The CHALLENGE

of ORAL DISEASE
A CALL FOR GLOBAL ACTION

The Oral Health Atlas

SECOND EDITION
THE CHALLENGE
OF ORAL DISEASE
A call for global action

The Oral Health Atlas

SECOND EDITION
Disclaimer Contents

First published by FDI World Dental Federation in 2015 Foreword 5

Text and illustrations copyright © FDI World Dental Federation 2015 Acknowledgements 6
Maps, graphics and original concept copyright © Myriad Editions 2015

All rights reserved Chapter 1 Introduction 8

ISBN: 978-2-9700934-8-0 Healthy teeth, healthy life 10

Produced for FDI World Dental Federation by

Myriad Editions Chapter 2 Oral Diseases and Health 12
Brighton, UK Oral health and general health 14
www.myriadeditions.com
Tooth decay
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means Burden of the disease 16
without the written permission of FDI World Dental Federation. For requests, please contact [email protected]. Development of the disease 18
Patient testimonies / What can be done? 20
The views expressed in this publication do not necessarily reflect those of FDI World Dental Federation. The mention of Periodontal disease
specific products or references does not imply endorsement or recommendation by FDI World Dental Federation. All Nature of the disease process 22
reasonable precautions have been taken to ensure accuracy of all information in this publication. In no event shall FDI Patient testimonies / What can be done? 24
World Dental Federation be held liable for any wrong information. Oral cancer
The designations employed and the presentation of the material in this publication do not imply the expression of any Burden of the disease 26
opinion whatsoever on the part of FDI World Dental Federation concerning the legal status of any country, territory, city
Patient testimonies / What can be done? 28
or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent HIV/AIDS and oral health 30
approximate border lines for which there may not yet be full agreement. The terms ‘low-, middle- and high-income Noma 32
country’ used in this publication follow the definitions of the World Bank Group. For reasons of space, FDI has used
Congenital anomalies 34
common popular names and abbreviations on the maps and other graphics for the following countries:
Oral trauma 36
B-H: Bosnia and Herzegovina Liecht.: Liechtenstein Switz.: Switzerland
Bolivia: Plurinational State of Bolivia Lux.: Luxembourg Syria: Syrian Arab Republic Chapter 3 Oral Diseases and Risk Factors 38
Brunei: Brunei Darussalam Moldova: Republic of Moldova Tanzania: United Republic of
Social determinants and common risk factors 40
Congo: Republic of the Congo Mont.: Montenegro Tanzania
Dem. Rep. Congo: Democratic Neth.: The Netherlands UAE: United Arab Emirates Sugar 42
Republic of the Congo North Korea: Democratic People’s UK: United Kingdom of Great Britain Tobacco 44
East Timor: Democratic Republic of Republic of Korea and Northern Ireland
Alcohol 46
Timor-Leste Russia: Russian Federation USA: United State of America
FYROM: The former Yugoslav St Vincent & Grenad.: Saint Vincent Uzbek.: Uzbekistan Diet 48
Republic of Macedonia and the Grenadines Venezuela: Bolivarian Republic of
Iran: Islamic Republic of Iran Slov.: Slovenia Venezuela
Chapter 4 Oral Diseases and Society 50
Laos: Lao People’s Democratic Slovakia: Slovak Republic
Republic South Korea: Republic of Korea Inequalities in oral health
Oral health status 52
All entries – data, sources and references – closed on 30 April 2015. Impact of oral diseases 54
Access to oral healthcare 56
Suggested citation: The Challenge of Oral Disease – A call for global action. The Oral Health Atlas. 2nd ed. Geneva:
FDI World Dental Federation; 2015.
 Foreword

Chapter 5 Oral Diseases: Prevention and Management 58 FDI World Dental Federation represents over 1 million dentists worldwide through the membership
of national dental associations (NDA) in some 150 countries. Through its four-part mission in
Provision of oral healthcare
NDA capacity building, knowledge transfer, continuing education and oral health advocacy, it
Dentists 60
Dental team 62 seeks to realize its vision of ‘leading the world to optimal oral health’, acknowledging that oral
Oral healthcare continuum 64 health is fundamental to general health and wellbeing.

Prevention of tooth decay A prerequisite of progress towards optimal oral health is to understand where we stand today. It
Fluorides 66 was with this in mind that FDI published a first Oral Health Atlas in 2009, with the stated aim of
Fluoride toothpaste 68 ‘mapping a neglected global health issue’. Dense, informative and authoritative, yet accessible
to the lay reader, it provided a novel and innovative approach towards a greater understanding of
oral diseases, their epidemiology and their risk factors, and highlighted specific areas of concern.
Chapter 6 Oral Health Challenges 70
Challenges in education 72 As a unique tool in presenting a complex issue to a variety of audiences, the atlas was well
received by dentists and dental researchers as well as by academics, health officials and other
Challenges of global migration 74
health practitioners. Encouraged by the book’s success, FDI decided to embark on a new
Challenges in research 76 publication, allying the virtues of the original atlas with a new activism. The focus was now not
only on identifying the issues, but also on bringing about change. The Challenge of Oral Disease
Chapter 7 Oral Health on the Global Agenda 78 – A call for global action is therefore far more than a source of important information; it is an
essential tool for FDI oral health advocacy.
Oral health and NCDs
A common action plan 80 FDI views oral health as a fundamental right, and echoes the 2010 Adelaide Statement on Health
A developing movement 82 in all Policies in its own principle of ‘oral health in all policies’. This new publication seeks
Oral health and global development 84 to enable this concept by including, where possible and appropriate, a series of action points
and recommendations. The overall aim is to assist leaders and policy makers, who may not be
Universal Health Coverage 86
specialists in the field of health, in integrating considerations of oral health, wellbeing and equity
Amalgam and the Minamata Convention 88 during the development, implementation and evaluation of policies and services.

Chapter 8 A Call for Global Action 90

Dr Patrick Hescot,
Oral health advocacy recommendations 92
FDI President

Annex 98
Milestones in dentistry 99
Comments on data and sources 106
Abbreviations 109
References 110
Photo credits 118
Index 119

5
Acknowledgements

FDI would like to thank everyone who helped in the Sincere thanks to the Hong Kong Dental Association for For their advice on specific chapters and data, we would Richard Watt, Research Department of Epidemiology and
preparation of The Challenge of Oral Disease – A call for their generous support of The Challenge of Oral Disease – like to thank the following contributors: Public Health, University College London, UK
global action. A call for global action. We would also like to thank our David Williams, Barts and The London School of Medicine
We would especially like to thank our Editors-in-Chief, partners GC Corporation, Henry Schein, Ivoclar Vivadent, Chapter 1 – Introduction and Dentistry, Queen Mary University of London, UK
Professor Habib Benzian, College of Dentistry, New Listerine, Morita, Sunstar and Unilever for their support Kitty Hse, School Dental Care Service, Hong Kong SAR,
York University, USA, and Professor David Williams, towards FDI’s advocacy activities within the frame of the China Chapter 5 – Oral Diseases: Prevention and Management
Barts and The London School of Medicine and Dentistry, FDI Vision 2020 initiative. Habib Benzian, College of Dentistry, New York University,
Queen Mary University of London, UK, for their extensive Chapter 2 – Oral Diseases and Health USA
involvement in and contribution to this project, as well as Lijian Jin, Faculty of Dentistry, The University of Hong Jo Frencken, College of Dental Sciences, Radboud
Tania Séverin, Associate Editor, FDI. Kong, Hong Kong SAR, China University Nijmegen, The Netherlands
Ira Lamster, Mailman School of Public Health, Columbia Brittany Seymour, Department of Oral Health Policy and
We would also like to thank our members of the Oral
University, USA Epidemiology, Harvard School of Dental Medicine, USA
Health Atlas Task Team for their supervision and guidance:
Peter Mossey, School of Dentistry, Dundee University, UK Nermin Yamalik, Faculty of Dentistry, University of
Lijian Jin, Faculty of Dentistry, The University of Hong Sudeshni Naidoo, Faculty of Dentistry, University of the Hacettepe, Turkey
Kong, Hong Kong SAR, China, Task Team Chair Western Cape, South Africa
Habib Benzian, College of Dentistry, New York University, Benoit Varenne, Regional Office for Africa, World Health Chapter 6 – Oral Health Challenges
USA Organization, Republic of the Congo Madhan Balasubramanian, Australian Research Centre for
Kevin Hardwick, American Dental Association, USA Saman Warnakulasuriya, Dental Institute, King’s College Population Oral Health, School of Dentistry, The University
London, UK of Adelaide, Australia
The late Fannye Thompson, Ministry of Health, Barbados
Domenick Zero, Oral Health Research Institute, Indiana David Brennan, Australian Research Centre for Population
David Williams, Barts and The London School of Medicine
University School of Dentistry, USA Oral Health, School of Dentistry, The University of
and Dentistry, Queen Mary University of London, UK
Adelaide, Australia
Our appreciation goes to our FDI staff: Claudia Marquina, Chapter 3 – Oral Diseases and Risk Factors Christopher Fox, International Association for Dental
Managing Editor, and Jean-Luc Eiselé, Executive Director Michael Eriksen, School of Public Health, Georgia State Research, USA
(2011–2015). University, USA Sally Hewett, Ihland Garden Dental, USA
Zairah Roked, Violence Research Group, Cardiff University,
UK Chapter 7 – Oral Health on the Global Agenda
Andrew Rugg-Gunn, School of Dental Sciences, Newcastle Robert Beaglehole, University of Auckland, New Zealand
University, UK Manu Raj Mathur, Public Health Foundation of India &
Aubrey Sheiham, Research Department of Epidemiology Research Department of Epidemiology and Public Health,
and Public Health, University College London, UK University College London, UK
Jonathan Shepherd, Violence Research Group, Cardiff Christopher Simpson, FDI World Dental Federation,
University, UK Switzerland
Carrie Whitney, School of Public Health, Georgia State David Williams, Barts and The London School of Medicine
University, USA and Dentistry, Queen Mary University of London, UK

Chapter 4 – Oral Diseases and Society Annex

Stefan Listl, Translational Health Economics Group, Malcolm Bishop, Dental Institute, Kings College London,
Heidelberg University Hospital, Germany UK
Georgios Tsakos, Research Department of Epidemiology
and Public Health, University College London, UK

6 7
 Introduction Chapter 1

The first edition of the Oral Health Atlas, pub- sion and presents a range of possible courses
lished in 2009, aimed at ‘mapping a neglected of action that can – and should – be taken to
global health issue’. The extent of neglect has alleviate the global burden of oral disease.
not changed in the intervening period, yet
New chapters in the book position oral health
there are new and encouraging opportunities
within the broader international develop-
for action addressing oral diseases on a global
ment picture, in which significant initiatives
scale. Recognizing these opportunities, the
such as the United Nations (UN) Sustainable
title of this second edition has been changed
Development Goals (SDGs), the recognition
to The Challenge of Oral Disease – A call for
of noncommunicable disease (NCDs) as an
global action.
increasing global burden, and the Minamata
This completely rewritten text is explicitly Convention on Mercury provide new and pow-
directed at policy makers and key opinion erful opportunities for advocacy, integration
leaders. It has the clear purpose of acting as and cross-sectoral approaches.
an advocacy resource for all oral healthcare
Complemented by a brief overview of the his-
professionals and those concerned about the
torical context of oral health and disease, the
unacceptable global burden of oral disease.
atlas closes with detailed ‘Comments on data
The book brings together information, data and
and sources’ that draw attention to the extent
facts on a broad range of topics related to oral
of gaps in oral health information.
health. It looks at the state of global oral health
through a public-health and population-fo- FDI’s vision of ‘leading the world to optimal
cused lens, and clearly aims at supporting ad- oral health’ requires a move from the current
vocacy and action. predominant curative care model, focused on
individual clinical patient services, towards
As this book shows, there are serious gaps in
population-wide preventive interventions.
recent epidemiological data on the major oral
diseases, particularly in low- and middle-in- This challenging paradigm shift will require
come countries. Thus, general awareness of oral a concerted effort from all stakeholders con-
diseases among policy makers, health planners cerned with oral health. It will also require the
and the health community at large remains forging of new partnerships with others from
low. Existing interventions to prevent and con- within and outside healthcare. International ef-
trol oral diseases are too often regarded as an forts to reduce the burden of other NCDs have
expendable luxury, rather than as a fundamen- shown that such bold moves are possible with
tal human right for everyone. Consequently, a strong leadership and broad political support.
large proportion of the global burden of oral It is now time to ensure that oral health is inte-
disease remains unattended, and oral diseases grated into these efforts.
receive only a low allocation of resources for
Habib Benzian
surveillance, prevention, care and research.
New York, USA
Raising awareness of the requirement to address Editor-in-Chief
the burden of oral disease among policy mak-
David Williams
ers is one of the main aims of this publication. It
London, UK
presents an overview of the main oral diseases
Editor-in-Chief
and the burden they represent. It lays out cur-
rent challenges faced by the oral health profes-

8 9
 Healthy teeth, healthy life
Healthy primary and A healthy and well-functioning dentition is im- with the lower primary incisors. By the age of At about six years of age, the lower permanent lead to disease or even tooth loss. Tooth decay
permanent teeth are portant during all stages of life since it supports two and a half, all primary teeth have erupted. incisors and the first permanent molars erupt. and periodontal disease are the most common
important for health essential human functions, such as speaking, The transition period from primary to perma- oral diseases, yet they are largely preventable.
Healthy primary teeth maintain the space for
and wellbeing smiling, socializing and eating. Teeth help to nent dentition typically lasts from 6 to 12 years
their permanent successors developing in the Proper self- and professional oral care,
throughout life. give the face its individual shape and form. of age. By age 21, ideally all 32 permanent
jaw underneath. Their premature loss, from combined with a healthy lifestyle and avoiding
teeth have erupted.
The normal set of teeth comprises 20 primary tooth decay or injury, often results in loss risks, such as high sugar consumption and
teeth, which are replaced by 32 permanent of space for their successors and may lead During the life course teeth and oral tissues are smoking, make it possible to retain a function-
teeth. Tooth eruption begins when babies are to crowding problems with the permanent exposed to many environmental factors that may ing dentition through life.
around 6 to 10 months old, usually starting dentition.

ORAL HEALTH FOR LIFE

The developing dentition
Age: 21 years old
Age: 6 years old Third molars (wisdom teeth)
Permanent teeth begin to appear. are the last to erupt.

Age: 2½ years old Age: 12 years old

Age: 6 months old All primary (upper and Most permanent teeth
Teething begins. lower) teeth have erupted. have erupted.

Good oral hygiene and

healthy habits, together with

CHAPTER 1 INTRODUCTION
Cleaning or wiping can Children can start Dry mouth as a result of
Develop a life-time habit regular dental check-ups, help
start with the eruption supervised tooth reduced saliva production
of twice-daily brushing Start to wear mouthguards Avoid sweets, tobacco to avoid tooth decay and
of a child’s first teeth. brushing twice a day may increase risk of
with fluoride toothpaste. for contact sports. and alcohol. periodontal disease. Pregnant
Pacifier bottles with with a pea-sized diseases. Regular check-
women should take extra care
sugary drinks or fruit amount of fluoride Establish good dietary ups may help keep a
of their oral health.
juices can cause early toothpaste. Regular habits, limiting amount healthy mouth and good
childhood tooth decay. dental check-ups can and frequency of quality of life.
Better to use plain start early in life. sugary snacks.
water instead.

Good habits for life

10 11
Oral Diseases and Health Chapter 2

What is oral health and why consider oral dis- Untreated tooth decay is now known to be the
eases as a serious public health threat? Oral most prevalent of the 291 conditions studied
diseases may directly affect a limited area between 1990 and 2010 within the frame of
of the human body, but their consequences the international Global Burden of Disease
and impacts affect the body as a whole. The Study. This is the most authoritative estimation
World Health Organization (WHO) defines of global disease burden and serves as a basis
oral health as ‘a state of being free from mouth for health policy planning and resource alloca-
and facial pain, oral and throat cancer, oral tion. Severe periodontitis, which is estimated to
infection and sores, periodontal disease, tooth affect between 5 and 20 percent of populations
decay, tooth loss, and other diseases and dis- around the world, was found to be the sixth
orders that limit an individual’s capacity in most common condition. Oral cancer is among
biting, chewing, smiling, speaking, and psy- the 10 most common cancers in the world,
chosocial wellbeing.’ and even more prevalent in South
Asia, with numbers expected to
This widely recognized defini- “Oral health is rise due to increasing tobacco
tion is complemented by the essential to general and alcohol consumption.
acknowledgement of oral
health and quality
health as an integral element Approximately 50 percent of
of the right to health, and of life.” the 35 million people living
thus of the basic human rights WHO fact sheet with HIV suffer from oral fungal,
enshrined in the UN Universal on oral health, 2012 bacterial or viral infections. Tens
Declaration of Human Rights of thousands of children are still af-
adopted by all nations. fected by noma in the poorest areas of
Sub-Saharan Africa. Moreover, one in every 500
A healthy mouth and a healthy body go hand
to 700 children is born with a cleft lip and/or
in hand. Conversely, poor oral health can have
palate. And oral and facial trauma, associated
detrimental consequences on physical and
with unsafe environments, sports and violence,
psychological wellbeing. Yet, the high burden
exacts a high toll, particularly on children.
of oral diseases represents a widely underes-
timated public health challenge for almost all These examples illustrate the huge burden of
countries worldwide. Oral diseases are often oral diseases that afflict humankind and which
hidden and invisible, or they are accepted as require population-wide prevention and access
an unavoidable consequence of life and age- to appropriate care. The many links between
ing. However, there is clear evidence that oral general and oral health, particularly in terms of
diseases are not inevitable, but can be reduced shared risk factors and other determinants, pro-
or prevented through simple and effective vide the basis for closer integration of oral and
measures at all stages of the life course, both at general health for the benefit of overall human
the individual and population levels. health and wellbeing.

13
 Oral health and general health SELECTED ASSOCIATIONS BETWEEN ORAL CONDITIONS AND GENERAL HEALTH

Oral health and Oral health is about more than healthy teeth and alcohol use. They result in a very similar Edentulousness:
and a good-looking smile. The mouth is a pattern of inequalities in oral and general The extensive or
general health are
complete loss of teeth
closely related and mirror of the body, often reflecting signs of sys- disease burden between different population Organ infections:
may negatively impact
Oral bacteria are
should be considered temic diseases. Examination of the mouth can groups. on nutrition, the ability
associated with
holistically. reveal nutritional deficiencies and unhealthy to eat and quality of life.
With the global improvement in life expectancy, infections of the heart,
habits such as tobacco or alcohol use. Oral brain and other organs.
a life-course approach to oral health will
lesions may be the first signs of HIV-infection,
become more important. Different ages in life
and changes in tooth appearance can indicate Noma:
have different oral health needs, and the specific
serious eating disorders. Acute necrotizing
problems of older people, who are often also Saliva: Can be used to gingivitis/periodontitis
Many general conditions increase the risk suffering from other diseases, are becoming identify specific is an important risk
of oral diseases, such as an increased risk of more prevalent. Knowledge and awareness of markers of disease, factor for noma.
such as HIV infection.
periodontal disease in patients with diabetes. the close associations between oral and general Cardiovascular disease:
Equally, poor oral health can adversely affect a health are thus important for holistic care, as is Periodontal disease may
number of general health conditions and their collaboration between oral and general health Pneumonia: be associated with
Oral infections can be cardiovascular disease.
management. professionals. associated with an
increased risk for
Most oral diseases share common risk factors The close bi-directional relationship between Preterm and
pneumonia.
with NCDs such as cardiovascular diseases, oral and general health, and its impact on an low-birth-weight
cancers, diabetes and respiratory diseases. individual’s health and quality of life, provides a babies: Periodontal
These risk factors include unhealthy diets (par- strong conceptual basis for the integration of oral Stomach ulcers: disease may be
The mouth may be a associated with
ticularly those high in added sugars), tobacco healthcare into general healthcare approaches. reservoir for bacteria increased risk for
associated with preterm and
stomach ulcers. low-birth-weight babies.
“...oral
Diabetes: Gastrointestinal and
health refers to the pancreatic cancers:
health of our mouth Periodontal disease
can be associated with Periodontal disease
athe
bre and, ultimately, supports diabetes and may may be associated
speak
and reflects the increase the risk for with gastrointestinal
exp health of the diabetic complications. and pancreatic
cancers.
entire body.”
re
ss

attract

Regina Benjamin,

CHAPTER 2 ORAL DISEASES AND HEALTH

taste Former Surgeon General of
the United States, 2010
SOME OF
THE THINGS
drink
WE CAN DO
WITH OUR MOUTH
bite make mu

sic
eat
whistle
lick kiss
suck spit

14 15
 2.2.1

Tooth decay
Untreated tooth Burden of the disease ICELAND
TOOTH DECAY
SWEDEN FINLAND
decay is the most NORWAY WORLDWIDE
Tooth decay (dental caries) is the most ESTONIA Average number
common chronic widespread chronic disease worldwide and LATVIA
LITHUANIA of decayed (D), missing (M),
disease, due to constitutes a major global public health chal- IRELAND
UK
DENMARK
and filled (F) teeth (T)
BELARUS
exposure to sugar lenge. It is the most common childhood disease,
NETH.
GERMANY
POLAND
in 12-year-olds
BELGIUM UKRAINE
CZECH RUSSIA
and other risks, the C A N A D A REP. SLOVAKIA latest available data
but it affects people of all ages throughout their FRANCE SWITZ.
LUX.
AUSTRIA HUNGARY
MOLDOVA
1994–2014
lack of effective lifetime. Current data show that untreated decay
SLOV.
B-H
ROMANIA
CROATIA
BULGARIA
prevention and of permanent teeth has a global prevalence of PORTUGAL
MONT. more than 3.5 high
ALBANIA FYROM
MONGOLIA
limited access to over 40 percent for all ages combined and is the U S A
SPAIN
ITALY
GREECE
2.6 – 3.5 moderate
appropriate oral most prevalent condition out of 291 diseases UZBEK. JAPAN 1.2 – 2.5 low
TURKEY SOUTH
healthcare. included in the Global Burden of Disease Study. CYPRUS SYRIA C H I N A
KOREA
0.0 – 1.1 very low
MALTA LEBANON
Untreated tooth decay frequently causes oral MOROCCO TUNISIA ISRAEL
JORDAN
IRAQ I R AN
no data
KUWAIT
pain and it affects up to seven in ten children MEXICO BAHAMAS
L I B YA BAHRAIN
PAKISTAN
NEPAL
BHUTAN

