diseases receive low political priority because the burden of morbidity from oral dis eases is not recognized among constrains caused by other diseases with high mortality.
The WHO Oral Health Country/Area Profile Programme is the only authoritative source of international data, but 41% of data entries for caries are 10–19 years old, 16% are older than 20 years, while only 8% of datasets are less than 5 years old.9 The global picture for the
prevalence of dental decay is presented in Figure 1 (using WHO/CAPP data). The map shows that prevalence of dental decay is generally high with the majority of countries reporting a prevalence of 60% or more.
Apart from a high disease burden there are several other problem areas that are symptoms of the neglect of global oral health:
• A focus of data collection based on DMFT as a measurement for caries, an index which does not permit the evaluation of the disease’s severity and progression over time; • Limited validity due to a lack of representativeness of studies masking differences with
in a country and making comparability between countries difficult;
• No uptodate epidemiologic information available for the majority of countries; • Lack of integration of oral health indicators as part of regular disease surveillance sys
tems, thus promoting a separate, parallel data collection and interpretation;
• Collected data is complicated to understand for lay persons and requires expert explana tion and interpretation.
1 C A N A D A ICELAND UK IRELAND DENMARK GERMANY BEL. NETH. NORWAY DENTAL DECAY Percentage of 6–19-year-olds with dental decay
latest available 1982–2007 80% or more 60% – 79% 40% – 59% fewer than 40% no data World average: 70% Highest: Argentina 100% Lowest: Japan 16% UZBEKISTAN SRI LANKA JAMAICA CUBA M A L A Y S I A SAUDI ARABIA C H I N A MYANMAR VIETNAM CAMBODIA BRUNEI LAOS THAILAND INDIA NEPAL BANGLADESH IRAN AFGHANISTAN IRAQ JORDAN UAE BAHRAIN KUWAIT YEMEN OMAN SOUTH KOREA U S A C A N A D A LIBYA NIGER SUDAN NIGERIA DEMOCRATIC REPUBLIC OF CONGO ETHIOPIA EGYPT SENEGAL GAMBIA CÔTE D’IVOIRE CAMEROON NAMIBIA MOZAMBIQUE MADAGASCAR ZAMBIA TANZANIA KENYA SIERRA LEONE SOUTH AFRICA GUATEMALA MEXICO BOLIVIA B R A Z I L HONDURAS NICARAGUA COSTA RICA PANAMA ECUADOR GUYANA ARGENTINA URUGUAY PHILIPPINES PAPUA NEW GUINEA A U S T R A L I A CHILE ZIMBABWE HAITI A NA HG BENIN UGANDA LEB. CYPRUS ISRAEL MAURITIUS LESOTHO MALDIVES SEYCHELLES Hong Kong SAR Macau SAR JAPAN I N D O N E S I A NEW ZEALAND MOROCCO TUNISIA CAPE VERDE BARBADOS TRINIDAD & TOBAGO
TURKEY ICELAND CRO. ITALY MAC. LITHUANIA LATVIA ESTONIA AUS.HUN. BUL. ROM. GREECE POLAND SL. B-H BELARUS UK IRELAND DENMARK FRANCE SPAIN PORTUGAL GERMANY SWITZ. BEL. NETH. NORWAY FINLAND SWEDEN SL. CZ. REP.
ANTIGUA & BARBUDA ST VINCENT & THE GRENADINES GUINEA-BISSAU MONGOLIA BHUTAN BURUNDI MARSHALL ISLANDS TONGA FIJI
IMPACT OF ORAL DISEASES
Copyright © - FDI World Dental Federation and Myriad Editions.