CAYMAN IS. CUBA DOMINICAN QATAR Macau SAR

EGYPT
in India, one in three teenagers in Tanzania and JAMAICA
REP.
PUERTO RICO
UAE
INDIA BANGLADESH HK SAR
HAITI SAUDI ARABIA KIRIBATI
ANGUILLA LAOS
almost one in three adults in Brazil. Untreated GUATEMALA
BELIZE
HONDURAS
ST KITTS & NEVIS ANTIGUA & BARBUDA OMAN MYANMAR
VIET NAM TUVALU
DOMINICA NIGER THAILAND TOKELAU
SENEGAL SUDAN ERITREA YEMEN
tooth decay can cause difficulties in eating and EL SALVADOR
NICARAGUA GRENADA ST LUCIA
BARBADOS
GAMBIA BURKINA
CAMBODIA
PHILIPPINES
TRINIDAD & TOBAGO FASO SAMOA
COSTA RICA
sleeping, may impact child growth and is a

BENIN
NIGERIA

GHANA
VENEZUELA CÔTE
PANAMA GUYANA SOUTH ETHIOPIA SRI LANKA
D’IVOIRE
SUDAN BRUNEI VANUATU
leading cause of absence from school and work. COLOMBIA SURINAME
MALAYSIA FIJI
UGANDA
COOK ISLANDS
SINGAPORE
ECUADOR KENYA NIUE
The burden of tooth decay for 12-year-olds is GABON
TONGA
SEYCHELLES
PAPUA
highest in middle-income countries, with about PERU TANZANIA I N D O N E S I A NEW
FRENCH POLYNESIA
BRAZIL GUINEA
two-thirds of decay remaining untreated. Whilst SOLOMON
ISLANDS

low-income countries have lower levels of BOLIVIA

tooth decay, this goes almost entirely untreated, NAMIBIA
MOZAMBIQUE
CHILE PARAGUAY
reflecting weak oral healthcare systems. Even
SWAZILAND AUSTRALIA
in high-income countries more than half of SOUTH
AFRICA
URUGUAY
tooth decay is left untreated. Tooth decay shares
the same social determinants and resulting
inequalities as many other oral diseases. NEW
ZEALAND
ESTIMATED
Despite the widespread nature of tooth decay,
NUMBER OF
reliable, standardized global data are limited.
PEOPLE AFFECTED
This is largely because oral health data are not GLOBAL DISTRIBUTION OF TOOTH DECAY The DMFT Index

CHAPTER 2 ORAL DISEASES AND HEALTH

BY COMMON
DISEASES integrated in national disease surveillance, Average number of affected teeth for 12-year-olds The DMFT index is generally used to
2010 particularly in low- and middle-income coun- by country income group report tooth decay in epidemiological
tries. Separate national oral health surveys epidemiologic information constrains the 2000 or latest available data studies. It records the number of
decayed (D), missing (M) and filled (F)
are complex and costly to conduct, and development of appropriate approaches to decayed (D) missing (M) filled (F)
teeth (T). While DMFT is not the only
hence not prioritized. This lack of up-to-date reduce the disease burden. 0.06 measure and has limitations, the oral
high income 0.77 0.69 health status of populations is often
3,054m summarized as a DMFT score (usually
upper-middle 1.46 0.25 0.50 of 12-year-olds). A DMFT score of 1.0
1,013m income
Tooth decay is the most prevalent of conditions, means that 1 of the 32 adult teeth is
lower-middle
743m affecting almost half (44%) of the world population income 1.31 either decayed, missing or filled.
untreated decay of 549m 334m in 2010, followed by tension-type headache (21%), 0.14 0.09 Scores for individuals are full
migraine low income 0.83 numbers, for populations they can
primary and severe migraine (15%), severe periodontitis (11%),
diabetes asthma diabetes (8%) and asthma (5%). 0.02 0.02 have decimal values.
permanent teeth periodontitis

16 17
 2.2.2

Tooth decay
Tooth decay is Development of the disease
principally caused by
Tooth decay (dental caries) is a multifactorial individuals and oral health professionals to Tooth decay develops over time and is triggered by TOOTH DECAY IS A MULTIFACTORIAL DISEASE
sugar consumption disease, caused by the interaction between take action to prevent or reduce the severity of acid production resulting from the breakdown of Modified from Fisher-Owens, 2007
and can largely be sugars. However, a wide range of other factors
the tooth surface, the bacterial biofilm (dental disease. influence the development of tooth decay and its
prevented by plaque) and the presence of sugars from severity. These factors act over time at the level of
reducing sugar Reducing acid attacks on the tooth enamel can
food. Biofilm bacteria metabolize sugars and the community, the family and the affected
intake, appropriate be achieved by reducing the total amount and individual.
produce acids, which over time break down
fluoride use and frequency of sugar consumed. Action to protect
tooth enamel.
the tooth surface can be taken by ensuring
promoting good oral EL INFLUENCES
Decay usually starts hidden from view in the adequate exposure to fluoride, for example by TY-LEV
hygiene. M UNI physical safety • cha
CO
M ment • racte
fissures of the teeth or in the tight spaces using fluoride toothpaste, or fluoridating water
en viron risti
cal cs o
between them. In its early stages the disease supplies. Action on the microbial biofilm can i
phys fh
eal
can be arrested and even reversed, but in the be taken by ensuring good oral hygiene t • thc
en are
m
later stages a cavity forms. Then treatment practices. iron sy
ste
becomes necessary to restore tooth function, en
v
-LEV EL INFLUENCES m
ILY •
In addition, a range of external factors, such as FAM on • h ea lth status o
involving the removal of decayed tissue or the uncti f par
ents
ily f

ch
where and how people live, also influence the am •

ar
placement of a filling or crown. If left f phy

alt

T
•

ac
development of tooth decay. This means that re sic

he

IM
ltu al

ter
untreated, decay can lead to extensive destruc- cu sa

ral

ist
although the decay process starts at the surface • fet

E
yo
y

ics
tion of the tooth, pain, and infection. The latter NFLUENCES
of the tooth the problem cannot be solved by -LEVEL I •
UAL s

nit

of
can result in abscess formation or septicaemia. ID d practices
DIV haviours an

mu

oc

den
concentrating on the teeth alone. It also neces-

ily
• ph
IN

ia
At this stage, root canal treatment or extraction e ysic

fam
om
b
owment • developm

ls

tal-
sitates action on the community level to lth d a
ent l and

up
a en
he

l•c

of
becomes necessary. ic

care
t

po
address the broader determinants underlying • ne de

lls
ge m

rt
apita

ski
o

system
Most of the factors involved in tooth decay are the disease process.

soc
ce
ing

gr
an

ap
culture • social c
modifiable, providing entry points for

ioec
cop

ur

hic
an
YE
L-CAVIT NVIRONM

ins
ORA

att

onom
gic
behaviours, practices and
EN

tal
T

rib
olo
den

utes
• bi

ic status
al care •
HOST

ent
AND

d
SUGAR

use of
TEETH

CHAPTER 2 ORAL DISEASES AND HEALTH

TOOTH

lth
DECAY

hea
BACTERIAL BIOFILM/
DENTAL PLAQUE DENTAL PLAQUE
Dental plaque is a biofilm consisting of
approximately 600 different species of bacteria.

T
IM
Several of the bacterial species have been
associated with causing tooth decay including

E
Streptococcus mutans.

18 19
 2.2.3

Tooth decay

What can be done?

Patient testimonies
“I am a very busy person. My job is “Our son had just turned 10 when he “I’ve always had a job. Whether it was
Reduce dietary sugar intake reducing the burden of tooth decay. Greater
highly demanding and many people was diagnosed with type 1 diabetes. waitressing or retailing… I’ve always
Untreated tooth decay is the most common emphasis on promoting good dietary habits
count on me to produce results on It was difficult to hear, but my had a job and it’s usually been in
of the 291 conditions included in the 2010 and a focus on reducing sugar consumption
time. Time is indeed money. For a husband and I decided to learn as constant contact with people. This all
Global Burden of Disease Study, despite the will be essential.
while, I had some toothache come much as possible about the disease changed when I got pregnant with
fact that it is largely preventable through
and go. The pain was manageable and ways to stabilize it. Our doctor my firstborn. I decided to take some Universal access to affordable and effective
simple and cost-effective interventions.
and I didn’t have time to go see the then told us about the importance of time off from work to fully enjoy fluoride
doctor, so I would take a painkiller avoiding chronic infections and motherhood. I spent about four The highest levels of tooth decay are found Exposure to fluoride is among the most
when it hurt and that would do the minimizing the risk of tooth decay. years at home with the kids. During in middle-income countries, where sugar cost-effective measures to prevent tooth
trick. Then one day, the pain got so So we started taking our son for this time, though, I developed the consumption is on the rise and health decay and improve oral health. Regular use
acute that I started having a fever regular dental checkups and we habit of snacking and drinking soda. systems are not able to provide appropriate of fluoride toothpaste is the most important
and painkillers were not working honestly feel more relieved now I must say this had a tremendous prevention or access to oral healthcare. The way to ensure a good preventive effect.
anymore. I rushed to the dentist who knowing that we are taking the right impact on my life. I decided to go consequences of untreated tooth decay,
Universal access to primary oral healthcare
told me that my tooth was in such preventive measures to keep our son back to work, only my employer said particularly for children, are negative
Existing inequalities in disease burden can
bad shape that I needed a root canal in good health. Luckily our health he wouldn’t take me because I had impacts on nutrition and growth, loss of
only be reduced with universal access to
treatment. Simple tooth decay that insurance covers oral healthcare too developed bad teeth. I didn’t realize days in school and at work, reduced overall
primary oral healthcare, covering at least
could have been quickly cured ended so we can do what is necessary for this had become so visible, but my productivity and significant impacts on
relief of pain, promotion of oral health and
up costing me numerous working our son’s wellbeing and overall bad eating habits had caused a lot of quality of life and social interactions.
management of oral diseases, including
hours (and money) because I waited health.” tooth decay. I was ashamed and
A combination of approaches is required tooth decay.

CHAPTER 2 ORAL DISEASES AND HEALTH

too long. This was a mistake I will devastated to learn I couldn’t
Teacher, Vancouver, Canada, to address the global tooth decay burden,
not make again.” continue working because of the way Surveillance, monitoring and evaluation
34 years old including:
I looked – especially in a business Global and national surveillance of oral dis-
Entrepreneur, Tokyo, Japan,
where there is social pressure to look Integration of oral health and NCDs eases must be an integral part of routine epi-
33 years old
good. This was a wake-up call to Full integration of oral health into popula- demiological surveillance. Monitoring risk
make drastic changes in my lifestyle tion-wide prevention and health-promotion factors and oral health needs is fundamental
“Simple tooth strategies is necessary for NCD reduction. to developing appropriate interventions
for the sake of my teeth, my job, my
decay that could have This is because curative interventions are nei- and programmes and to evaluating their
children and my own health.”
been quickly cured ended ther realistic nor sustainable approaches to effectiveness.
up costing me numerous Retailer, Paris, France, 54 years old
working hours (and money)
because I waited too long.
This was a mistake I will
not make again.”
20 21
 Periodontal disease ICELAND

SWEDEN FINLAND
NORWAY

Periodontal disease is Nature of the disease process ESTONIA SEVERE CHRONIC

one of the DENMARK
LATVIA
LITHUANIA PERIODONTITIS
Periodontal (gum) disease begins as gingivitis IRELAND
UK
Estimates of
commonest diseases (chronic inflammation of the gums), which
NETH. POLAND
BELARUS

BELGIUM
GERMANY
UKRAINE
average prevalence
of humankind, but is is very widespread and for the majority of LUX.
CZECH
REP. SLOVAKIA among those 15 years
MOLDOVA
CANADA HUNGARY RUSSIA
largely preventable FRANCE SWITZ. AUSTRIA
ROMANIA or older per country
patients completely reversible. It may progress SLOV.
CROATIA B-H SERBIA 2010
through good oral to periodontitis, a more serious condition that PORTUGAL
MONT.
BULGARIA
KOSOVO
ANDORRA ITALY ALBANIA FYROM
hygiene and destroys tooth-supporting tissues and bone. In SPAIN KAZAKHSTAN more than 15.0%
GREECE MONGOLIA
preventive policies about 15 percent of the population the disease NORTH
10.1% – 15.0%
GEORGIA
GEEORGIIIA KYRGYZSTAN KOREA
addressing common can progress further to severe periodontitis that U S A AZERBAIJAN
ARMENIA TURKMEN.
UZBEK.
SOUTH
JAPAN
10% or less
TURKEY TAJIKISTAN KOREA
risk factors. leads rapidly to tooth loss. CYPRUS SYRIA C HINA
TUNISIA
MALTA LEBANON IRAQ IRAN
AFGHANISTAN no data
MOROCCO ISRAEL
JORDAN
The disease process is still poorly understood, BAHAMAS
GAZA
WEST BANK
KUWAIT PAKISTAN
NEPAL
BHUTAN
ALGERIA L I B YA BAHRAIN
but it tends to progress through phases of rapid, MEXICO CUBA
DOMINICAN
EGYPT QATAR
UAE
BANGLADESH
MICRONESIA, FED. STATES OF
HAITI REP. SAUDI ARABIA MARSHALL ISLANDS
irreversible tissue destruction. By the age of 65 JAMAICA
BELIZE ANTIGUA & BARBUDA
CAPE
VERDE MAURITANIA OMAN
INDIA MYANMAR
LAOS
VIET NAM
GUATEMALA HONDURAS MALI
DOMINICA KIRIBATI
to 74 years about 30 percent of people have lost EL SALVADOR
NICARAGUA
ST VINCENT & GRENAD.
ST LUCIA
SENEGAL
GAMBIA BURKINA
NIGER CHAD SUDAN ERITREA YEMEN
THAILAND
PHILIPPINES
GRENADA BARBADOS CAMBODIA
all their teeth, with periodontal disease being COSTA RICA TRINIDAD & TOBAGO GUINEA-
BISSAU GUINEA
FASO DJIBOUTI

BENIN
VENEZUELA

GHANA
NIGERIA

TOGO
PANAMA GUYANA CÔTE SOUTH ETHIOPIA
SIERRA LEONE D’IVOIRE CENTRAL SRI LANKA
the main cause. Severe periodontal disease COLOMBIA SURINAME LIBERIA AFRICAN REP. SUDAN
MALDIVES
BRUNEI SAMOA

EQUATORIAL CAMEROON SOMALIA MALAYSIA

has serious consequences for those affected, in- GUINEA UGANDA
KENYA SINGAPORE
VANUATU
FIJI
ECUADOR GABON
SÃO TOME
cluding problems with chewing and speaking, & PRINCIPE CONGO
DEM. REP.
OF CONGO
RWANDA
BURUNDI SEYCHELLES
PAPUA
PERU
which adversely affect general wellbeing and TANZANIA I N D O N E S I A NEW
GUINEA SOLOMON
TONGA
BRAZIL COMOROS ISLANDS
quality of life. The disease represents a major ANGOLA
MALAWI
EAST TIMOR

ZAMBIA
global oral disease burden with significant BOLIVIA
ZIMBABWE MAURITIUS
MADAGASCAR
NAMIBIA
social, economic and health-system impacts. PARAGUAY
BOTSWANA
MOZAMBIQUE
CHILE

Specific bacteria are the essential cause of SOUTH

SWAZILAND
LESOTHO
AUSTRALIA

AFRICA
periodontal disease. Other important risk URUGUAY

factors include tobacco use, unhealthy diet, ARGENTINA

genetic factors, stress and excessive alcohol

consumption. Periodontal disease may also NEW
ZEALAND

be associated with systemic diseases such as STAGES OF PERIODONTAL DISEASE

diabetes, cardiovascular diseases, adverse Chronic gingivitis Destructive periodontitis
pregnancy outcomes and respiratory diseases.
Inadequate oral hygiene leads to The defence of the local immune

CHAPTER 2 ORAL DISEASES AND HEALTH

Because of the shared risk factors and its accumulation of dental plaque containing system breaks down and the
two-way relationship with some systemic harmful bacteria and bacterial products that inflammation process advances.
cause chronic inflammation of the gum Tooth-supporting tissues are
diseases, periodontal disease is receiving irreversibly destroyed and result in
adjacent to the tooth surface. However, the
global attention from healthcare professionals, cells of the immune system counter these pocket formation, with loss of
governments, and insurance and pharmaceuti- damaging effects and the inflammation supporting bone. In advanced stages
cal companies. Yet, many people do not remains localized. For many patients, the affected teeth may become loose
disease never progresses beyond this point and be lost.
know about it and the measures to prevent it.
and is reversible in many cases.
Specialized periodontal care is not generally
Links with general health
available; when it is, it is unaffordable for
Products from inflammation around the tooth and the bacteria in dental plaque enter the bloodstream and may cause systemic
many. As with tooth decay, prevalence and
harm. Diseases with an impact on the immune system, such as diabetes, increase the risk of more serious forms of periodontal
severity data on a global level are scarce. disease.

22 23
 2.3.2

Periodontal disease

What can be done?

Periodontal disease is a major public health regular check-ups, are important elements
problem that challenges health systems in prevention of periodontal disease. There
around the world. It largely goes unnoticed is a strong social gradient in the prevalence
by patients until it reaches an advanced of periodontal disease, which requires inter-
“I was scared of
stage. Public awareness of the disease and ventions addressing the wider determinants
what that meant:
the importance of proper oral hygiene is of health.
Would I lose all my teeth?
Would I be able to chew
low, so opportunities for early intervention
Early detection and management
again? Would this affect and effective management are often missed.
Patient testimony Through regular visits to the dentist, perio-
the way I talk? Could I Periodontal disease shares common risk dontal disease can be detected at early
“I started smoking in my early 20s. What didn’t think it was anything afford the dental factors with other major NCDs, with a strong stages and appropriate measures for disease
began as a social habit quickly turned into a serious. I figured it was one of the treatment?” relation to tobacco and alcohol use, high control can be taken. More advanced cases
daily routine. Smoking was a fashionable perks of getting older. Then, just sugar consumption, obesity and unhealthy may require specialized care.
trend at the time, so I didn’t think I had recently, my teeth started moving and diet. It may also be associated with systemic
anything to worry about. I was going to looked longer than they did before. I saw that Strengthening inter-professional
diseases, including diabetes. In about 10 to
university, I was meeting people and going my gums were swollen and often bleeding collaboration
15 percent of patients, common gingivitis
out… I was enjoying life. Then I met my when I brushed my teeth. Then, some of my A holistic approach to managing periodontal
may progress to severe periodontal disease,
husband to-be when I started working. We got front teeth started becoming mobile. I felt disease by integrating it into the prevention
and increasing attention is being given to
married after three years together, and before scared, so I rushed to the dentist where she and management of NCDs is called for, with
identifying this high-risk group before their
I knew it we were expecting our first child. My told me I had suffered major bone loss and stronger collaboration between oral health
disease has progressed to the stage where
pregnancy was a joyful time in my life, which had severe periodontal disease. professionals and physicians, general practi-
tooth loss is inevitable. As with all chronic
was sadly shadowed by some complications tioners and other appropriate health profes-
I was scared of what that meant: Would I lose diseases, effective lifelong self-care, together
linked to my baby’s premature birth. During sionals. Equally, periodontal disease may be
all my teeth? Would I be able to chew again? with appropriate professional oral care, is
my visits to the doctor, I remember him a symptom of underlying systemic diseases
Would this affect the way I talk? Could I afford key to preventing disease progression and
warning me already about smoking and the that require care. Improved periodontal
the dental treatment? I am coping with the tooth loss.

CHAPTER 2 ORAL DISEASES AND HEALTH

negative effects it had on my general health, health may contribute to better management
disease as best as I can, but looking back, I In addition, population-wide strategies to of systemic diseases such as diabetes.
my pregnancy and the baby’s health. I told
regret not making different lifestyle choices. I address severe periodontitis are required:
myself I would smoke less and quit Integrated disease surveillance
wish I had taken my doctor’s advice to stop
eventually, but never really managed to. Healthy living and prevention Integrating indicators for periodontal dis-
smoking when it could have made a
I was around 40 when I started noticing gaps difference. I wish I knew back then what I The promotion of a generally healthy life- ease, together with other oral diseases, into
between my teeth. They were not painful, so I know about health today.” style, with low exposure to risk factors such routine surveillance will help to fill major
as tobacco or alcohol use, together with knowledge gaps about disease prevalence
Retired, Kiev, Ukraine, good personal oral hygiene, awareness and and severity for many countries worldwide.
60 years old

24 25
 Oral cancer ICELAND
ORAL CANCER
SWEDEN FINLAND
NORWAY Incidence per 100,000 population
Oral cancer is among Burden of the disease ESTONIA
RUSSIA
of oral and lip cancer
LATVIA
among those 15 years or older
the 10 most common DENMARK
LITHUANIA
Oral cancer is a disease with high mortality IRELAND
UK RUS.
2012 estimates
cancers, but reducing and is among the 10 most common cancers,
NETH.
GERMANY
POLAND BELARUS
BELGIUM
tobacco and alcohol LUX. CZECH UKRAINE 7.0 or more
depending on country or world region. It is CANADA FRANCE
REP.
AUSTRIA
SLOVAKIA
MOLDOVA
RUSSIA
consumption can estimated that 300,000 to 700,000 new cases SWITZ. SLOV.
HUNGARY ROMANIA
5.0 – 6.9
CROATIA B-H SERBIA
largely prevent it. occur every year, but reliable surveillance PORTUGAL
MONT.
BULGARIA
KOSOVO 2.5 – 4.9
SPAIN ALBANIA FYROM
Survival rates can be data are missing. South and Southeast Asia ITALY TURKEY
KAZAKHSTAN
less than 2.5
GREECE MONGOLIA
improved with early are among the regions with the highest rates no data
NORTH
GEORGIA KYRGYZSTAN JAPAN
detection. of new cases, but Eastern Europe, France and U S A AZERBAIJAN
ARMENIA TURKMEN.
UZBEK. KOREA
SOUTH
TURKEY TAJIKISTAN
KOREA
parts of Africa and Latin America also suffer MALTA
CYPRUS SYRIA AFGHANISTAN C HINA
GUAM
LEBANON IRAQ
TUNISIA IRA N
from a high disease burden. Oral cancer is MOROCCO ISRAEL
GAZA JORDAN
KUWAIT PAKISTAN
BAHAMAS WEST BANK NEPAL BHUTAN
generally a disease of middle-aged men, but MEXICO
CUBA ALGERIA L I B YA
EGYPT
BAHRAIN
QATAR
DOMINICAN UAE
women and younger people are increasingly HAITI
REP. PUERTO RICO
SAUDI ARABIA
BANGLADESH
LAOS
BELIZE JAMAICA
CAPE INDIA MYANMAR
MAURITANIA OMAN VIET NAM
affected. The disease typically presents as an GUATEMALA HONDURAS GUADELOUPE
MARTINIQUE
VERDE
SENEGAL
MALI
NIGER CHAD SUDAN ERITREA YEMEN
THAILAND
EL SALVADOR PHILIPPINES
GAMBIA
ulcer that does not heal; other symptoms may NICARAGUA
COSTA RICA
BARBADOS
TRINIDAD & TOBAGO GUINEA-
BURKINA
FASO DJIBOUTI
CAMBODIA SAMOA
BISSAU GUINEA

BENIN
VENEZUELA

GHANA
NIGERIA
include pain, swelling, bleeding and difficulty

TOGO
PANAMA GUYANA CÔTE SOUTH ETHIOPIA SRI LANKA
SIERRA LEONE D’IVOIRE VANUATU
SURINAME SUDAN BRUNEI
COLOMBIA LIBERIA FIJI
in chewing and swallowing. FRENCH GUIANA
EQUATORIAL CAMEROON
GUINEA UGANDA SOMALIA
MALDIVES MALAYSIA

KENYA SINGAPORE
ECUADOR GABON
DEM. REP. RWANDA
Up to 70 percent of oral cancers are preceded CONGO OF CONGO BURUNDI NEW CALEDONIA
PAPUA
PERU TANZANIA
by precancerous oral lesions, such as persistent I N D O N E S I A NEW
GUINEA
BRAZIL COMOROS
EAST TIMOR SOLOMON
red or white patches in the mouth. The cancer ANGOLA
ZAMBIA MALAWI
ISLANDS

may go unnoticed during its early stages, so it BOLIVIA

ZIMBABWE MADAGASCAR
MAURITIUS
NAMIBIA
is often advanced when the patient finally seeks PARAGUAY
BOTSWANA
MOZAMBIQUE RÉUNION
CHILE
care. Consequently, the average 5-year survival SWAZILAND AUSTRALIA
rate is only 50 percent. Common locations are LESOTHO
URUGUAY
the tongue, the insides of the cheeks and the ARGENTINA

floor of the mouth. Treatment usually consists

of a combination of surgical removal, radiother- NEW
ZEALAND
apy or chemotherapy; however, survival rates
ORAL CANCER FACTS
for oral cancer are among the lowest of all can-
cers and have remained unchanged in recent Facts about oral cancer Risk factors Profile of those at highest risk
decades. 50% Cigarette smoking is the most A typical high-risk profile for oral cancer
The average 5-year survival

CHAPTER 2 ORAL DISEASES AND HEALTH

common form of tobacco use, is a man, over age 40, who uses tobacco
The main causes of oral cancer are tobacco and rate of patients with oral but all forms of tobacco are and/or is a heavy user of alcohol.
alcohol use, accounting for about 90 percent cancer is about 50%. linked with increased risk of
of oral cancers. Chewing tobacco, often with oral cancer: regular use of
pipes, cigars, waterpipes, as However, the male–female ratio has
other carcinogenic substances in betel quid, 95%
About 95% of all well as all forms of smokeless dropped from 6 to 1 in 1950
is a common cause in Asia, while human papil- oral cancers occur tobacco (snus, chewing to about 2 to 1 at present.
lomavirus (HPV) infection is an emerging risk in persons over 40 40 tobacco, etc.).
Timely referral to multi-disciplinary treatment years of age.
factor, particularly in high-income countries. All three forms of alcohol
centres is a key factor in determining patient
(beer, spirits and wine)
Oral health professionals are in a strong outcomes, but this is a challenging goal in The average age have been associated with
position to screen high-risk patients for early low- and middle-income countries where the at the time of diagnosis oral cancer, although
signs of oral cancer, yet the opportunity for a necessary facilities are unavailable, inadequate 60 is about 60. spirits and beer have a
higher associated risk. 1950 2015
simple oral examination is frequently missed. or unaffordable.

26 27
 2.4.2

Oral cancer

What can be done?

Oral cancer is a common cancer worldwide, chemotherapy or radiotherapy. Rehabilita-
and the typical patient is a middle-aged man. tion after therapy is best performed by
In some countries in South Asia oral cancer is multi-disciplinary teams so that the patient’s
the second most frequent cancer for men and quality of life is as good as possible. Such
is the most common cause of their premature approaches are unavailable in many low-
death. Generally, death rates for oral cancer and middle-income countries, particularly
exceed those of many other cancers; only in South Asia, where existing facilities are
Patient testimonies half of all patients survive the first five years overwhelmed with new cases. Furthermore,
after diagnosis. Despite advances in diagnosis the cost of care is beyond the means of
“Head and neck cancer can be caused by “It was a terrible shock. I mean, I just went
and treatment, this number has not changed many patients and their families.
many things, including HPV virus, smoking, into total silence for a few days. Early
in the past decades. In addition, the impacts
alcohol, drug abuse, genes, environment and detection made all the difference. I’m one of Integrative policies to address risk factors,
of oral cancer, even after treatment, result in
stress. the lucky ones.” determinants and inequalities
severely reduced quality of life for those who
Building on the Common Risk Factor
I do not know what caused my particular Rod Stewart survive.
Approach, and integrating prevention and
cancer. If I did I'd have a Nobel Prize. I do British Rock Singer Songwriter, 2002
Generally, the following areas need to be control of oral cancer in general cancer
know that I am here today because of all the
strengthened and improved globally: and NCD approaches is the best avenue
incredible advances in cancer research and
to address the growing problem in the
treatment. “Early Early detection and timely referral
long-term. Incidence, survival rates and
detection made Early detection improves treatment outcomes
Early awareness is a key factor. If this episode quality of life of oral cancer patients show
all the difference. through timely referral for specialist care. Yet,
contributes to public awareness, all the I’m one of the
huge inequalities based on socioeconomic
delays in referral persist, even in high-income
better.” lucky ones.” status.
countries, and opportunities for screening
Michael Douglas patients at risk are frequently missed. While Inclusion of oral cancer care in universal
American Actor and Producer, 2013 general population screening is not recom- health coverage, the strengthening of health

CHAPTER 2 ORAL DISEASES AND HEALTH

mended, there is good evidence for its effec- systems and a comprehensive approach to
tiveness for patients with risk factors such risk-factor reduction may help in addressing
“Early as smoking or high alcohol consumption. these inequalities.
awareness is a key Primary healthcare workers can even perform
factor. If this episode Disease surveillance
screening after minimal training.
contributes to public Oral cancer needs to be integrated in routine
awareness, all the Availability of effective and appropriate disease surveillance used for other cancers,
better.” specialist care including specialized oral cancer registries.
Oral cancer requires specialist care in dedi- Capacities in oral pathology and histological
cated centres providing advanced surgery, diagnosis need to be strengthened.

28 29
 2.5

HIV/AIDS and oral health ICELAND

HIV/AIDS
SWEDEN FINLAND
NORWAY Percentage of the population
First signs of HIV Globally, 35 million people were estimated to ESTONIA
RUSSIA
aged 15–49 years
LATVIA
who are HIV-positive
infection often live with HIV-infection in 2013, many of whom UK
DENMARK
RUS. 2011 estimates
IRELAND
appear in the mouth were surviving thanks to life-saving Highly NETH.
GERMANY
POLAND
BELARUS

BELGIUM UKRAINE
and can seriously Active Antiretroviral Therapy (HAART). More CZECH
REP.
20.0% or more
LUX. MOLDOVA

impact quality of life than half of HIV-positive people develop oral CANADA FRANCE SWITZ. AUSTRIA
SLOV.
ROMANIA RUSSIA
10.0% – 19.9%
SERBIA
and nutrition. The symptoms early in the course of the disease, ITALY
BULGARIA
KOSOVO 1.0% – 9.9%
PORTUGAL

involvement of oral including fungal, bacterial and viral infections; SPAIN

K AZ AK HS TAN less than 1.0%
health professionals severe periodontitis; hairy leukoplakia; warts; GREECE MON GOLI A

U S A no data
in effective dry mouth; Kaposi sarcoma; and lymphoma. GEORGIA
AZERBAIJAN
UZBEK. KYRGYZSTAN

multi-disciplinary These can all cause pain and discomfort, ARMENIA

TAJIKISTAN
SOUTH
KOREA Largest populations of
leading to difficulty in chewing, swallowing MALTA LEBANON
people living with HIV
care is essential. MOROCCO ISRAEL IRA N
2013 estimates
and tasting food, which has significant negative BAHAMAS
PAKISTAN NEPAL BHUTAN
ALGERIA
impacts on quality of life. MEXICO CUBA
DOMINICAN
EGYPT
INDIA
BANGLADESH
2 million or more
HAITI REP.
JAMAICA LAOS
CAPE
BELIZE MAURITANIA MYANMAR
Those with HIV/AIDS continue to experience GUATEMALA HONDURAS
VERDE
SENEGAL
MALI
NIGER CHAD SUDAN ERITREA THAILAND
VIET NAM

YEMEN
social stigma and discrimination. Dentists
EL SALVADOR
NICARAGUA
BARBADOS
GAMBIA BURKINA 1 million – 1.6 million
FASO CAMBODIA
TRINIDAD & TOBAGO GUINEA- DJIBOUTI
COSTA RICA
BISSAU GUINEA NIGERIA

BENIN
VENEZUELA

GHANA
and other oral healthcare professionals have

TOGO
PANAMA GUYANA CÔTE SOUTH ETHIOPIA
SIERRA LEONE D’IVOIRE CENTRAL SRI LANKA
COLOMBIA SURINAME LIBERIA AFRICAN REP. SUDAN
SOMALIA 600,000 – 790,000
an obligation to provide ethical, equitable CAMEROON
UGANDA
MALDIVES MALAYSIA
EQUATORIAL
care to all patients, irrespective of their HIV ECUADOR GABON GUINEA
RWANDA
KENYA SINGAPORE

CONGO BURUNDI
status. HIV-related oral lesions can be used to PERU
SÃO TOME
& PRINCIPE TANZANIA
I N D O N E S I A
PAPUA
NEW
GUINEA
diagnose HIV infection, monitor the disease ANGOLA
BRAZIL
progression, predict immune status and ZAMBIA
MALAWI

contribute to timely therapeutic intervention. BOLIVIA ZIMBABWE MADAGASCAR

MAURITIUS

A
NAMIBIA

N
WA
The treatment and management of oral HIV le- MOZAMBIQUE

TS
CHILE PARAGUAY

BO
sions can considerably improve quality of life SOUTH
SWAZILAND AUSTRALIA
LESOTHO
AFRICA
and wellbeing. Dentists and oral healthcare URUGUAY

professionals can also ensure that patients ARGENTINA

with oral manifestations are referred for

testing of HIV/AIDS, have appropriate medical NEW
ZEALAND

follow-up, and are monitored for compliance

with HAART. “The mouth
South Africa “My doctor
can reveal so much
Healthcare providers can enhance surveillance about overall health and advised me to test for
16%

CHAPTER 2 ORAL DISEASES AND HEALTH

of oral lesions associated with HIV infection disease, notably HIV infection, HIV, but I was terrified. The
other
by conducting a simple, quick and inexpensive countries 24% stigma surrounding HIV in
mandating regular, thorough oral
oral examination as part of patient care. This soft-tissue exams by appropriate Nigeria [Botswana] is still so massive. Too
can be the first step in detecting, preventing professionals. As well as showing HIV/INFECTIONS 10% many people still link HIV to witchcraft.
and treating this life-threatening disease. Work- features of HIV infection in the form Proportion of Too many people think the virus is
Brazil 2%
new HIV infections incurable. They don’t understand that
ing together as a team, health professionals of a number of lesions…the mouth Cameroon 2%
2% by country 7%
from different backgrounds can effectively can be a useful way to test for USA Uganda HIV can be beaten with proper testing
3% 2013
address the needs of people and communities HIV infection through saliva- Zambia and the right kind of treatment. Yes,
3% 6%
they care for. based assays.” I am HIV-positive, but now that I
China 3%
3% 5% India can take my medicines I
Zimbabwe 4% 4% 5%
John S. Greenspan, Oral Pathologist/AIDS Expert, 2015
feel alive again. ”
Tanzania Mozambique
Deborah Greenspan, Oral Medicine Specialist/
AIDS Expert, 2015
Indonesia Russia Kenya Paul Kebakile, Gaborone, Botswana, 2003

30 31
 Noma
Noma mainly affects Noma is a neglected disease mainly affecting Preventive efforts addressing extreme poverty, ESSENTIAL ACTIVITIES IN ENHANCING DETECTION AND MANAGEMENT OF NOMA
children in children under six years old in Sub-Saharan malnutrition, and childhood diseases must be With appropriate prevention, awareness and early region. International NGOs, many of them members of
Africa. It is characterized by rapidly progress- political priorities for the eradication of noma. interventions noma can be effectively prevented. The the NoNoma Federation, are involved in collaboration
Sub-Saharan Africa.
WHO Regional Office for Africa is coordinating the with the Ministries of Health of countries affected in
It is a rapidly ing, severe gangrenous destruction of the This has been recognized by the UN Human Regional Programme for Noma Control and provides prevention, care and rehabilitation of noma patients,
progressive, soft and hard tissues of the mouth and face. Rights Council, which has urged member states technical support to eight countries in the African as well as resource mobilization.
destructive and Though rare, it devastates the lives of those to better protect the human rights and the right
frequently lethal affected. If left untreated, 70 to 90 percent of to food for children.
affected children die. Support comprehensive measures
disease of poverty
that contribute to reducing
and neglect. Survivors suffer lifelong disfigurement and are poverty, malnutrition and other
often left unable to speak or eat due to massive environmental and behavioural
tissue destruction. The condition carries signifi- risk factors of noma for children.
cant social stigma for victims and their families, “More than
increasing the risk of poverty for the household. a disease, noma is a
Poverty and malnutrition are the main risk tragedy. As a problem
factors for noma. Other predisposing factors confronting public health, Strengthen early detection of
include poor oral hygiene and diseases such WHO strongly believes that it noma cases based on integrated
as HIV, malaria and measles. The highest
belongs to the political agenda of community health strategies.
affected countries. But it goes
disease burden occurs in Burkina Faso, Mali,
further still, as an issue that
Niger, Nigeria, Senegal and Ethiopia, which
transgresses the boundaries
are collectively labelled ‘the noma belt of the
of human rights and
world’.
equity.”
High mortality rates and the lack of reliable doc- Provide rapid and appropriate
Matshidiso Moeti,
umentation mean that accurate epidemiologic WHO Regional Director for Africa, primary care for patients with
data are lacking. If diagnosed at an early stage, 2012 early stages of noma.
simple and effective treatment is possible.
However, cases are often advanced by the time
they present. If they survive, patients require
costly and complex surgery and this is often “The eradication of
unavailable. Informing population groups at noma needs concerted
risk, especially mothers, about the disease is efforts to alleviate poverty, Ensure referral of patients with
vital if early detection and prevention are to be promote improved nutrition of advanced noma to specialist care.

CHAPTER 2 ORAL DISEASES AND HEALTH

achieved. both pregnant women and
infants, and help to teach
The WHO Regional Programme for Noma parents to recognize early
Control, coordinated by the Regional Office for signs of the disease.”
Africa, supports governments in developing na-
tional strategies against noma, initiating capac-
ity-building interventions, and implementing Strengthen integrated surveillance
Geneva Study Group on Noma,
Top to bottom: public-awareness campaigns. 2013 systems through documentation
Acute case of noma; and reporting of noma cases.
destruction resulting
from noma; same
patient after
reconstructive surgeries.