Wereldkaart hfd1.pdf 1 28-10-13 10:24
Figure 1: Prevalence of dental decay in % of 619yrolds affected (latest available data 1982
2008)
Political decisions in health are often guided by impact assessments based on the Quality of
Life Adjusted Year (QALY) or Disability Adjusted Life Years (DALY) concepts. These assessment
methods, however, focus primarily on mortality and on older age groups, thus resulting in an underestimation of diseases with low mortality but high morbidity (like dental caries), or diseases with a high impact on younger age groups.39 Moreover, the DMFT index is not
compatible with these impact measurement frameworks due to its cumulative nature and the fact that it doesn’t assess the consequences of untreated dental caries. Caries is not one single entity in terms of burden – different impacts in terms of pain and discomfort can result from different manifestations of the decay process. Moreover, besides the absence of epidemiologic data of severe forms of caries which are highly prevalent in low and middle
1
income countries a possible relation between severe forms of caries and child development has received little attention. The failure to differentiate and assess the various stages of caries and their consequences for health in the DMFT index has resulted in the low calcula tions of burden in the context of measuring disease burden through the DALY concept. The recently published low estimations of disease burden for oral conditions are again highlight ing the need to develop realistic assessment tools for the most prevalent oral diseases.40
Lack of attention on aspects of efficacy of fluoride toothpaste
The corporations involved in oral care products owe much of their evergrowing economic success to the thriving global market for oral care products, which creates and meets de mands of more affluent consumers.41 Yet the most important means to prevent dental decay,
fluoride toothpaste, is still not used by a majority of the world’s population and remains prohibitively expensive for many.42 Furthermore, the quality and anticaries effectiveness
of fluoride toothpaste is not adequately addressed as evidenced by a total lack of attention for free available fluoride in toothpastes in the International Standard Organization (ISO) requirements.43 There are indications that fluoride toothpastes in low and middleincome
countries, with weak quality control and regulation mechanisms, vary considerably in the amount of available fluoride and thus their efficacy.44
Unfamiliarity with integrated mass prevention in oral health
Available costeffective preventive approaches, such as the universal access to appropriate fluorides for the prevention of dental caries, are not prioritised and strengthened. It has been shown, particularly for dental caries, that curative, health professionalled approaches are unrealistic for health systems of most low and middleincome countries and are unaf fordable for population groups with lower socioeconomic status.19,45 Initiatives aiming at
a change, such as the ‘Global Child Oral Health Task Force’46,47 and the ‘Global Caries Initia
tive’48,49, are both based on vertical nonintegrated approaches to oral disease prevention, are
lacking comprehensive intersectoral thinking and are unlinked with the mainstream of the international health and development discourse.
Furthermore, the emerging recognition of the determinants of health and oral health, such as unhealthy diet high in salt, sugar and fat, is so far more of a conceptual approach, which has not yet found widespread reflection in the practice of oral health professionals and oral health advocates.
1 Lack of coordinated advocacy for oral health
Coordinated advocacy for recognition and the development of realistic models for integra tion of oral diseases into newly emerging health strategies, such as strategies related to the growing burden of noncommunicable diseases, are lacking impact and fail to generate broad support.
Responding to a renewed interest in school health, particularly pushed by activities of the World Bank,50 and building on the lessons learnt in the Philippines, advocacy for more
international attention is needed on effective schools health which is based on a conceptual framework. The underlying concepts are the common risk factor approach, intersectoral col laboration on determinants of health and integration of oral health in other disease contexts, mainly in the context of the growing international momentum related to noncommunicable diseases (NCDs) which will dominate health agendas for the coming decade.10,14,5159
1
Aim of the PhD research
The overall aim of the research presented in this thesis is to exemplify different areas of in ternational neglect of oral diseases and to highlight possible ways to address this situation. Specific objectives are:
1. To better understand the process and importance of political priority setting in the con text of global oral health (Chapter 2);
2. To highlight symptoms of the neglected state of global oral health (Chapters 3, 5 and 7); 3. To contribute to an improved understanding of the impact of dental caries (Chapters 4
and 5); and
4. To give examples of successful activities and opportunities to address the state of ne glect of oral health (Chapters 6 and 8).
Outline of the thesis
The key theme and argument of the thesis, the neglected state of global oral health, is pre sented in Chapter 2, which analyses through an analytical framework the essential factors determining political priorities. This analysis is a first step towards more effective global oral health advocacy. Chapter 3 examines the problem of service provision in oral care which is more than a legal problem and analyses the associated ethical, cultural, economic and health issues in greater detail based on a case study from Guyana. To meet the shortcomings of cur rent dental caries indices, Chapter 4 introduces a new index for assessment of the advanced consequences of untreated dental decay, as well as the need for urgent treatment, in a simple way and complements existing epidemiological indices for caries. Chapter 4b presents the rationale for not integrating the PUFA index into an overall caries index. Chapter 5 investi gates another dimension of neglect of oral diseases and explores the relation between severe untreated decay and child development in terms of Body Mass Index (BMI). The chapter also presents a conceptual framework of acknowledging dental decay in a standard framework of health determinants for child development that may point the way to more detailed fu ture research. Chapter 6 embarks on the issue of efficacy of fluoride toothpastes in low and middleincome countries and presents guidelines for the consumers. Chapter 7 showcases a school health model that has been developed in the Philippines. It shows how oral health issues can be integrated in the broader context of general health and thereby creating more political support for sustainability. Responding to a renewed interest in school health, par
1 ticularly pushed by activities of the World Bank,50 and building on the lessons learnt in the
Philippines, Chapter 8 first presents a paper advocating for more international attention and action on effective school health. Furthermore it presents reflections related to political ad vocacy aimed at raising the profile of oral health on political agendas and in prioritysetting processes. Chapter 9 presents the summary and discusses issues related to the main findings. It also provides recommendations to facilitate political priority for global oral health.
1
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