32 33
 2.7

Congenital anomalies
Cleft lip and/or Congenital anomalies of the face and mouth policies and counselling services, especially GEOGRAPHICAL PREVALENCE OF OROFACIAL CLEFTS ETHNIC DIFFERENCES IN
palate are the most are frequent, with cleft lip and/or palate (orofa- targeting future mothers. Per 10,000 births INCIDENCE OF OROFACIAL CLEFTS
by region Incidence per 10,000 live births
frequent birth defects cial clefts – OFC) accounting for two-thirds
Restoring normal eating, speaking and appear- 2010 for different ethnic groups from 17 countries
of the face and of the total. Clefts occur either alone (70
ance in patients with cleft lip and/or palate is 2006
mouth, creating a percent) or as part of a syndrome, affecting Sub-Saharan
3.8
possible and can avoid social stigma, but it Africa, East African Americans
heavy burden in more than 12 in 10,000 newborns worldwide.
requires early multi-disciplinary interventions. 5.0
terms of mortality, For example, in India alone it is estimated that North Africa 4.4
Specialist nursing, plastic surgery, paediatric
disability, quality of approximately 100 babies with clefts are born Sub-Saharan Africa, Caucasians
dentistry, speech therapy, orthodontics, genetics Southern
4.5
life and financial every day and the majority of these infants do 15.2
and psychological services are all important Sub-Saharan Africa,
cost. not survive; in the USA a baby with a cleft is 5.4
for complete rehabilitation of patients with Central Mongolians and American Indians
born every 75 minutes. Sub-Saharan Africa,
such anomalies. Many of these services are not 15.3
West 5.4
Less serious but more prevalent genetically available in low- and middle-income countries, Asians
determined conditions, such as malocclusion, although in some places specialized NGOs Caribbean 9.3
22.5
occur in around 50 percent of the world’s assist in providing at least the primary surgery.
Middle East 10.2
population. Other minor congenital dental Cleft surgery was recently included in the
anomalies, such as hypodontia (missing teeth) list of cost-effective essential surgery services Southern Europe 10.7
and extra teeth, have a general population recommended by WHO.
Central Asia 11.9
incidence of up to 20 percent, and 2–3 percent
The direct cost of cleft care in the USA is
respectively. 12.2 TREATMENT OF
estimated at around US$200,000 per patient, Eastern Europe
OROFACIAL CLEFTS
Although genetic predisposition is an important and the annual global cost of care for 175,000 world average
(mean) 12.5 If lip and palate clefts are
factor for congenital anomalies, other modifia- patients would be US$35 billion. Including properly treated by
ble risk factors also play a role. Poor nutrition, the indirect costs would probably double the East Asia 12.8 surgery, complete
smoking, alcohol and obesity during pregnancy financial burden that adds to the tremendous Latin America, rehabilitation is possible.
12.9
are all documented additional risk factors, psychological burden for the patient and Andean
highlighting the importance of preventive families affected. Southeast Asia 13.6

Central Europe 14.5

Latin America,
Central 15.4

“Lack of South Asia 16.0

POLICIES TO IMPROVE TREATMENT
RECOMMENDATIONS

OF CONGENITAL ANOMALIES access to advice and

CHAPTER 2 ORAL DISEASES AND HEALTH

Asia Pacific 16.5
surgical provision can
1 Strengthen national registries for birth defects and OFC, as they are result in death of the child or Western Europe 16.6
crucial for planning services and evaluating primary preventive
interventions.
commit an otherwise healthy
individual to lifelong Oceania 18.5
2 Encourage combined efforts in essential healthcare, primary prevention
and education to improve access to care for children with OFC. disfigurement and functional
North America 20.0
3 Require a more comprehensive approach for NGOs involved in care for impairment, as well as
OFC, which goes beyond primary surgery services. educational and social Australasia 20.1
4 Ensure that primary prevention takes account of genetic and exclusion.”
environmental factors if the causes of OFC are to be addressed Northern Europe 20.3
effectively. Sarah Hodges, Latin America,
5 Ensure that primary prevention and essential surgery services for birth Paediatric Anaesthesiologist, 23.9
Southern
defects (including OFC) are available in the context of integrated 2009
Latin America, 23.9
healthcare. Tropical

34 35
 2.8

Oral trauma “Dental

injuries happened quite
Oral trauma is Oral injuries account for 5 percent of all inju- Prevention of oral injuries is important, and im- MAIN CAUSES OF often during my hockey
common and can be ries, and craniofacial trauma is responsible for proving the safety of the environment is a key ORAL TRAUMA career. The most serious was when
prevented by about half of the estimated total 8.5 million element. Improving road safety, and introduc- Comparison of Europe I received a cross check directly to
and Rwanda the teeth … The team dentist looked at
improving public trauma deaths worldwide. They include frac- ing helmets, facemasks and mouthguards are
Europe 2014, Rwanda
tures of the jaws and other facial bones, as important measures in reducing the frequency me then proceeded to place a tongue
health policies and 2003
well as fractures, dislocations and loss of and severity of dental and craniofacial trauma. depressor behind my front teeth and
raising awareness of assault and domestic violence
teeth. Risk factors include traffic and bicycle pull them back … From that day on
risks related to Violence and child abuse are important fall
I started to wear a mouthguard
violence, sports and accidents, falls, physical violence, contact sports accident
causes of oral injuries and have serious, and would never get on the
road safety. sports and tongue and lip piercings. Oral inju- road traffic accident
lifelong consequences. Dentists may be the ice without it.”
ries have significant physical, psychosocial work
first or only point of contact for victims in a
and economic impacts and are a major public others
healthcare setting. Oral health professionals Mike Bossy,
health problem, particularly affecting children
should therefore be able to recognize signs of 3% Former NHL Player, 2012 2%
and young adults.
abuse, which commonly affect the head, neck
Craniofacial injuries are often complex and or face. Awareness and education on these 5%
occur together with other bodily injury, requir- matters needs to be strengthened, and oral 15%
ing costly and time-consuming treatment. health professionals made aware of their legal 11%
Approximately half of all trauma involving and ethical responsibility to report cases of
permanent teeth requires dental treatment. abuse.
39%
The annual direct treatment costs of dental 18%
11% Europe Rwanda
trauma in Denmark have been estimated at
US$2–5 million/million population.
60%

“The 6%
bottom line is that
31%
domestic violence is a very
difficult issue. We have to be
able to train and educate our
future generation of healthcare
providers on the role dentistry 53%
plays in this very serious MAXILLOFACIAL
public health issue.” FRACTURES FROM
MOTORCYCLE ACCIDENTS

CHAPTER 2 ORAL DISEASES AND HEALTH

IN KERALA, INDIA
POLICIES TO PREVENT AND REDUCE SEVERITY Leslie Halpern, Incidence of fractures in motorcyclists
RECOMMENDATIONS

Oral and Maxillofacial Surgeon, wearing or not wearing helmets

OF ORAL TRAUMA
2008
2014
1 Enforce regulations to increase road safety through the mandatory use
of seat belts, child seats, motorcycle and bicycle helmets, and the I N DI A
prevention of drunk-driving.
2 Implement appropriate strategies to reduce violence and bullying at
14%
school.
3 Enforce the mandatory use of helmets or mouthguards to improve safety
for contact sports.
Kerala
4 Strengthen the role of dentists in diagnosing trauma as a result of
violence and child abuse.
wearing helmet not wearing helmet
5 Ensure appropriate emergency care for improved post-trauma response.

36 37
Oral Diseases and Risk Factors Chapter 3

Oral diseases, like all other diseases, share a behaviours also determine oral health. These
wide range of risk factors. Some, such as age, determinants include poor living conditions,
sex and hereditary conditions, are intrinsic to low education, unemployment, limited access
the individual and cannot be changed or mod- to safe water and sanitary facilities, and limited
ified. Others, which are subject to behaviours access to oral healthcare. General socioeco-
and lifestyle, are considered to be modifiable nomic, cultural and environmental conditions
risk factors, because individual action and also affect individuals’ oral health, but these
modification of a particular habit or behaviour are beyond the influence of any given indi-
is possible. In reality, this change may be dif- vidual. Tobacco control legislation and water
ficult to achieve without additional supportive fluoridation programmes are examples of so-
interventions. The modifiable risk factors of oral called ‘upstream’ measures to address such
diseases include an unhealthy diet, particularly factors. Across the whole social gradient, from
one high in sugar, tobacco use, and unhealthy the richest to the poorest, those in lower po-
alcohol consumption. These key risk factors are sitions suffer worse health and poorer access
also shared with most of the other major NCDs. to appropriate care than those immediately
This chapter details all of these key risk factors, above them. In all societies the poorest have
highlights their damaging potential and shows the worst health, the worst access to care and
the magnitude of their impact on oral health on the worst health outcomes. These inequalities
a global scale. Specific recommendations to can be observed both between and within re-
curb these risks from a public health and popu- gions and countries.
lation perspective are provided.
All too often, approaches and policies focus
As an illustration, the risk for oral cancer is in- on changing individual behaviour, particularly
creased 15-fold when alcohol and tobacco con- with regard to so-called lifestyle choices. How-
sumption are combined. Tobacco use is impli- ever, all our choices are strongly influenced by
cated as the cause of 50 percent of periodontal many factors, including socioeconomic cir-
disease. Free sugars are the main cause of tooth cumstances and social norms. Consequently,
decay in children and adults. Moreover, several strategies based on the lifestyle approach are
major risk factors occur together in the same often of limited effectiveness and may even in-
group of individuals. For example, smokers are crease the very health inequalities they were
more prone to eat a diet high in fats and sugars designed to reduce.
and low in fibre, and to exercise less than
Tackling risk factors should always take the
non-smokers. Additionally, alcohol and smok-
broader determinants of risk behaviour into
ing frequently go hand-in-hand. Such individual
account and try to address these underlying
behaviours and lifestyle choices not only have a
reasons, as a basis for supporting individuals to
negative influence on oral health, but they very
adopt healthier behaviour. The principle of the
often also impact the overall quality of life.
Ottawa Charter for Health Promotion applies
A range of external factors that can be mit- perfectly here: Making the healthier choice the
igated to only a small extent by individual easier choice!

39
 3.5

Social determinants and

common risk factors COMMON RISK FACTORS AND THEIR
IMPORTANCE FOR ORAL HEALTH
Modified from Sheiham & Watt, 2000
Both the general and All major NCDs, including most oral diseases, and many more. The unequal distribution of all
oral health of whole share the same social determinants and a small these determining factors accounts for the
populations are number of common risk factors – sugar, persisting and growing global differences in
largely determined tobacco, alcohol and poor diet – which are health status and disease burden. These Tooth decay
considered on the following pages. These unhealthy
by social factors and inequalities in general and oral health within tobacco
diet use
their interaction with shared risk factors provide the conceptual and between populations pose significant Periodontal disease
a set of common risk basis for the Common Risk Factor Approach, challenges for policy makers and those in
factors, namely which is one of the most important concepts public health.
stress Oral trauma alcohol
sugar, tobacco, for oral disease prevention. At the same time it
Prevailing interventions that focus on modify-
alcohol and poor paves the way for the close integration of oral
ing health behaviours and lifestyle choices
health into strategies addressing NCDs. Diabetes
diet. have only limited success and have been
The social determinants of health are the criticized because they ignore the wider social
circumstances into which people are born, influences that determine these choices. Only Obesity
grow, live, work and age. These circumstances, a broader integrative strategy that takes
which largely determine the behaviours account of the common risk factors and the lack of control Cancers
lack of exercise
people adopt and the choices they make, are root determinants of health will result in fair
in turn shaped by a wider set of forces: and equitable approaches to promoting better Cardiovascular disease
economics, social policies, education, politics oral health and general health.
Respiratory disease

poor hygiene injuries

POLICIES TO ADDRESS SOCIAL DETERMINANTS

RECOMMENDATIONS

1 Support approaches aimed at reducing poverty, increasing social THE SOCIAL DETERMINANTS r al a n d e n v i r
c, c ultu onm
inclusion, improving the general levels of education and employment, on omi ent
OF HEALTH i oec al
co
reducing barriers to healthcare, promoting affordable housing, safe water oc nd
Modified from Whitehead ls iti
and sanitation, and protecting minority and vulnerable groups for ra poverty on
& Dahlgren,1991 e

CHAPTER 3 ORAL DISEASES AND RISK FACTORS

sustainable improved health and oral health status. en and s
G
2 Systematically include health and oral health in all policies to reduce work inequality
negative effects from policy decisions made in other sectors on health water
equity and contribute to increasing synergies for better health status of
populations. m unity
unemployment d co m n et
3 Maximize opportunities to work effectively across disciplines and sectors ia l an wo sanitation
oc rk
to reduce inequalities in social determinants and people’s health. S l lifestyle fa s
vi dua ct o
4 Target resources to address health inequalities and support those with the di
tobacco alcohol

rs
In
greatest and more complex needs to reduce inequalities. nutrition
5 Enforce measures reducing exposure to risk factors to health and oral housing
health through the regulation of unhealthy foods and the reduction of Age, sex
tobacco and alcohol use. sugar and hereditary diet
factors
education healthcare

40 41
 Sugar ICELAND
AVERAGE CONSUMPTION OF
SUGARS AND SWEETENERS
SWEDEN FINLAND
NORWAY

Sugar is a leading risk Sugars are part of the bigger family of sweeten- ESTONIA Grams per person per day
factor for tooth ers – substances that are either naturally part
UK
DENMARK
LATVIA 2011
LITHUANIA
IRELAND
decay. Reducing its of or added to food and drinks and create the NETH. POLAND
BELARUS more than 100
GERMANY

consumption as part sensation of sweetness. They are an important, BELGIUM

CZECH
REP. SLOVAKIA
UKRAINE
MOLDOVA
76 – 100
FAROELUX.
IS.
RUSSIA
of a healthy diet essential source of daily energy intake, but CANADA FRANCE SWITZ. AUSTRIA HUNGARY
SLOV. ROMANIA 51 – 75
promotes better oral their excessive consumption has severe conse- CROATIA B-H SERBIA
BULGARIA

PORTUGAL
ITALY MONT. KOSOVO 26 – 50
health and may quences. As part of a high-calorie diet, they SPAIN
ALBANIA FYROM
KAZAKHSTAN
LIECHT.
L T 25 or less
reduce diabetes, have increasingly been recognized as causes GREECE MONGOLIA

for major NCDs such as diabetes and obesity. U S A GEORG

GIA
A
GEORGIA KYRGYZSTAN
NORTH
KOREA no data
obesity and other TURKEY
AZERBAIJAN
ARMENIA TURKMEN.
UZBEK.
SOUTH
JAPAN
TAJIKISTAN
KOREA
NCDs. The nomenclature used for sugars and sweeten- MALTA
CYPRUS SYRIA CHINA
LEBANON IRAQ AFGHANISTAN
BERMUDA MOROCCO TUNISIA IRAN
ISRAEL
ers is complex. Free sugars – all sugars added to GAZA JORDAN
KUWAIT
BAHAMAS WEST BANK PAKISTAN NEPAL KIRIBATI
ALGERIA
foods by the manufacturer, cook or consumer, MEXICO CUBA L I B YA
EGYPT Macau SAR
DOMINICAN UAE
plus sugars naturally present in honey, syrups JAMAICA REP.
ST KITTS & NEVIS CAPE
SAUDI ARABIA INDIA
BANGLADESH
LAOS
HK SAR
BELIZE HAITI MYANMAR SAMOA
VERDE MAURITANIA VIET NAM
and fruit juices – are the only cause of tooth GUATEMALA
HONDURAS
ST VINCENT & GRENAD.
ANTIGUA & BARBUDA
DOMINICA
SENEGAL
MALI
NIGER CHAD SUDAN YEMEN
THAILAND
EL SALVADOR GRENADA ST LUCIA PHILIPPINES
NICARAGUA GAMBIA VANUATU
decay in children and adults. Sugar consump- COSTA RICA
BARBADOS
TRINIDAD & TOBAGO GUINEA-
BURKINA
FASO DJIBOUTI CAMBODIA FIJI
BISSAU GUINEA

BENIN
VENEZUELA

GHANA
NIGERIA
tion shifts the healthy mix of bacteria present in

TOGO
PANAMA GUYANA CÔTE ETHIOPIA
SIERRA LEONE D’IVOIRE CENTRAL SOUTH SRI LANKA
SURINAME AFRICAN REP. SUDAN BRUNEI
COLOMBIA LIBERIA
the mouth towards bacteria that convert sugars CAMEROON
UGANDA SOMALIA
MALDIVES MALAYSIA
NEW CALEDONIA
KENYA
into the acids that demineralize tooth enamel. ECUADOR
SÃO TOME
GABON
RWANDA
FRENCH POLYNESIA

& PRINCIPE CONGO

Repeated episodes of sugar intake throughout PERU TANZANIA I N D O N E S I A
SOLOMON
ISLANDS
POLICIES the day increases the frequency of acid attacks
RECOMMENDATIONS

BRAZIL
ANGOLA EAST TIMOR
FOR SUGAR MALAWI
and the risk of developing tooth decay. ZAMBIA

REDUCTION BOLIVIA ZIMBABWE

MADAGASCAR
MAURITIUS
NAMIBIA
Sugar consumption is influenced by many CHILE PARAGUAY
BOTSWANA
MOZAMBIQUE
1 Enforce higher
biological, behavioural, social, cultural and en- SWAZILAND AUSTRALIA
taxation on SOUTH
sugar-rich food and vironmental factors. Worldwide consumption AFRICA
LESOTHO
URUGUAY
sugar-sweetened has tripled over the past 50 years, and this ARGENTINA

beverages. increase is expected to continue, particularly in

2 Ensure transparent emerging economies. To curb the growing epi- NEW
food labelling for ZEALAND
demic of tooth decay and other NCDS, WHO
informed consumer SUGAR FACTS
choices. recommends limiting the daily consumption of
Sugar consumption WHO-recommended daily sugar intake Sugar content per 100g of various foods

CHAPTER 3 ORAL DISEASES AND RISK FACTORS

3 Strongly regulate free sugars to 5 percent or less of total energy.
for children and adults
sugar in baby foods This is equal to 25 grams or 5 teaspoons of
and sugar-sweetened Average sugar 166g Strong recommendation Chocolate-coated biscuits 45.8g
sugar per day. 109g
beverages. and sweetener No more than 10% of total
consumption energy intake: Frosted cornflakes 37g
4 Limit marketing and A number of measures are being explored
per person per ~50g or 10 teaspoons. 10%
availability of to reduce global sugar consumption. These day in 2011: global USA Tomato ketchup 27.5g
sugar-rich foods and
include additional taxes on products with high
sugar-sweetened <25g Stir-in sweet and sour sauce 20.2g
sugar content, reducing the overconsumption Only 19 countries
beverages to children
consume less than
and adolescents. of sugar-sweetened beverages, limiting sugar 25g per person per day. Salad cream 16.7g
5 Provide simplified content of foods and drinks, introducing Additional recommendation
nutrition guidelines, No more than 5% of total Fruit yoghurt 16.6g
regulations for transparent labelling of food >100g
including sugar 65 countries energy intake: 5%
intake, to promote
ingredients, and constraining the marketing consume more than 100g ~25g or 5 teaspoons. Coca-Cola 10.9g
healthy eating and to children and adolescents of food high in per person per day.
Sweetened fruit juice 9.8g
drinking. sugars.

42 43
 Tobacco ICELAND TOBACCO SMOKING
NORWAY
SWEDEN FINLAND
Age-standardized prevalence of
Globally, tobacco Tobacco use is the most common cause of pre- ESTONIA adult tobacco smoking
LATVIA 2011
use is the leading ventable death globally. Cigarettes kill half of DENMARK
LITHUANIA
UK

preventable cause of all lifetime users and in the 20th century tobac- NETH. POLAND
BELARUS 40% or more
GERMANY

death and disease, co use caused 100 million deaths. This number BELGIUM
CZECH
REP. SLOVAKIA
UKRAINE
30% – 39%
MOLDOVA
RUSSIA
including oral is expected to rise to 1 billion in the 21st CANADA FRANCE SWITZ. AUSTRIA
SLOV.
HUNGARY
ROMANIA 20% – 29%
conditions. Oral century if smoking patterns remain unchanged. CROATIA B-H SERBIA
BULGARIA
KOSOVO less than 20%
PORTUGAL

health professionals Moreover, exposure to secondhand smoke SPAIN

ALBANIA
KAZAKHSTAN
LIECHT.
L T
ITALY no data
have an important accounts for approximately 600,000 deaths GREECE MONGOLIA

role in reducing each year. Additionally, smokeless tobacco use GEORGIA

AZERBAIJAN
UZBEK. KYRGYZSTAN JAPAN
TURKEY ARMENIA

tobacco use. is a growing global problem. TUNISIA CHINA MARSHALL ISLANDS

CYPRUS
MALTA NAURU
ISRAEL IRAQ IRAN
MOROCCO
Tobacco use is a major global public health GAZA JORDAN
KUWAIT KIRIBATI
WEST BANK PAKISTAN
threat for all countries, and no form of tobacco MEXICO
ALGERIA L I B YA BAHRAIN NEPAL

DOMINICAN EGYPT
use is safe; yet tobacco is grown in more than REP.
CAPE
SAUDI ARABIA
INDIA
BANGLADESH
LAOS
BELIZE MAURITANIA OMAN MYANMAR VIET NAM
VERDE
120 countries. In 2013, more than 6 trillion GUATEMALA ST KITTS & NEVIS
DOMINICA
SENEGAL
MALI
NIGER CHAD ERITREA YEMEN
THAILAND
EL SALVADOR PHILIPPINES VANUATU
GAMBIA
cigarettes were consumed by almost 1 billion COSTA RICA
BARBADOS
GUINEA
CAMBODIA

BENIN
COOK ISLANDS

GHANA
NIGERIA
smokers. More than 300 million people use

TOGO
PANAMA GUYANA CÔTE
SIERRA LEONE D’IVOIRE SRI LANKA
BRUNEI
COLOMBIA LIBERIA TONGA
smokeless tobacco in over 75 countries. UGANDA
MALDIVES MALAYSIA

KENYA
Smokeless tobacco is particularly dangerous SÃO TOME
& PRINCIPE
GABON
DEM. REP.
CONGO OF CONGO SEYCHELLES
for oral health, since it comes in direct contact I N D O N E S I A
PAPUA
NEW
GUINEA
with the tissues of the oral cavity. BRAZIL COMOROS
SOLOMON
MALAWI
ISLANDS
ZAMBIA
There are a number of effective approaches to BOLIVIA
NAMIBIA
reduce tobacco use. The WHO’s Framework CHILE PARAGUAY
BOTSWANA MAURITIUS

Convention on Tobacco Control provides a SWAZILAND AUSTRALIA

RECOMMENDATIONS

POLICIES FOR legal binding outline of effective policies to

SOUTH
AFRICA
TOBACCO URUGUAY
curb global tobacco use. Policies that create ARGENTINA
CONTROL
smoke-free areas, increase tobacco taxes and
WHO MPOWER increase the retail price of tobacco are the NEW
recommendations for ZEALAND
most effective in reducing tobacco use.
effective tobacco TOBACCO FACTS
control:
Strict and coherent regulation at all levels of Tobacco use Types of tobacco use Effects of tobacco on oral health

CHAPTER 3 ORAL DISEASES AND RISK FACTORS

1 Monitor tobacco use
tobacco production and use, from growing the
and prevention
plant to disposal of waste, has the potential
800 million men smoke. Smoking Smokeless Increases risk of:
policies.
to decrease consumption rates and promote
200 million women smoke. snuff, dry
• oral cancer
2 Protect people from “Raising cigarettes
tobacco smoke. cessation. Comprehensive tobacco control pro- taxes on tobacco is 600,000 individuals die each year from and moist • smoker’s palate
secondhand smoke: 156,000 men,
3 Offer help to quit grammes that promote cessation through popu- the most effective way bidis • periodontal disease
281,000 women and 166,000 children.
tobacco use. lation-based interventions give governments to reduce use and save • premature tooth loss
4 Warn about the At least 300 million people use
the opportunity to decrease tobacco-related lives. Determined action kreteks chewing
dangers of tobacco. smokeless tobacco and 90% of these are • gingivitis
on tobacco tax policy tobacco
morbidity and mortality. in Southeast Asia.
5 Enforce bans on pipes • staining
tobacco advertising, hits the industry In 2011, manufacturers spent about
Dentists and the dental team can be effective • halitosis (bad breath)
promotion and where it hurts.” US$9.5 billion on advertising snus
sponsorship.
in helping patients to reduce or quit tobacco cigarettes and smokeless tobacco. cigars
• loss of taste and smell
6 Raise taxes on consumption, and should be a role model and Margaret Chan, Governments spend less than dissolvables
tobacco. refrain from using tobacco themselves. WHO Director-General, 2014 US$1 billion on tobacco control waterpipes
each year.

44 45
 3.3

Alcohol ICELAND ALCOHOL CONSUMPTION

SWEDEN FINLAND
NORWAY Average consumption of pure alcohol
Harmful use of The consumption of alcohol has been an inte- ESTONIA per person aged 15 years or older
LATVIA 2013 or latest available data
alcohol is a major gral part of many cultures for millennia. Today, UK
DENMARK LITHUANIA
RUS. Litres
IRELAND
risk factor for more the harmful use of alcohol is at high levels NETH.
GERMANY
POLAND BELARUS
BELGIUM UKRAINE
than 200 diseases, and it results in a significant health, social and CZECH
REP. SLOVAKIA 11.00 or more
LUX. MOLDOVA
RUSSIA
including oral cancer economic burden on societies. CANADA FRANCE SWITZ. AUSTRIA
SLOV.
HUNGARY
ROMANIA 6.00 – 10.99
CROATIA B-HSERBIA
and periodontal Alcohol is the third leading risk factor for disa- MONT. KOSOVO
BULGARIA
1.00 – 5.99
PORTUGAL ANDORRA ALBANIA FYROM
disease, and must be bility in the developed world, after tobacco SPAIN ITALY KAZAKHSTAN
less than 1.00
GREECE MONGOLIA
addressed as part of a use and hypertension. Its use is associated with NORTH no data
GEORGIA KYRGYZSTAN KOREA
UZBEK. JAPAN
comprehensive more than 200 diseases, including oral diseas- U S A
TURKEY
AZERBAIJAN
ARMENIA TURKMEN. SOUTH
TAJIKISTAN KOREA
approach to all es. Alone or in combination with tobacco, it MALTA
CYPRUS SYRIA
AFGHANISTAN
C HINA MICRONESIA, FED. STATES OF
LEBANON IRAQ
TUNISIA I R AN
NCDs. is a major risk factor for cancers of the mouth,
MOROCCO ISRAEL
JORDAN
KUWAIT
NAURU
PAKISTAN
BAHAMAS NEPAL KIRIBATI
larynx, pharynx and oesophagus, and it is MEXICO
CUBA ALGERIA L I B YA
EGYPT
BAHRAIN
QATAR
UAE
TUVALU
DOMINICAN
associated with other oral diseases such as JAMAICA HAITI
REP.
ST KITTS & NEVIS CAPE
SAUDI ARABIA
INDIA
BANGLADESH
LAOS
BELIZE MAURITANIA OMAN MYANMAR VIET NAM
ANTIGUA & BARBUDA VERDE SAMOA
periodontal disease. Its use increases the risk GUATEMALA
EL SALVADOR
HONDURAS
ST VINCENT & GRENAD.
DOMINICA
SENEGAL
MALI
NIGER CHAD SUDAN ERITREA YEMEN
THAILAND
ST LUCIA GAMBIA PHILIPPINES
NICARAGUA
of facial and dental injuries through falls, road COSTA RICA GRENADA
BARBADOS
TRINIDAD & TOBAGO GUINEA-
BURKINA
FASO DJIBOUTI
CAMBODIA
VANUATU
FIJI
BISSAU GUINEA

BENIN
GHANA
VENEZUELA NIGERIA

TOGO
traffic accidents or interpersonal violence. PANAMA GUYANA
SURINAME
SIERRA LEONE
CÔTE
D’IVOIRE CENTRAL
AFRICAN REP.
ETHIOPIA SRI LANKA
BRUNEI
COLOMBIA LIBERIA
Furthermore, alcoholic drinks can be acidic EQUATORIAL CAMEROON
UGANDA SOMALIA MALAYSIA TONGA
RECOMMENDATIONS

POLICIES GUINEA
KENYA SINGAPORE
and high in sugar, resulting in damage to teeth ECUADOR
SÃO TOME
GABON
DEM. REP. RWANDA
TO REDUCE & PRINCIPE CONGO OF CONGO BURUNDI SEYCHELLES

HARMFUL USE in the form of tooth erosion and tooth decay. PERU TANZANIA I N D O N E S I A
PAPUA
NEW
GUINEA SOLOMON
BRAZIL COMOROS
OF ALCOHOL The abuse of alcohol during the early stages ANGOLA EAST TIMOR
ISLANDS

MALAWI
ZAMBIA
1 Implement effective of pregnancy increases the risk of damage to BOLIVIA
ZIMBABWE MADAGASCAR
MAURITIUS

measures that the developing foetus. It has a direct effect on

NAMIBIA
BOTSWANA
MOZAMBIQUE
PARAGUAY
regulate alcohol CHILE

availability, such as
the cells that give rise to the structures of the SWAZILAND AUSTRALIA
SOUTH
limiting hours and mouth and teeth, resulting in abnormal facial URUGUAY
AFRICA
LESOTHO

days of sale. growth that is one of the symptoms of foetal ARGENTINA

2 Enforce zero alcohol syndrome.

tolerance for drunk
NEW
driving to reduce Strategies to curb alcohol use are ideally ZEALAND

alcohol consumption integrated with other common risk factors

and related traffic
for NCDs. Approaches focus on availability “The alcohol-
accidents.

CHAPTER 3 ORAL DISEASES AND RISK FACTORS

attributable disease
3 Raise taxes on
and pricing of alcohol, and on prevention
burden as well as the social
alcoholic beverages interventions and treatment in healthcare ALCOHOL FACTS
and economic burden may
to effectively reduce systems. Oral health professionals need to be Alcohol consumption Impact of alcohol on general health Impact of alcohol on oral health
consumption. increase further unless effective
aware of the harms that alcohol causes and to
4 Enforce laws prevention policies and Globally, harmful use of alcohol Alcohol is the third leading Alcohol and tobacco are major risk
provide adequate advice and care to patients.
restricting sale to and measures based on the best causes approximately 3.3 million risk factor for disability in factors for cancers of the mouth,
purchase of alcohol available evidence are deaths every year. developed countries. larynx, pharynx and oesophagus,
by minors to tackle implemented world- and for periodontal disease.
6.2
underage drinking. Global average adult annual
wide.” consumption in 2010: 1 Excessive consumption of alcohol can
5 Reduce exposure and Alcohol abuse in the lead to injury, often to the mouth and
6.2 litres of pure alcohol.
incentives for Oleg Chestnov, WHO Assistant early stage of teeth.
alcohol consumption Director-General for Noncommunicable pregnancy can cause
by regulating or Diseases and Mental Health, 2014 5.1% of the global burden abnormal facial The acidity and high sugar content of
banning alcohol of disease is attributed to growth in the foetus. alcoholic drinks can cause tooth
advertising and alcohol consumption. 5.1% erosion and decay.
promotion.

46 47
 3.4

Diet ICELAND OVERWEIGHT AND OBESITY

NORWAY
SWEDEN FINLAND
Percentage of people aged 20 years or more
A healthy diet, low in Socioeconomic development, urbanization ESTONIA with a body mass index of 25 or more
LATVIA 2008
sugar, salt and fat, and rapid globalization have led to major DENMARK LITHUANIA
UK RUS.
IRELAND
and high in fruit changes in the way we produce, store, prepare NETH. POLAND BELARUS
70% or more
GERMANY
and vegetables and consume food. Despite achievements BELGIUM CZECH
REP. SLOVAKIA
UKRAINE
50% – 69%
LUX. MOLDOVA RUSSIA
CANADA
contributes to in reducing global hunger, many countries FRANCE SWITZ.
AUSTRIA HUNGARY
SLOV. ROMANIA 25% – 49%
reducing the risk of still face high rates of undernutrition and CROATIA B-HSERBIA
BULGARIA
ANDORRA
MONT. KOSOVO fewer than 25%
oral diseases, obesity malnutrition, which especially affect the PORTUGAL
SPAIN
ALBANIA FYROM
KAZAKHSTAN
ITALY MONGOLIA no data
and other NCDs. development of children and their chances GREECE
NORTH
U S A
in life. 100 million under-fives worldwide GEORGIA
GEO
EORGIA
ORGIA
RGIA
A
AZERBAIJAN
UZBEK. KYRGYZSTAN KOREA
JAPAN
TURKEY ARMENIA TURKMEN. SOUTH
are underweight. At the same time, rates of CYPRUS SYRIA
TAJIKISTAN KOREA

MALTA
C HINA
AFGHANISTAN
overweight and obesity are increasing steadily, MOROCCO TUNISIA
LEBANON
ISRAEL
IRAQ I R AN
JORDAN
challenging societies and health systems with a MEXICO BAHAMAS
ALGERIA L I B YA
KUWAIT
BAHRAIN
PAKISTAN NEPAL
BHUTAN
MICRONESIA, FED. STATES OF
CUBA QATAR
EGYPT MARSHALL ISLANDS
growing burden of lifelong diseases, including DOMINICAN
REP.
UAE
BANGLADESH
NAURU
HAITI SAUDI ARABIA PALAU
ST KITTS & NEVIS LAOS
diabetes, cardiovascular diseases and cancer. GUATEMALA
BELIZE JAMAICA
HONDURAS
ANTIGUA & BARBUDA
CAPE
VERDE MAURITANIA
MALI
OMAN
INDIA MYANMAR VIET NAM
KIRIBATI
RECOMMENDATIONS

DOMINICA NIGER THAILAND

POLICIES TO Worldwide, 52 percent of adults over 18 are EL SALVADOR
NICARAGUA
ST VINCENT & GRENAD.
GRENADA
ST LUCIA
BARBADOS
SENEGAL
GAMBIA BURKINA
CHAD SUDAN ERITREA YEMEN
PHILIPPINES
CAMBODIA
PROMOTE A either overweight or obese, a figure that has COSTA RICA TRINIDAD & TOBAGO GUINEA-
BISSAU GUINEA
FASO DJIBOUTI SAMOA

BENIN
GHANA
VENEZUELA NIGERIA

TOGO
PANAMA GUYANA CÔTE ETHIOPIA
HEALTHY DIET SIERRA LEONE D’IVOIRE CENTRAL SOUTH SRI LANKA VANUATU

doubled since 1980. Moreover, malnutrition COLOMBIA SURINAME LIBERIA

EQUATORIAL CAMEROON
AFRICAN REP. SUDAN
MALDIVES
BRUNEI
MALAYSIA
FIJI
COOK ISLANDS
UGANDA SOMALIA
1 Restrict sales of – deficiencies of essential micronutrients and ECUADOR
GUINEA
GABON KENYA SINGAPORE TONGA
SÃO TOME DEM. REP. RWANDA
unhealthy foods and vitamins, such as vitamin A, iron or iodine – & PRINCIPE CONGO OF CONGO BURUNDI SEYCHELLES
PAPUA
drink; increase PERU TANZANIA I N D O N E S I A NEW
causes serious diseases that can coexist with GUINEA
taxation on both, and BRAZIL
ANGOLA
COMOROS
EAST TIMOR

limit their serving overnutrition or undernutrition. ZAMBIA

MALAWI
SOLOMON
ISLANDS

sizes and availability. BOLIVIA

ZIMBABWE MAURITIUS
Nutrition and oral health are closely linked. NAMIBIA
BOTSWANA
MADAGASCAR

2 Enforce systematic PARAGUAY MOZAMBIQUE

consumer-friendly
High sugar intake is directly related to tooth CHILE

SWAZILAND AUSTRALIA
food-labelling decay, and untreated tooth decay has strong SOUTH LESOTHO
AFRICA
regulations to associations with low BMI in children. URUGUAY
ARGENTINA
facilitate informed Extended periods of micronutrient deficiencies
food choices. “Something
can lead to serious oral symptoms. Under- and
3 Implement integrated is wrong. Part of our HEALTHY-EATING PLATE NEW
approaches to malnutrition are co-factors for noma. ZEALAND
out-of-balance world still
nutrition counselling
A healthy and balanced diet is thus essential starves to death. Another Oil Water
by addressing Healthy oils such as olive oil are Water, tea or coffee (with little or no
part stuffs itself into a level

CHAPTER 3 ORAL DISEASES AND RISK FACTORS

general health for growth and healthy body functions. Many
recommended. Trans fats should sugar) are the recommended main
aspects and those countries provide nutrition guidelines defining of obesity so widespread
be avoided. sources of liquid. Sugar-sweetened
linked with oral recommended daily intake for different that it is pushing beverages should be avoided.
health. life-expectancy figures
food categories. The ‘healthy-eating plate’
4 Ban sugar-sweetened backwards.” Vegetables/Fruits Whole Grains
beverages and
concept takes into account variation in recom- WHO recommends a Staple starchy foods,
unhealthy snacks in mendations between countries and cultures, minimum of five servings preferably whole grain,
Margaret Chan,
schools and make and focuses on the basic principles of variety, of fruits and vegetables should be the main
WHO Director-General, 2014
healthy meal options every day. source of daily energy
proportions and frequency of consumption of intake.
available.
respective food categories.
5 Promote the use of and encouraging healthy consumer choices
natural and Oral health professionals have an important are among key policy strategies, as well as Healthy Protein
indigenous products Fish, poultry, beans and
role in addressing NCDs and oral diseases, par- regulating the advertising of energy-rich foods nuts are preferable to red
with good nutritional
values over the use ticularly obesity and tooth decay, by promoting to children, and restricting their availability in meat and processed meat.
of processed food. healthy eating. Transparency in food labelling school settings.

48 49
Oral Diseases and Society Chapter 4

Poor oral health impacts individuals in vari- inequalities because of poor coverage in pri-
ous ways: many conditions cause pain, affect mary healthcare. For example, more than 40
quality of life, reduce school and work produc- percent of US residents must pay for their den-
tivity; and the required care results in a signif- tal costs themselves, compared to 10 percent
icant financial burden to healthcare systems for physician consultations. Only about two-
and those concerned. thirds of the world’s populations have access to
adequate oral healthcare, with big differences
Oral health is affected by a wide range of so-
between countries. This chapter illustrates the
cial determinants, which WHO defines as ‘the
many dimensions of inequalities, describes
circumstances in which people are born, grow
their causes and their impacts.
up, live, work and age’. In turn, these are influ-
enced by wider socioeconomic and An essential entry point to improv-
political circumstances. Oral
“The ing oral health globally is
health, like general health, improvement therefore to address the so-
is also characterized by in dental health, as with cial determinants of oral
a social gradient, with the improvement in general health. In this respect
better health status at health, must be enjoyed by all in the Ottawa Charter
the top and a higher society. This worthy goal is unlikely for Health Promo-
disease burden at
to be achieved unless we put social tion, with its focus
the bottom of the on empowerment,
gradient. This is a
justice at the heart of all decision provides an appro-
general phenomenon making.” priate framework to
observed in all coun- Michael Marmot, bring about tangible
tries and across all pop- Professor of Epidemiology and Public change. A ‘bottom-up’
ulations within countries. Health at University College perspective and acquiring
This social gradient in health London, 2010 a better understanding of why
means that inequalities in general people with lower socioeconomic
health and oral health affect everyone. position have more difficulties in looking
after their own health may help to develop
Striking examples of inequalities include the
more responsive policies.
prevalence of tooth decay, which affects only
16 percent of Japanese aged 6 to 19 years, Approaches that promote equity in access and
but 97 percent of 12-year-old Filipinos; eden- benefit, such as water fluoridation and school
tulousness affects the poor much more than health programmes, are ways of providing en-
the rich; and the number of missed school vironments conducive to better oral health.
days due to poor oral health is significantly Other strategies include the enforcement of
higher for children from lower-income fami- food policies, comprising transparent label-
lies, ethnic minorities and immigrants. Access ling of foods and restricting the availability of
to oral healthcare shows particularly strong sugar-sweetened beverages in schools.

51
 Inequalities in oral health
Socioeconomic status Oral health status Deprivation INEQUALITIES WITHIN A RICH MEGA-CITY
is a fundamental high medium low Level of deprivation in London 2012
Health inequalities refer to differences in 2008, WHO highlighted the underlying causes
determinant of both health status, both within and between of inequalities as ‘social determinants – the Compared with:
oral and general countries, that are deemed avoidable, unfair conditions in which people are born, grow, 79 years or less 80 – 83 years 84 years or more life expectancy at birth 2005–09 00
health. Action to and unjust. Reducing health inequalities is now live, work and age’. Life expectancy
reduce oral health a global public health priority. Health inequal- percentage of five-year-olds with %
inequalities needs to The social gradient in oral diseases has 88 experience of toothache 2012
ity is not simply about differences between the
profound implications for policy. The
address the rich and poor in society. As is the case in Barbican The UK multiple deprivation
traditional clinical ‘high risk’ approach to 79 78 46%
underlying causes of general health, a consistent stepwise social index integrates seven aspects
prevention fails to address the importance and 46% White City Mile End of deprivation: income;
disease. gradient exists for oral diseases – oral health
impact of the broader determinants of health. Tower Hamlets employment; health
steadily worsens in line with socioeconomic deprivation and disability;
Instead, action is needed to address the scope Brent
status. education skills and training;
of underlying causes of poor oral health.
barriers to housing and
This social gradient is a universal phenomenon Working in partnership across relevant services; crime; living
across the life course, from early childhood to sectors, agencies and professions using environment.
older age, affecting almost all oral diseases to a upstream, midstream and downstream strate-
varying degree, such as tooth decay, periodon- gies is essential. Dental teams and their
tal disease and oral cancers. Social gradients national professional bodies have an import- 20%
42%
can be observed in all countries and popula- ant advocacy role in promoting policies to 85
tions around the world. What causes this reduce health inequalities in the populations Barking Havering
Ealing
universal social patterning of oral disease? In they serve.

1 2.
20
SOCIAL GRADIENTS OF 17%

td
w s & Media L
EDENTULOUSNESS
Age-standardized prevalence
Richmond
among those aged 45 or older
by occupation and 19%

Ne
welfare state regime

ian
2013
Kingston

ard
Gu
manager and professionals

©
intermediate 25.6% 78

ht
90

rig
manual workers Brixton

py
Knightsbridge Co
Levels of edentulousness

CHAPTER 4 ORAL DISEASES AND SOCIETY

show similar patterns in
18.4% 18.6%
people with similar 17.1% second second
professional and richest richest intermediate poorest poorest
education background, 15.0% 0
irrespective of the type 12.7%
12.1% 11.6% 11.6%
of healthcare system in -1
the country they live in. number of
8.2%
SOCIAL GRADIENTS OF teeth lost
In surveys, soc -2 compared
edentulousness is always 6.3%
TOOTH LOSS ial
gra
5.2% 5.4% Difference in number of die with those
highest for manual 4.2% nt
natural teeth retained by UK -3 in richest
workers and lowest for 2.4% residents aged 65 or over quintile
managers and
according to income quintile -4
professionals.
measured against richest quintile
Anglo-Saxon Bismarckian Eastern Scandinavian Southern
2015
-5

52 53
 4.2

Inequalities in oral health ICELAND

SWEDEN FINLAND
NORWAY

Oral conditions have Impact of oral diseases ESTONIA

LATVIA
BURDEN OF ORAL
considerable impact LITHUANIA CONDITIONS
Oral conditions affected 3.9 billion people UK
DENMARK
RUS.

on the quality of life

IRELAND
BELARUS
Disability adjusted life years
worldwide in 2010, with untreated tooth BELGIUM
NETH.
GERMANY
POLAND
(DALYS) lost due to tooth decay
of individuals and decay being the most prevalent, and severe FAROELUX.
IS.
CZECH
REP. SLOVAKIA
UKRAINE RUSSIA
and periodontal disease
MOLDOVA
CANADA HUNGARY
populations, periodontitis the sixth most prevalent of all
FRANCE SWITZ. AUSTRIA
SLOV. ROMANIA 2010
CROATIA B-HSERBIA
particularly among 291 conditions studied. Their impact on the MONT.
BULGARIA
KOSOVO 1.9m – 2.3m
PORTUGAL ANDORRA FYROM
ALBANIA
younger population wellbeing of people and societies is evident at SPAIN
ITALY KAZAKHSTAN
100,000 – 462,000
L
LIECHT.
T
T.
GREECE MONGOLIA
groups and those different stages across the life course. Evidence
KYRGYZSTAN
NORTH 10,000 – 99,999
with lower from different countries demonstrates the U S A
TURKEY
GEORGIA
AZERBAIJAN
UZBEK. KOREA JAPAN
ARMENIA TURKMEN.
TAJIKISTAN
SOUTH
less than 10,000
socioeconomic considerable school and work absenteeism CYPRUS SYRIA CHINA
KOREA

MALTA AFGHANISTAN
position. TUNISIA LEBANON IRAQ IRAN
no data
related to oral conditions. Furthermore, dental MOROCCO ISRAEL
GAZA JORDAN
KUWAIT
WEST BANK PAKISTAN NEPAL BHUTAN
status affects diet and nutrition, particularly in MEXICO
CUBA
BAHAMAS ALGERIA
LIBYA BAHRAIN
QATAR
DOMINICAN EGYPT UAE
children and older people, while oral condi- JAMAICA HAITI REP.
SAUDI ARABIA
BANGLADESH
LAOS
MICRONESIA, FED. STATES OF
BELIZE ANTIGUA & BARBUDA CAPE INDIA MYANMAR MARSHALL ISLANDS
tions and tooth loss have a significant negative GUATEMALA HONDURAS
DOMINICA
VERDE MAURITANIA
MALI
NIGER
OMAN
THAILAND
VIET NAM

EL SALVADOR ST VINCENT & GRENAD. SENEGAL CHAD SUDAN ERITREA YEMEN

ST LUCIA PHILIPPINES
impact on people’s quality of life, not only NICARAGUA
GRENADA
BARBADOS
GAMBIA
GUINEA-
BURKINA
FASO DJIBOUTI CAMBODIA KIRIBATI
COSTA RICA TRINIDAD & TOBAGO
BISSAU GUINEA

BENIN
GHANA
affecting them functionally, but psychologi- VENEZUELA NIGERIA

TOGO
PANAMA GUYANA CÔTE ETHIOPIA
SIERRA LEONE CENTRAL SOUTH SRI LANKA
D’IVOIRE
SURINAME LIBERIA AFRICAN REP. SUDAN BRUNEI
COLOMBIA
cally and socially. Globally, oral conditions EQUATORIAL CAMEROON
UGANDA SOMALIA
MALDIVES MALAYSIA SAMOA
GUINEA
accounted for 15 million Disability Adjusted ECUADOR
SÃO TOME
GABON
DEM. REP.
KENYA
RWANDA
SINGAPORE
VANUATU
& PRINCIPE CONGO OF CONGO BURUNDI
Life Years in 2010; this is an average health loss PERU
SEYCHELLES
INDONESIA
PAPUA
NEW
FIJI

BRAZIL TANZANIA
GUINEA
of 224 years per 100,000 people. COMOROS
THE IMPACT OF ANGOLA
MALAWI
EAST TIMOR SOLOMON
ISLANDS
TONGA

ZAMBIA
HOUSEHOLD As with general health, the impact of oral BOLIVIA ZIMBABWE MAURITIUS
MADAGASCAR
INCOME ON conditions on quality of life is unequally PARAGUAY
NAMIBIA
BOTSWANA
MOZAMBIQUE
CHILE
ORAL-HEALTH distributed between different socioeconomic SWAZILAND AUSTRALIA
RELATED groups. Subjective measures of oral health and SOUTH
AFRICA
LESOTHO

QUALITY OF LIFE quality of life among dentate adults show

URUGUAY

ARGENTINA
Perception of oral
considerable inequalities, with worse percep-
function among adults
with their own teeth tions the lower the socioeconomic position. 20 NEW
ZEALAND
in different income These social gradients are stronger at younger Addressing oral health inequalities
quartiles ages, but no such inequalities in quality of life requires public health action on the
1998–2002
exist among edentulous older adults. However, broader determinants of health, and
severity score the degree of social inequalities in quality of particular emphasis on the younger genera- 15

CHAPTER 4 ORAL DISEASES AND SOCIETY

10 life varies between countries and is affected by tion, where inequalities in quality of life seem EFFECT OF EDUCATION
political factors and the social context. to be more pronounced. ON PERCEIVED ORAL HEALTH
8 Probability of dentate British adults
10 of different educational backgrounds
and age groups assessing their own
6 oral health as bad/very bad
2009
4 5 21–34 years
quartile 1 lowest income
quartile 2 35–49 years
2 50–64 years
quartile 3
quartile 4 highest income ≥ 65 years
0 0
Australia Finland Germany UK degree some no qualification
qualifications

54 55
 Inequalities in oral health
€55.0bn €71.1bn
Oral diseases have Access to oral healthcare €79.0bn
considerable impact €51.0bn
Oral diseases impact on individuals, commu- for Canada alone. Earlier findings from the USA
in terms of treatment respiratory Alzheimer’s
nities, society, health systems and the indicate that 2.4 million days of work and 1.6
costs and diseases oral diseases €105.0bn
economy. Yet, the full significance of this million days of school were lost due to oral cancer
productivity losses. €38.0bn
impact is unclear due to the lack of compre- disease in 1996. Absenteeism from school and
Providing equitable COST OF DISEASES
hensive and comparable international statistics work can limit academic achievement and Direct expenditure (public and private)
€14.6bn stroke
access to oral on oral diseases, particularly for low- and reduce employment opportunities. for selected diseases in the CVDs
healthcare is a major middle-income countries. 27 European Union countries
People from the upper end of the socioeco- average yearly expenditure 2008–12
public health
WHO estimates that oral diseases are the nomic scale are more likely to seek regular multiple sclerosis
challenge and €137.0bn
fourth most expensive diseases to treat. Annual dental care than those from the lower end. The
substantial €7.7bn
spending on oral healthcare in the 27 USA and other countries see increasing
inequalities persist
European Union member states was estimated emergency hospital admissions for dental
between population
at €79 billion (annual average 2008–12), while problems, simply because such emergency neuromuscular diabetes
groups and countries. disorders
the USA alone spent more than US$110 care is free of charge. Admissions in the USA
billion. Dental expenditure also plays a signifi- have doubled in the last 10 years and related
cant part in household medical spending. costs amount to US$2.7 billion.
Across OECD countries, average out-of-pocket
Affordability of oral care is a clear barrier since OUT-OF-POCKET EXPENDITURE TAKE-UP OF DENTAL CARE
payment for dental care represents about 55
most of the treatment costs are borne by the As a percentage of total Probability of visit to dentist
percent of total dental care expenditure, dental expenditure in past 12 months
patient. However, amplified public subsidies
compared to an average of 20 percent in OECD26 by income group
for dental care, extending coverage of health 2011 or latest available data 2009 or latest available data
out-of-pocket spending for general healthcare.
insurance, and improved availability of oral selected OECD countries selected OECD countries
In addition to treatment costs, the indirect costs healthcare services will not by themselves
Richest to poorest
of oral conditions are significant. A Canadian reduce inequalities unless those worse off are
Spain Spain
study found that 3.5 working hours/year/person aware of the benefits of good oral health, and
were lost due to oral diseases, translating to policy programmes address the broader Denmark Denmark
productivity losses of over CND$1 billion/year determinants of health. Poland Poland

with hospitalization Estonia Estonia

$5,044 New Zealand New Zealand

Hungary Hungary

CHAPTER 4 ORAL DISEASES AND SOCIETY

Finland Finland

Austria Austria

Belgium Belgium

Slovakia Slovakia

Canada Canada
THE PRICE OF
Czech Rep. Czech Rep.
NEGLECT
comprehensive without
The average cost USA USA
check-up hospitalization
of dental care regular check-up
$172 France France
per person in California $41 $60
in US$ Slovenia Slovenia
2009 visits to the hospital emergency department
routine dental care due to dental causes 0% 20% 40% 60% 80% 100% 90 70 50 30 10 0

56 57
Oral Diseases: Prevention and Management Chapter 5

At the UN High-Level Meeting on the Preven- Other preventive measures address risk factors
tion and Control of Non-communicable Dis- for oral disease that include unhealthy diet – in
eases in 2011, Helen Clark, Administrator of particular high sugar intake – tobacco use,
the United Nations Development Programme alcohol consumption, and a set of broader
(UNDP) and former New Zealand Prime health determinants. Many of these risk factors
Minister, recognized that oral diseases are an are shared between oral disease and other
obstacle to human development. major NCDs. The Common Risk Factor
Approach can thus contribute not only to
Historically, approaches to oral care have
improved oral health, but also to alleviating
focused on individual curative care rather than
the global burden of NCDs.
on population-based preventive interventions.
However, the financial and human resource The integration of oral and general health
costs of this approach are unaffordable for should be the cornerstone of policy approaches
many countries, and unsustainable on a global to improve prevention and control of oral
scale. Most oral diseases can largely be pre- diseases. This is acknowledged in the Oral
vented through simple, cost-effective measures Health Action Plan adopted by the 60th World
that involve reducing exposure to recognized Health Assembly in 2007. This emphasizes ‘the
risks and strengthening healthy behaviours. intrinsic link between oral health, general
Prevention, and oral health promotion are health and quality of life’ and identifies ‘the
highly cost-effective strategies to address the need to incorporate programmes for promotion
global burden of oral diseases. For instance, of oral health and prevention of oral diseases
estimates from the USA show that every dollar into programmes for the integrated prevention
spent on preventive dental care could save and treatment of chronic diseases’. In the same
between US$8 and US$50 in restorative and document, the ministers of health call for the
emergency treatment, emphasizing the impor- creation of innovative workforce models to
tance of increasing the focus on the prevention integrate essential oral healthcare into primary
of oral disease. healthcare. This is also one of the key strategies
set out in FDI’s Vision 2020.
Prevention of oral disease and promotion of
oral health can be directed towards individuals, The challenge in addressing oral diseases and
communities or entire populations. Adequate promoting oral health will require the right
access to fluoride is one of the most successful balance between a greater emphasis on
population-based preventive interventions. population-wide prevention, strengthening the
Fluoridation programmes have demonstrated oral health workforce that still suffers from low
their efficiency, cost-effectiveness and safety numbers, and also changing and adapting the
over the past 60 years in targeting tooth capacities and skills of oral healthcare
decay, the most prevalent health condition providers; all of this in the context of increased
worldwide. integration across disciplines and sectors.

59
 5.1

Provision of oral healthcare

Dentists are the Dentists Global average oral disease ICELAND THE BURDEN OF
principal providers of burden/provider ratio
SWEDEN FINLAND
DISEASE/PROVIDER RATIO
Differences in disease burden, inequalities in NORWAY

oral disease ESTONIA The ratio between burden of

access to care, and the unequal distribution of With about 2 million oral LATVIA oral disease in DALYs
treatment and health providers and a DENMARK
LITHUANIA
dentists between and within nations present UK and number of oral health
burden of over 10 million IRELAND
prevention. Their role major challenges to global healthcare systems.
NETH. POLAND
BELARUS
personnel per country
DALYS resulting from tooth BELGIUM
GERMANY
UKRAINE
is changing in These challenges require cost-effective manage- decay and periodontal LUX.
CZECH
REP. SLOVAKIA
MOLDOVA highest ratio 500 or more
AUSTRIA HUNGARY RUSSIA
response to emerging ment of the existing disease burden, and effec- disease, the global average FRANCE SWITZ.
SLOV. ROMANIA
SERBIA 100 – 499
risk factors, evolving ratio is 5.3. CROATIA
BULGARIA
tive prevention to achieve sustainable improve- PORTUGAL ANDORRA
MONT. KOSOVO
CANADA FYROM 20 – 99
disease burdens, ments in oral health. Changing global trends, SPAIN
ITALY KAZAKHSTAN
GREECE MONGOLIA 2 – 19
demographic exposures to risk factors and demographic U S A
UZBEK. KYRGYZSTAN JAPAN lowest ratio 2 or less
changes, and broader developments have resulted in new disease AZERBAIJAN
ARMENIA TURKMEN.
TURKEY TAJIKISTAN
health system and patterns that demand innovative multi-sectoral CYPRUS SYRIA
no data
MALTA
CHINA
LEBANON IRAQ AFGHANISTAN
TUNISIA IRA N
socioeconomic and inter-professional collaboration. MOROCCO ISRAEL
JORDAN
KUWAIT PAKISTAN BHUTAN
BAHAMAS
pressures. CUBA
ALGERIA LIBYA BAHRAIN QATAR
NEPAL

The majority of dentists worldwide work MEXICO

DOMINICAN
EGYPT UAE
BANGLADESH
MARSHALL ISLANDS
JAMAICA REP.
HAITI SAUDI ARABIA
in private-practice settings, with a smaller pro- BELIZE
ANTIGUA & BARBUDA
CAPE
VERDE MAURITANIA MALI
OMAN
INDIA MYANMAR
LAOS
KIRIBATI
GUATEMALA HONDURAS
portion working in public clinics, academia, EL SALVADOR
NICARAGUA GRENADA
DOMINICA

BARBADOS
SENEGAL
GAMBIA BURKINA
NIGER CHAD SUDAN ERITREA YEMEN
THAILAND
PHILIPPINES
FASO DJIBOUTI CAMBODIA
research, administration and industry. They are COSTA RICA TRINIDAD & TOBAGO GUINEA-
BISSAU GUINEA

BENIN
SAMOA

GHANA
VENEZUELA NIGERIA

TOGO
PANAMA GUYANA CÔTE ETHIOPIA
SIERRA LEONE D’IVOIRE CENTRAL SRI LANKA
key providers of oral healthcare, education, COLOMBIA SURINAME LIBERIA AFRICAN REP.
MALDIVES
BRUNEI
VANUATU
EQUATORIAL CAMEROON SOMALIA MALAYSIA FIJI
prevention, supervision and management ECUADOR
GUINEA
GABON
UGANDA
KENYA SINGAPORE
SÃO TOME
within the dental team. A growing number of & PRINCIPE CONGO
DEM. REP.
OF CONGO
RWANDA
BURUNDI SEYCHELLES TONGA
PAPUA
PERU TANZANIA
women are practising as dentists, and many I N D O N E S I A NEW
GUINEA SOLOMON
BRAZIL COMOROS ISLANDS
nations have, or soon will have, a majority of ANGOLA EAST TIMOR

ZAMBIA
female dentists. BOLIVIA ZIMBABWE
MAURITIUS
MADAGASCAR
NAMIBIA
The burden of disease/ BOTSWANA
MOZAMBIQUE
Affordability and availability are major barriers provider ratio CHILE
PARAGUAY

CHAPTER 5 ORAL DISEASES: PREVENTION AND MANAGEMENT

AUSTRALIA
to accessing care. Dentists tend to concentrate LESOTHO
SWAZILAND

The map displays data

in more affluent urban areas, leaving rural URUGUAY
derived from a new index – ARGENTINA
or disadvantaged populations relatively the ratio between DALYS
underserved. The services of private dentists are lost due to tooth decay and
periodontal disease (2010)
PROPORTION OF FEMALE/MALE DENTISTS
unaffordable for many, and oral healthcare is In selected countries
NEW
ZEALAND
per number of oral health
often not integrated into the primary healthcare female 2014 female male
personnel (2006–13, latest
system. available). It therefore 0
relates disease burden to 10
Strategic dental workforce planning should thus available dentistry
20
be embedded in overall planning for human personnel, thus showing 80
resources in health, so that pressing social the potential for providing 30 70
determinants of oral and general health can be oral care. A country with a 40 60
high disease burden and
addressed effectively, and crucial service and low provider numbers will 50 50
access gaps be reduced. The gap between the score high, while a country 60 40

Dem. Rep. Congo

burden of disease and the availability of care with a similar disease

Hong Kong SAR

70 30
can be addressed by creating dentist-led oral burden but higher provider

Netherlands

South Korea
Switzerland
Czech Rep.
numbers will score lower 80

Mauritius
20

Germany
Sri Lanka
healthcare teams, that include a flexible mix of

Portugal
Pakistan

Rwanda
Sweden
Panama

Canada
(more detail provided in Croatia

Ireland

Austria
Poland

Turkey
Benin

Japan
complementary mid-level providers and others, 10

Togo

USA
Iraq
the annex).
0
as required by local needs.
male

60 61
 5.4

Provision of oral healthcare

Oral healthcare is Dental team ICELAND

SWEDEN FINLAND
GLOBAL AVAILABILITY OF
best delivered by a
The dental profession leads the development
NORWAY DENTISTRY PERSONNEL
team led and
ESTONIA
Number of dentists and
and implementation of oral healthcare services, LATVIA
LITHUANIA other oral health personnel
supervised by providing equitable and appropriate oral IRELAND
UK
DENMARK
RUS.
per 1 million people
BELARUS
dentists, and healthcare for all. Dental teams are led and su- BELGIUM
NETH.
GERMANY
POLAND
UKRAINE
latest available 2000–13
CZECH
composed of oral pervised by a dentist, and may include various LUX.
REP. SLOVAKIA
MOLDOVA
RUSSIA
CANADA AUSTRIA HUNGARY
FRANCE SWITZ. ROMANIA fewer than 100
health professionals oral health professionals with different training,
SLOV.
CROATIA SERBIA
BULGARIA
with different skills MONT. 100 – 499
competencies, practice limits, registration, PORTUGAL ANDORRA
MONACO KOSOVO
FYROM

and training, thus recognition and supervision requirements,

SPAIN
ITALY
KAZAKHSTAN
500 – 999
GREECE MONGOLIA

ensuring quality care depending on community needs, available U S A

KYRGYZSTAN
NORTH 1,000 or more
UZBEK. KOREA JAPAN
AZERBAIJAN
for all. resources and national legislation. TURKEY ARMENIA TURKMEN.
TAJIKISTAN
SOUTH no data
KOREA
CYPRUS SYRIA CHINA
MALTA AFGHANISTAN
Dentists lead the team, are responsible for MOROCCO TUNISIA
LEBANON
ISRAEL
JORDAN
IRAQ IRAN
KUWAIT
diagnosis, providing oral healthcare and CUBA
BAHAMAS
ALGERIA L I B YA BAHRAIN
PAKISTAN
NEPAL
BHUTAN
MICRONESIA, FED. STATES OF
MEXICO QATAR MARSHALL ISLANDS
EGYPT
prescriptions as well as supervision and man- JAMAICA
DOMINICAN
REP.
UAE
BANGLADESH NAURU
SAUDI ARABIA
INDIA LAOS PALAU
agement. They also ensure quality and safety of BELIZE
GUATEMALA HONDURAS
ST KITTS & NEVIS
CAPE
VERDE MAURITANIA
MALI
OMAN
MYANMAR
KIRIBATI
ST VINCENT & GRENAD. DOMINICA NIGER THAILAND
SENEGAL CHAD SUDAN ERITREA YEMEN TUVALU
care in accordance with national regulations. EL SALVADOR
NICARAGUA GRENADA
ST LUCIA
BARBADOS
GAMBIA BURKINA
CAMBODIA
PHILIPPINES
TRINIDAD & TOBAGO GUINEA- FASO DJIBOUTI
COSTA RICA
Other oral healthcare professionals, including BISSAU GUINEA

BENIN
VENEZUELA

GHANA
NIGERIA

TOGO
PANAMA GUYANA CÔTE ETHIOPIA SAMOA
SIERRA LEONE D’IVOIRE CENTRAL SOUTH SRI LANKA
SUDAN BRUNEI
dental surgery assistants, dental nurses and COLOMBIA SURINAME LIBERIA
EQUATORIAL CAMEROON
AFRICAN REP.
MALDIVES MALAYSIA VANUATU
GUINEA UGANDA
chairside assistants, may assist dentists with a ECUADOR GABON
KENYA SINGAPORE
FIJI
COOK ISLANDS
SÃO TOME DEM. REP. RWANDA
range of clinical duties. Dental hygienists work & PRINCIPE CONGO OF CONGO BURUNDI SEYCHELLES
PAPUA
NIUE
TONGA
PERU TANZANIA I N D O N E S I A NEW
in the field of prevention, oral hygiene BRAZIL COMOROS
GUINEA

“We can and promoting healthy behaviours.

ANGOLA EAST TIMOR
SOLOMON
ISLANDS
ZAMBIA
shape a new model of Dental technicians provide BOLIVIA
ZIMBABWE MAURITIUS
MADAGASCAR
NAMIBIA
oral healthcare delivery which technical laboratory services in CHILE PARAGUAY
BOTSWANA
MOZAMBIQUE
relies on a team-based collabora- close collaboration with the SWAZILAND AUSTRALIA

CHAPTER 5 ORAL DISEASES: PREVENTION AND MANAGEMENT

tive approach where fully trained dentist.
SOUTH
AFRICA
LESOTHO
URUGUAY
dentists take responsibility for supervis- ARGENTINA
ing a team, provide sufficient training to Mid-level providers may in-
the healthcare workforce and delegate clude dental therapists, who
NEW
specific tasks … while retaining full provide limited restorative Le ga l s
ractice
ZEALAND
cop
of p eo I l l eg
al p
responsibility for diagnosis, and surgical services, some- Illegal dentistry is still an ethical, pe fp rac
Illegal
l sco ra
c t i ce
treatment planning and times for specific population public health and legal problem in provider a
l health training
Ora

tic
g
without any

Le
treatment.” groups such as children. Clinical many countries. Illegal practitioners are unregu- 1 Oral health

e
training
professional
dental technicians, or denturists, may lated and lack proper education and licensing, Legal 4 overstepping legal

e
necessary instruments, cross-infection control

gal practic
fabricate removable prosthetic appliances registration scope
FDI Vision 2020 – Shaping the
future of oral health, 2012 either with or without prescription from a and patient safety standards for state-of-the-art
dentist, and work directly with patients. The oral care. Their practice may incur serious

Ille
Fully licensed
role of community oral health workers may health dangers for patients, yet they may be the oral health
include provision of simple emergency care only available or affordable provider in certain Illegal 2 professional TYPOLOGY OF
provider ILLEGAL DENTISTRY
in primary healthcare settings, oral health pro- settings. Innovative and flexible workforce with
training 3 The four basic types of illegal practice
motion, screening, and referral when needed. models, integrated within a primary healthcare ce of dentistry, depending on oral health
cti
The names and scope of practice of all these system, may address the needs of deprived or l p ra
Legal provider Illega training and legal scope of practice.
professions are defined nationally. remote communities in a better and safer way. for medical clinical Modified from Benzian et al, 2010
work without oral
health training

62 63
 Provision of oral healthcare
Access to basic oral Oral healthcare continuum THE ORAL HEALTHCARE CONTINUUM
care is mandatory for
Systems that provide general healthcare and oral traditional approaches focused on curative care. low high
all countries. It is healthcare have generally evolved separately Clinical oral healthcare is generally costly and
possible even for around the world over the last 150 years. Oral thus unaffordable for the weaker health systems
resource-poor health healthcare is often only partially integrated characteristic of resource-poor economies.
systems, through the into public healthcare systems, or it is entirely Specialist
use of cost-effective, The Basic Package of Oral Care is a model for
absent. As a result, access to appropriate and oral care by
evidence-based integrating basic oral healthcare and prevention dentists and
affordable oral healthcare services is a distant
into the entry levels of healthcare systems. specialists
interventions that aspiration for the majority of the world’s popula-
It is currently the only WHO-approved oral
emphasize tions. Untreated tooth decay in permanent and Advanced oral care
health system model for the management of the
prevention and primary teeth ranks first and tenth respectively provided by dentist (may be
commonest oral diseases. It comprises modular first entry level to formal
self-care. among the 291 commonest diseases. These are

Frequency of need
components that can be adapted and scaled healthcare system in settings with
damning statistics and provide stark evidence of
to match available resources and community more resources)
the neglect of oral health.
needs. It has an initial focus on self-care and

Costs
An ideal primary (oral) healthcare system prevention, with other priorities set according Basic oral healthcare services – first entry
should provide universal coverage; be to disease burden and available resource. level to formal healthcare system (provided by
non-dentist personnel in low-resource settings)
people-centred; have demand-led policies and The minimum requirement is to cover basic
programmes; and be integrated with general emergency care and pain relief. Curative and
health in all policies, including labour, environ- specialist care can be added, resulting in the Informal community care and traditional medicine
ment and education. It is more likely to benefit full range of services in a universal coverage (self-help groups, community health programmes
a greater proportion of the population than context. involving non-health professionals)

Self-care and prevention

BASIC PACKAGE OF ORAL CARE Maintaining oral hygiene
Using fluoride toothpaste

CHAPTER 5 ORAL DISEASES: PREVENTION AND MANAGEMENT

Oral Urgent Treatment Avoiding risk factors to oral health
Oral Urgent Treatment (OUT) is an on-demand service providing basic
high low
emergency oral care. The three fundamental elements of OUT are:
• relief of oral pain
Quantity of care needed
• first aid for oral infections and dento-alveolar trauma
• referral of complicated cases.
OUT can be provided by trained non-dentist personnel. 94.3% 92.8%
GETTING ORAL HEALTHCARE WHEN NEEDED
Affordable Fluoride Toothpaste 81.8% Percentage of adults reporting oral health problems
Use of Affordable Fluoride Toothpaste (AFT) is one of the most important 77.0% and able to get oral care in selected countries
71.4% 2002–04
preventive measures in managing tooth decay. However, fluoridated 66.7%
toothpaste is often too expensive for disadvantaged groups in low- and 58.8% 56.8%
middle-income countries to purchase. Approaches to AFT aim at enabling
everyone to clean teeth twice daily with quality fluoride toothpaste. 48.0% 46.5%
41.6%
Atraumatic Restorative Treatment 32.2% 32.1% 30.5% 28.4%
Atraumatic Restorative Treatment (ART) is a caries management 21.2%
approach, consisting of a preventive (fissure sealant) and a restorative
component (restoration). ART can be performed inside and outside a
dental clinic, as it uses only hand instruments and a powder-liquid
high-viscosity glass-ionomer, and requires neither electricity nor running
Slovakia Luxembourg Finland Russia Brazil Malaysia Paraguay South India China Philippines Ghana Bangladesh Zambia Laos Burkina
water. It is relatively painless, minimizing the need for local anaesthesia Africa Faso
and making cross-infection control easier.

64 65
 Prevention of tooth decay
FLUORIDE IN WATER
Percentage of population
The use of fluorides Fluorides with access to appropriate adjusted
for the prevention of or natural levels of fluoride in water
Good oral hygiene, a reduction in consumption the choice of the most suitable fluoridation FINLAND
tooth decay is safe, of dietary sugars, and the regular, appropriate 2012
strategy depends on many factors, including SWEDEN
efficient and highly use of fluoride are key elements of effective the evidence of effectiveness, the setting and
UK
DENMARK
IRELAND 76% – 100%
cost-effective. tooth-decay prevention strategies. the resources available. CANADA
CZECH REP.
Increased efforts are 51% – 75%
FRANCE AUSTRIA

required to promote Fluoride has been used for over 70 years in the Fluorides are safe and effective if applied at SERBIA 26% – 50%
access and use of prevention of tooth decay. A large body of scien- recommended levels. However, exposure to SPAIN KOSOVO
6% – 25%
U S A SOUTH
tific evidence demonstrating its effectiveness in higher-than-recommended levels of fluoride KOREA
appropriate fluorides MALTA CYPRUS
CHINA less than 5%
population-wide studies supports its use. How- during tooth development (between birth and ISRAEL
in order to achieve no data
ever, the evidence is still evolving and varies for four years of age) may cause dental fluorosis. MEXICO
LIBYA
universal access. INDIA
different modes of delivery. The effect of fluoride The majority of cases are mild and unnoticea- HAITI
HK SAR
VIET NAM
GUATEMALA THAILAND PHILIPPINES
is local (topical) on the tooth surface: inhibiting ble, only the severe forms appear as brown SENEGAL

VENEZUELA NIGERIA
bacterial acid production, stopping enamel spots or discolouration of the teeth. PANAMA
GUYANA
BRUNEI
KIRIBATI
COLOMBIA SRI LANKA

demineralization, enhancing remineralization MALAYSIA

Sodium-fluoride is part of WHO’s model list GABON

DEM. REP.
SINGAPORE
PAPUA
(repair) and improving enamel resistance to OF CONGO NEW

of essential medicines, and access to fluorides PERU TANZANIA

GUINEA

future acid attacks. BRAZIL

has been recognized as a part of the basic ZAMBIA
FIJI

Fluoride can reach the tooth surface in many human right to health. The potential for reduc- NAMIBIA
ZIMBABWE

CHILE
ways: it can be added to water, salt ing inequalities in the tooth-decay AUSTRALIA
or milk as part of community in- “The experts burden through universal access
GLOBAL URUGUAY

terventions; be professionally reaffirmed the to fluorides for dental health ARGENTINA

FLUORIDE USE
Estimated number of applied or prescribed as efficiency, cost-effective- is largely missed through ab- NEW
people worldwide using gel, varnish or tablets; or ness, and safety of the daily sence of preventive national
ZEALAND

different sources of comprise part of self-care in use of optimal fluoride. They fluoride policies promoting
fluoride 2001 confirmed that universal
salt 2013 toothpaste and mouthrinses. availability, affordability or
access to fluoride for dental

CHAPTER 5 ORAL DISEASES: PREVENTION AND MANAGEMENT

water 2012 The evidence for these fluori- use of fluoride products, and CHOOSING THE RIGHT FLUORIDE INTERVENTION
health is a part of the
dation methods varies from mandating water, salt or milk Estimated suitability of fluoride interventions in high-income (HIC)
fluoridated milk basic human right to and low-/middle-income (LMIC) country settings using the Fluoride
very strong to weak, so that fluoridation.
less than 1 million health.” Intervention Score (FLIS) Criteria for selecting a fluoride
intervention:
fluoride drops/tablets evidence strength
Call to Action to Promote Dental Health Fluoride Intervention
15 million Score (FLIS) setting requirements 1 Strength of scientific evidence:
by Using Fluoride, WHO,
60 • Effectiveness
FDI and IADR, 2006 implementation feasibility
water with naturally FLUORIDE FACTS suitable for • Efficiency
appropriate levels of fluoride implementation • Safety
18 million Use of fluorides is among the top 10 • Compliance
45
professionally applied topical fluoride greatest public health achievements ever implementation
30 million (according to US Centers for Disease Control) possible, but 2 Setting requirements:
challenging aspects
• Feasibility
fluoride mouthrinses 30
100 million Fluoride can lead to a 20% – 60% • Equity
reduction in tooth decay, depending on • Legislation
not suitable for
salt fluoridation delivery method. implementation, • Fluoride mapping
300 million high challenges
3 Implementation feasibility:
water fluoridation (adjusted) US$1 spent on salt fluoridation • Quality assurance
370 million

fluoride toothpaste
=
US$250
savings in future dental treatment costs.
0
HIC LMIC HIC LMIC HIC LMIC HIC LMIC
• Sustainability
• Surveillance
• Communication
1,500 million toothpaste water salt milk

66 67
 5.3.2

Prevention of tooth decay

Fluoride toothpaste is Fluoride toothpaste TOOTHBRUSHING HABITS IN EUROPE
highly effective in Proportion of 11- to 15-year-olds
Fluoride toothpaste is the most widespread and weak. The international standard ISO 11609 SWEDEN FINLAND who report brushing their teeth
preventing tooth most rigorously evaluated means of fluoride defines minimum quality, labelling and testing more than once every day
NORWAY
decay. It is safe and use for preventing tooth decay. The evidence requirements, but national compliance and 2010
readily available, but for its decay-preventing effect in both primary enforcement varies greatly.
ESTONIA
RUSSIA
75% or more
greater effort is and permanent dentitions is strong. Its use in
Scotland
LATVIA
required to improve There are huge differences in affordability LITHUANIA 65% – 74%
combination with water or salt fluoridation DENMARK
and quality of fluoride toothpaste. Even 55% – 64%
its affordability and is safe. Furthermore, the protective effect is
though widely available for purchase, the Wales
quality to ensure increased. Toothbrushing without fluoride POLAND less than 55%
cost of toothpaste, particularly for poor GERMANY
universal access. toothpaste helps improve oral hygiene, but has BELGIUM no data
populations, is a major barrier to regular CZECH
no decay-preventing effect. REP.
use. The low quality of certain toothpastes
Fluoride was first added to toothpaste in 1914, in low- and middle-income countries may FRANCE AUSTRIA HUNGARY

but it was only in 1955 that the first commercial also reduce their decay-preventing effect.
fluoride toothpaste (Crest®) became available. Labelling requirements are not always met,
Most toothpaste sold in high-income countries so that transparency for the consumer is
now contains fluoride, and its widespread use compromised, and counterfeit toothpaste
is seen as the main reason for the significant may not even contain fluoride.
decline of tooth decay in these countries in AFFORDABILITY OF
Since water and salt fluoridation are not availa-
recent decades. FLUORIDE TOOTHPASTE
ble to the majority of the world’s population,
TOOTHPASTE FACTS Days of household expenditure
Typical formulations of effective fluoride tooth- fluoride toothpaste remains the most significant by the poorest 10% of the population
paste contain 1,000 to 1,500ppm (parts-per- decay-preventing intervention globally, yet Main functions of toothpaste: Best toothbrushing practice: needed to buy a year’s supply
million) fluoride; low-fluoride child toothpastes more efforts are required to improve affordabil- of the cheapest fluoride toothpaste
Tooth decay prevention: standard • Brush twice a day. per person
exist, but evidence for their effectiveness is ity and quality. (1,000 – 1,500ppm) or high fluoride • Do not rinse after brushing. 2006
content (2,500 – 5,000ppm).
• Use a pea-sized amount of 30.4
Plaque control: addition of

CHAPTER 5 ORAL DISEASES: PREVENTION AND MANAGEMENT

“The issue of toothpaste.
antibacterial substances.
toothpaste cost deserves Reduction of tooth sensitivity. • For children up to the age of six,
additional attention because supervise their brushing.
Whitening or bleaching effect.
price will determine access to tooth Freshening breath.
pastes, especially in the emerging
market economies (EME) of the world. The US$1 spent on promoting the use of
need for fluoridated toothpaste is particu- fluoride toothpaste in Nepal = savings of US$87–US$356
in treatment costs.
POLICIES TO IMPROVE QUALITY AND larly critical in many EME countries, where
RECOMMENDATIONS

REDUCE COST OF FLUORIDE TOOTHPASTE water fluoridation may be impractical,

14.3

US$14bn
1 Remove taxation and tariffs, which constitute a significant cost factor, where salt fluoridation has not yet
Size of the global
and pass on savings to the consumer. gained traction, and where the
toothpaste market
2 Increase taxation of toothpastes without fluoride to discourage their use. infrastructure for dental public in 2016:
3 Enforce equity pricing – differential prices for different populations, health services may be 8.6
depending on purchasing power. underdeveloped.”
4 Promote generic competition and local production, while ensuring
John Stamm, University of 4.3
quality standards. 3.2
North Carolina, 2007
5 Improve capacities of national food and drug administrations for better 2.0
1.2
monitoring of toothpaste quality. 0.1 0.2 0.5
6 Strengthen and enforce the regulations of ISO 11609.
USA Australia Italy Thailand India Brazil Cambodia Senegal Tanzania Zambia

68 69
Oral Health Challenges Chapter 6

In 2012, FDI’s Vision 2020 document Shaping wealthier countries carries the risk of increas-
the Future of Oral Health identified a wide ing pressures on already strained health sys-
range of challenges and opportunities for oral tems in the former. On the other hand, migra-
health. ‘Persisting oral health inequalities; lack tion may have many positive effects, such as
of access to oral healthcare; unaffordability of boosting local economies through remittances.
dental treatment in many places; a growing Although the human right to free movement
and ageing population; workforce migration; should not be restricted, strategies to enhance
dental tourism; the emergence of new educa- effective retention of dentists in their countries
tional models; the evolving distribution of tasks of origin, combined with ethical codes to miti-
between members of the oral healthcare work- gate the negative effects of active recruitment
force; ongoing legislative actions targeting by high-income countries, should be in place
hazardous materials; and the increasing use of to ensure that oral health professionals are
information and communication technologies available where they are needed.
in all segments of our lives and professions’
At the same time as the mobility of oral health
were listed among those opportunities and
professionals has increased, the mobility of
challenges that require appropriate and timely
patients is also on the rise and the number of
action.
individuals travelling abroad to seek oral
This chapter focuses on some of these chal- healthcare has increased sharply in the past
lenges and details important aspects where decade. This represents a new challenge for
oral health professionals and policy makers oral healthcare, as it raises questions about
need to collaborate closely in order to identify access and quality of care, legal aspects and
and implement adequate solutions. ethical responsibilities.

Dental education is an area where new solu- The challenges for research in oral health are
tions are needed so that the educational model diverse and fundamental. In the future the fo-
responds to new needs, effectively bridges the cus of research will not only be on basic dis-
gap between medical and dental education, covery science and the clinical and technical
promotes and strengthens collaborative prac- aspects of providing oral care. In addition,
tice, and includes public health, disease pre- there will need to be a greater emphasis on im-
vention and health promotion as core activities plementation and translational research, taking
of every oral health professional. Unless such into account the global health implications of
changes are brought about, the long-term goal oral diseases and the different needs of low-
of having sufficient numbers of appropriately and middle-income countries.
skilled and motivated oral health professionals
As set out in FDI’s Vision 2020, all of these
in every healthcare system will remain an un-
challenges highlight the need to shape an in-
fulfilled wish.
clusive and effective new model of oral health-
In the context of the global health workforce care, for the ultimate benefit of all patients
crisis, the migration of health professionals has worldwide. The measure of our success in
received increasing attention. People have al- achieving this will be the increase in people
ways moved to another country for work, but who retain a full set of healthy teeth through-
the accelerated migration from poorer to out life.

71
 Challenges in education
ICELAND
SWEDEN FINLAND
NORWAY
DENTAL SCHOOLS PER COUNTRY
Contemporary dental Dental education has developed over the last ESTONIA
2014
LATVIA
education equips oral 150 years generally separate from medical DENMARK
IRELAND
UK
50 or more
health professionals education, and often focuses on restorative and NETH. POLAND BELARUS
GERMANY
clinical dentistry. The recognition of the links BELGIUM 10 – 49
with the required mix CANADA
FAROE IS. CZECH
REP. SLOVAKIA
UKRAINE
RUSSIA

of skills and between oral and general health and of the FRANCE
SWITZ.
AUSTRIA
SLOV.
HUNGARY
ROMANIA
2–9
competencies to shared wider determinants of oral health have CROATIA SERBIA
BULGARIA
KOSOVO 1
meet the needs of led to new models of dental education that PORTUGAL
SPAIN ITALY
no data
MONGOLIA
GREECE
their patients and foster active collaboration among healthcare UZBEKISTAN
JAPAN
populations. professions and disciplines. Emphasis on public U S A
TURKEY
AZERBAIJAN
ARMENIA SOUTH
TAJIKISTAN
KOREA
health, evidence-based health promotion and TUNISIA
LEBANON
SYRIA CHINA
MALTA IRAQ IRAN
disease prevention, along with critical-thinking MOROCCO ISRAEL
JORDAN
KUWAIT PAKISTAN NEPAL
skills to evaluate new research information are MEXICO
CUBA
ALGERIA LIBYA
EGYPT UAE
DOMINICAN
among the new core competencies that lead REP. SAUDI ARABIA
HK SAR FIJI
HAITI INDIA LAOS
MYANMAR VIET NAM
the profession towards addressing population GUATEMALA HONDURAS
TRINIDAD THAILAND
EL SALVADOR SENEGAL SUDAN
PHILIPPINES
needs that go beyond the dental chair. NICARAGUA & TOBAGO
COSTA RICA
PANAMA VENEZUELA CÔTE NIGERIA
ETHIOPIA SRI LANKA
Dental degree programmes generally comprise COLOMBIA
D’IVOIRE
MALAYSIA
essential health sciences and clinical skills KENYA
SINGAPORE
ECUADOR
in oral diagnosis and care, requiring four to DEM. REP.
OF CONGO
RWANDA
PERU
six years of study, depending on national legis- TANZANIA I N D O N E S I A
BRAZIL
lation. A range of postgraduate specializations
exists, as well as formal education pathways BOLIVIA MADAGASCAR
for other professionals of the dental team. PARAGUAY
CHILE

There are large regional disparities in the SOUTH

AUSTRALIA

AFRICA
provision of dental education, with Africa The integration of dental URUGUAY

having the lowest number of dental schools education with general health ARGENTINA
259
COST OF DENTAL out of all the world regions. In contrast, dental professional education is a 251
EDUCATION education has become a lucrative business crucial element in shaping the NEW
ZEALAND
Average educational
in some countries, with a rapidly increasing scope of practice, and scaling “… Educators
debt incurred by dental
graduate in private number of predominantly private dental up the number and impact of in dental schools are …
and public dental training institutions. This poses increasing oral health professionals worldwide. facing demands to introduce GOING PRIVATE
schools in the USA, challenges for ensuring educational quality, Adequate public investments in oral and health a curriculum to develop Number of dental 175
adjusted for inflation colleges in India
governance and licensing. Accreditation of professional education are required, together awareness of public health service

CHAPTER 6 ORAL HEALTH CHALLENGES

2004–11 1950–2014
dental education programmes and licensure with curricular and institutional reforms, in and policy, inter-professional
private school cooperation, critical thinking and private colleges
requirements vary regionally, and there are no order to create an effective global oral health
public school decision making, self-management
globally recognized competency standards. workforce. public colleges 104
and organization culture, and
US$
250,000 reflection and interpersonal
feedback.”
200,000
31
150,000
Young Guk Park, Dean of Kyung Hee
5 39 42
University School of Dentistry, 2015 10 1 30 31
24
3 13 17
100,000 1950 1960 1970 1980 1990 2000 2005 2010 2014
2004 2005 2006 2007 2008 2009 2010 2011

72 73
 6.2 v2

Challenges of global migration

Migration and Migration of oral health professionals Dental tourism
mobility of oral
International mobility and migration are part of ment by receiving countries may be detrimen- Medical and dental tourism are increasing revenue stream for certain destinations and
health professionals our increasingly globalized, interlinked econo- tal for health systems in source countries, trends facilitated by the ease of travel, informa- may contribute to strengthening local health-
and of patients result mies. The cross-border movement of oral which lose the educational investment made tion and trade in the wake of globalization. The care systems.
from complex push health professionals is a recognized phenome- in those health professionals who migrate. On international mobility of patients who seek care
and pull factors. The Main reasons for dental tourism include lower
non with both positive and negative effects. Yet the other hand, the economy of some net outside their home country involves complex
positive and negative costs of care in the destination country, no
very little is known about the extent of the exporting countries may depend on remit- issues related to ethics, quality of care and the
impacts on sending waiting times and short time-span of treatment,
migration of oral health professionals, because tances from those migrating abroad. provider–patient relationship, but also related
combining treatment with travel to exciting
and receiving no recent international statistics are available. to costs, commercialization and consumerism.
Receiving countries, in turn, are required to and exotic holiday destinations,
countries need to be “FDI
Migration of health workers is a complex issue ensure the competence and quality of care Problems may arise from cross-border and the availability of proce-
balanced through acknowledges that access
both for source and receiving countries, with provided by foreign-trained professionals, as insurance coverage, warranty aspects and dures that are not legally
appropriate policies to oral healthcare as well as
many drivers for workforce migration, both well as their rights to equal pay and opportuni- treatment complications. On the other hand, available in the home
and regulations. migration for professional, economic
professional and personal. These include lack ties. Such efforts must be mindful of the human medical tourism has developed into a major country.
or personal reasons are human rights
of career opportunities or specialization; right to free movement, as well as the rights
and all countries need to plan accordingly
personal and family reasons, such as educa- and opportunities for locally trained profes-
… Planned international recruitment of
tion for children; or economic reasons, includ- sionals.
oral health professionals can only be a
ing a better and more stable income. These
WHO and other organizations have developed partial solution to domestic shortages. It
factors coexist with broader health-system,
codes of practice for international recruitment is essential that international
social and political issues.
alongside policy options for countries to facili- recruitment be done without
There is a recognized global shortage of skilled tate effective national workforce planning, detriment to health services
human resources for health, but international mitigate possible negative effects of interna- of countries.”
recruitment is only a partial and temporary tional migration, and monitor workforce flows
solution to national shortages. Active recruit- more effectively. FDI Policy Statement on Ethical International
MEDICAL TOURISM DOMAINS Recruitment of Oral Health Professionals, 2006
AND TREATMENT APPROACHES
Modified from Hall, 2011

MEDICAL HEALTH WELLNESS

TOURISM TOURISM TOURISM
Medical
interventions
requiring special legal
conditions: stem-cell

CHAPTER 6 ORAL HEALTH CHALLENGES

therapy, organ Cosmetic
transplantation, surgery, Visits
abortion, fertility hair to spas
treatment. trans- and health
plantation. resorts.
Orthopaedic
surgery,
specialized dental General
surgery (implants), dental
plastic surgery. care.
MIGRATION OF
ORAL HEALTH
Treatment spectrum
PROFESSIONALS
Major flows Curative Preventive Promotive
1999–2000

74 75
 6.4

Challenges in research
Oral health research, Science and research provide the foundation oral care, mainly in high-income countries. It THE IADR-GOHIRA 1 Identify critical gaps in knowledge.
encompassing the full for evidence-based health programmes, poli- is only recently that more emphasis has been RESEARCH PRIORITIES
2 Develop and implement, in partnership with cognate evidence-based medical and
range of basic, cies and clinical practice. More than 4 billion placed on implementation and translational The International Association for
dental organizations, a knowledge base that uses a standard set of reporting criteria
Dental Research (IADR) Global Oral
clinical, translational people worldwide suffer from oral diseases, research, taking into account the global health and includes a registry of implementation trials.
Health Inequalities Research Agenda
and applied generating an enormous health and economic implications of oral diseases and the different (GOHIRA) initiative has identified 3 Emphasize the significance of psychosocial determinants of oral health, oral
health-system burden. It is thus imperative to promote, needs of low- and middle-income countries. priorities for research required to health-related behaviour, and oral healthcare-seeking behaviour, on whole
coordinate and support the full range of basic, implement strategies that could populations and underprivileged communities.
research is essential The so called ‘90/10 Gap’, whereby 90 percent reduce oral health inequalities
to address the clinical and translational research, together 4 Emphasize the importance of integrating research on oral health inequalities, with
of research and spending are directed towards worldwide.
with research training and capacity building, wider approaches to reducing health inequality as a whole.
unacceptably high the needs of only 10 percent of the world’s
health and economic to reduce this disease burden. 5 Emphasize the importance of multi-disciplinary and translational research, seeking
population also applies to oral health research. input from a range of social scientists and health professionals.
burden of oral Oral health research faces the same challenges The bias in the origin of research publications
6 Develop disease-prevention strategies based on broad social and environmental
diseases, and to of dissemination and implementation of is an indicator of this. Furthermore, a paradigm determinants of health, adopting upstream rather than downstream strategies.
improve oral health research findings as the rest of the health shift is required, with greater emphasis on
7 Develop strategies that are capable of local interpretation in a way that respects
worldwide. sector. The continuum from discovery to global prevention and the integration of oral health re- cultural sensitivities and socioeconomic constraints for improving oral health literacy.
application recognizes the different levels and search into the mainstream of clinical science.
8 Develop community-based regional- and country-level systems for oral health
types of research, as well as their interplay,
Developing and coordinating international promotion and healthcare, recognizing previous experience and resource
in order to make best use of research in improv- implications, and, where appropriate, emphasizing whole and at-risk populations.
collaborative research priorities is a crucial
ing global oral health. The first step in this
element in a concerted effort to fill essential 9 Raise the issue of oral health inequalities, with the need to promote proportionate
continuum is the translation from basic science universalism and specific emphasis on underprivileged communities, in wider public
knowledge gaps in oral health. A particular
to clinical practice. The subsequent, equally debates.
focus on evaluating social and behavioural
important steps are related to translation and 10 Advocate for the inclusion of oral health with other sectors in all policies, in line with
interventions, implementation and delivery
facilitation of broad health-system adoption the Adelaide Statement of Health in All Policies.
will be required if the major global oral health
and population-level measures.
inequalities are to be reduced.
Oral health research has traditionally focused on
basic, clinical and technical aspects of providing APPLYING RESEARCH FROM DISCOVERY TO HEALTH
Modified from Dzau et al, 2010

DISCOVERY TRANSLATION CLINICAL TRANSLATION GLOBAL HEALTH

RESEARCH & ADOPTION
8,661
• basic discovery • pharmacodynamics • clinical • practice guidelines • improve community
• preclinical • toxicology development • practice adoption health status
research • human proof of • government • community • global health service

CHAPTER 6 ORAL HEALTH CHALLENGES

• in-vivo analysis concept approval assessment and research
• evidence-based • care delivery;
medicine health-services
4,527 research

3,307
2,900 2,769
PUBLICATIONS 2,028 2,012 1,982
Papers published on 1,307 1,194 1,186 1,159 1,137 1,021
dental research 992
per country of origin
2007–11
USA Brazil Japan England Germany China Italy Turkey South Korea Netherlands Spain Sweden Switzerland Canada India

76 77
Oral Health and the Global Agenda Chapter 7

Historically, oral health and dentistry have improving oral health can also yield important
struggled for recognition as a speciality sepa- contributions towards achieving the voluntary
rate from health and medicine. This long-held global NCD targets set for 2025.
and deliberate focus on a separate ‘identity’
Similarly, oral diseases were directly or indi-
has now become recognized as one of the rea-
rectly linked to all of the MDGs (2000–15).
sons for the low priority and neglect of oral
However, this entry point has not been used
health on international health agendas. The re-
systematically to improve the prioritization
sulting disconnect between oral health, den-
and integration of oral health in international
tistry and the mainstream of global health
public health agendas. With the replacement
policy and practice fails to recognize that oral
of MDGs by a range of SDGs (2015–30), health
health and oral healthcare are intrinsically
will play a central role as a prerequisite and an
linked with many other sectors, within and
outcome of sustainable development. Again,
outside the field of health. As a consequence,
ensuring that oral health is related to SDG tar-
there has been a failure to integrate oral health
gets and indicators from the beginning will
into overall health strategies and messages.
strengthen the case of cross-sectoral integra-
One of the main challenges faced by oral tion of oral health in the context of sustainable
health professionals and dental public health human development.
advocates today is thus to ensure adequate
In particular, this strong connection can serve to
recognition and consideration of oral health
promote oral healthcare in the context of Uni-
matters on the global health agenda. At the
versal Health Coverage, which, as discussed in
same time, policies need to be translated into
this chapter, constitutes an essential element to
tangible actions giving everyone equitable
foster progress on oral health outcomes, ine-
access to effective prevention and appropriate
qualities and socioeconomic impact.
care.
This chapter closes on an environmental note
The global fight against NCDs, which is now
and, more specifically, on the Minamata Con-
guided by the WHO’s global action plan, is a
vention on Mercury. Oral health professionals
good example for the benefits of integrating oral
and their representative organizations partici-
and general health. Oral diseases are recog-
pated actively in the drafting process of the
nized as an area of major public health concern
convention and the agreement to phase-down
and a deeper integration of oral health into
amalgam use. This involvement is another
NCD policies could lead to general health
demonstration that the dental profession takes
benefits.
international responsibilities and commitments
Oral health can benefit from strategies address- seriously; and that oral healthcare can be part
ing NCDs, and in particular common risk fac- and parcel of other important issues that top
tors; and vice versa, strategies aimed at the global health and development agendas.

79
 Oral health and NCDs ICELAND
NONCOMMUNICABLE DISEASES
SWEDEN FINLAND
NORWAY Age-standardized death rate
from NCDs per 100,000 population
NCDs are a growing A common action plan ESTONIA

LATVIA
2012
global threat. Oral DENMARK
LITHUANIA

Noncommunicable diseases (NCDs) are the IRELAND

UK

diseases are integral leading cause of death and disability, responsi-

NETH.
GERMANY
POLAND
BELARUS
800 or more
BELGIUM UKRAINE
CZECH
to prevention and ble for over two-thirds of all deaths, 80 percent LUX.
REP. SLOVAKIA
MOLDOVA 700 – 799
CANADA AUSTRIA HUNGARY RUSSIA
FRANCE SWITZ.
control of NCDs. of which occur in low- and middle-income
SLOV.
ROMANIA
600 – 699
CROATIA B-H SERBIA
BULGARIA
countries. The four main NCDs are cancer, PORTUGAL
MONT.
ALBANIA
KOSOVO
FYROM 400 – 599
KAZAKHSTAN
diabetes and cardiovascular and chronic respi- SPAIN
ITALY
GREECE MONGOLIA less than 400
Political Declaration ratory diseases. Oral diseases are important NORTH

of the High-Level
GEORGIA UZBEK. KYRGYZSTAN KOREA
JAPAN no data
NCDs: untreated tooth decay is the single most U S A
TURKEY
AZERBAIJAN
ARMENIA TURKMEN. SOUTH
Meeting of the TAJIKISTAN KOREA

General Assembly on
prevalent and preventable disease, and oral MALTA
CYPRUS
LEBANON
SYRIA
AFGHANISTAN
CHINA
TUNISIA IRAQ IRAN
MOROCCO ISRAEL
the Prevention and cancer among the 10 most common cancers. JORDAN
KUWAIT PAKISTAN BHUTAN
BAHAMAS NEPAL
Control of Noncom- MEXICO
CUBA ALGERIA L I B YA BAHRAIN
QATAR

municable Diseases The underlying causes of NCDs are social, DOMINICAN

REP.
EGYPT UAE
BANGLADESH
JAMAICA SAUDI ARABIA FIJI
LAOS
economic and environmental determinants, BELIZE HAITI CAPE
VERDE MAURITANIA
MALI
OMAN
INDIA MYANMAR
VIET NAM
We, Heads of State GUATEMALA HONDURAS
NIGER THAILAND

and Government and including poverty, unemployment, discrimina- EL SALVADOR

NICARAGUA
TRINIDAD &
TOBAGO
BARBADOS
SENEGAL
GAMBIA
BURKINA
CHAD SUDAN ERITREA YEMEN
PHILIPPINES
CAMBODIA
GUINEA- FASO DJIBOUTI
representatives of tion, and lack of education and inequitable COSTA RICA
VENEZUELA BISSAU GUINEA

BENIN
GHANA
NIGERIA

TOGO
PANAMA GUYANA CÔTE ETHIOPIA
SIERRA LEONE D’IVOIRE CENTRAL SOUTH SRI LANKA
States and Govern- trade policies; and common risk factors such COLOMBIA SURINAME LIBERIA AFRICAN REP. SUDAN
MALDIVES
BRUNEI
CAMEROON MALAYSIA
SOMALIA
ments… as tobacco and alcohol use, lack of physical EQUATORIAL UGANDA
ECUADOR GUINEA KENYA SINGAPORE
GABON
DEM. REP.
1 Acknowledge that activity and unhealthy diets high in salt, CONGO OF CONGO
RWANDA
BURUNDI
the global burden PERU TANZANIA I N D O N E S I A
PAPUA
NEW

and threat of
saturated fat and free sugars. Oral diseases BRAZIL
COMOROS
GUINEA
EAST TIMOR SOLOMON

noncommunicable share all of these underlying determinants and ANGOLA

ZAMBIA
MALAWI ISLANDS

diseases constitutes risk factors with the other major NCDs. The BOLIVIA
ZIMBABWE MADAGASCAR MAURITIUS

one of the major Common Risk Factor Approach provides the

NAMIBIA
BOTSWANA
CHILE PARAGUAY MOZAMBIQUE
challenges for
development in the
basis for the inclusion of oral diseases in NCD SWAZILAND AUSTRALIA
SOUTH
21st century, which prevention and control programmes. URUGUAY
AFRICA
LESOTHO

undermines social ARGENTINA

and economic The growing burden of NCDs worldwide was
development recognized by the UN High-Level Meeting on THE WHO GLOBAL ACTION PLAN
throughout the the Prevention and Control of NCDs in 2011 FOR PREVENTION AND CONTROL OF NCDS
NEW
ZEALAND

CHAPTER 7 ORAL HEALTH AND THE GLOBAL AGENDA

world and
which committed member states to a compre- Nine targets for 2025
threatens the
achievement of hensive range of actions to address NCDs.
internationally Paragraph 19 of the resulting political declara-
agreed develop- tion explicitly mentions oral diseases as sharing
ment goals; COST OF ACTION V INACTION ON NCDS Establish
the same determinants as the other NCDs. 25%
19 Recognize that In low- and middle-income countries 80% availability
of affordable reduction in
renal, oral and eye WHO’s World Health Assembly adopted a prevalence of
Action US$11 billion a year estimated technology and
diseases pose a global action plan in 2013 to bring about a
cost of implementing medicine to treat high blood
major health
reduction in the global NCD burden. Although Global Action Plan NCDs. 25%
pressure.
burden for many
countries and that many countries have subsequently developed Halt the reduction in
these diseases specific policies, the 2014 UN progress review rise in premature death of
Inaction
US$7 trillion
10% 30%
share common risk diabetes and people aged 30–70
revealed that more must be done. Continued Ensure that reduction in reduction in
factors and can obesity. years from 10%
advocacy for the integration of oral diseases over 15 years 50% of people the harmful use tobacco
benefit from receive preventive of alcohol. NCDs. reduction in
into these national action plans is essential if estimated loss of productivity and use.
common responses therapy for 30% prevalence of
to NCDs. reductions in oral health inequalities and the price of healthcare if no action is reduction in insufficient
heart attacks
taken salt intake. physical
burden of oral disease are to be achieved. and strokes.
activity.

80 81
 Oral health and NCDs
The global A developing movement
momentum for NCDs “Oral diseases
The meeting of the UN General Assembly in While oral health may benefit from strategies
is a window of 2011 and the adoption of the High-Level Politi- addressing NCDs, particularly from reducing are often overlooked
opportunity to cal Declaration on Prevention and Control of consumption of sugar, tobacco and alcohol, among NCDs by the
improve oral health Non-communicable Diseases marked a major strategies aimed at improving oral health can international community, and it is a
on a global scale. turning point in global health. The declaration also make important contributions towards health area that we cannot afford to
and the subsequent planning and target-setting achieving the voluntary global NCD targets set ignore and that is largely preventable. I
implore my fellow heads of state and
process have recognized the shift from commu- for 2025. The WHO Sugars Guideline published
governments to include oral health among
nicable towards noncommunicable diseases in 2015 is an important example of this. The
the NCDs, and for health ministries to
that will transform the global health landscape strong recommendation that sugars should not
become more engaged. We must have
in the next decade. The increasing health, exceed 10 percent of energy intake was based
a shared sense of moral duty to
social, and financial burden they cause is the on evidence for their effect on tooth decay.
make proper oral health a
key factor for the prioritization of NCDs. However, it is anticipated that adherence to
priority.”
the guidelines will also reduce other NCDs,
The prevention and control of NCDs is based
especially obesity.
on the integration of the Common Risk Factor
Jakaya Mrisho Kikwete,
Approach and interventions addressing the Because so many of the determinants of both President of Tanzania,
shared wider social determinants of health. oral and general health lie outside the direct 2011

Because oral diseases share the same risk influence of healthcare systems, comprehensive
2013
factors and determinants, there is a compelling intersectoral action is required to achieve WHO Global Action Plan
case for integrating oral health goals into improvements in health. It is imperative that oral on Prevention and Control
approaches directed at all NCDs. Furthermore, health is included in all such strategies directed of NCDs 2013–20 includes
evidence for the enormous economic and against the NCD epidemic. Every opportunity A GLOBAL MOVEMENT AND ITS nine global targets and 25
MILESTONES indicators.
social impact of poor oral health continues to should be taken to advocate for the inclusion of
UN Task Force on NCDs
accumulate. ‘Oral Health in all Policies’. established.
2011
UN General Assembly WHO Africa Regional 2015
High-Level Meeting on Consultative Meeting on WHO publishes new
Prevention and Control Oral Health and NCDs. guidelines on sugars
2004 2007 intake for adults and

CHAPTER 7 ORAL HEALTH AND THE GLOBAL AGENDA

of NCDs. WHO SEARO Regional
WHO Global Strategy on World Health Assembly NCD Action Plan – children.
2009 FDI attends UN
2000 Diet, Physical Activity and 2007 Resolution A60 recognizes oral diseases
WHO publishes consultation meeting in Country frameworks for
WHO publishes first Global Strategy Health. R17: Oral Health: Action and oral cancer.
Global Strategy to June 2011 and is action to engage
for the Prevention and Control of Plan for Promotion and
FDI contributed to the Reduce the Harmful involved in all FDI issues Policy Statement sectors beyond health
NCDs. Integrated Prevention.
consultation process. Use of Alcohol. consultation processes. on Oral Health and NCDs. on NCDs.

2000 2001 2003 2004 2005 2007 2008 2009 2010 2011 2012 2013 2014 2015 2025

2001 2003 2005 2008 2010 2012 2014 2025

Millennium WHO adopts Framework WHO FCTC WHO publishes World Economic Forum Global Risks FDI issues a guide to UN Secretary General report Attainment of the
Development Convention on Tobacco endorsed by WHA. Global Action Plan Report prioritizes NCDs. advocacy following the on progress since UN nine global targets
Goals launched. Control (WHO FCTC) on the Global NCD Alliance founded. UN High-Level Meeting High-Level Meeting. for NCDs.
WHO publishes
FDI had been part of the report: Preventing Strategy for the on NCDs. FDI answers WHO
WHO makes recommendations on the
WHO FCTC negotiation Chronic Diseases: Prevention and FDI joins the NCD consultation on draft guideline
marketing of foods and non-alcoholic
process since 1998. A vital investment. Control of NCDs Alliance common interest on sugar consumption.
beverages to children.
2008–2013. group.
First WHO Global Status report on NCDs.

82 83
 7.2

Oral health and global development

Linking and The Millennium Development Goals (MDGs) reinforce those where progress was made, STRENGTHS AND WEAKNESSES
integrating oral from 2000 to 2015 were a concerted interna- but also put new emphasis on a framework OF THE MILLENNIUM DEVELOPMENT GOALS
health with the SDGs tional effort to eradicate extreme poverty, to for integrating action across multiple sectors (2000–15)
is crucial for better promote education, health and environmental to facilitate human development in a manner
prioritization of oral protection, as well as to accelerate development that optimizes the use of planetary resources MDGS helped to: But…
diseases in the and cooperation worldwide through a set of without endangering sustainability. • Position health in • Focused the
eight agreed goals. These were supported by the development attention on
context of global Health, as a precondition and an outcome of agenda communicable
public health and a comprehensive monitoring mechanism that
sustainable development, has a central role • Focus attention and diseases and omitted
development. obliged UN member states to track progress and action on major NCDs
in the SDG context, in particular through
report regularly. Health was directly addressed health problems of • Fragmented the
Goal 3, to ‘Ensure healthy lives and promote health system
by three of the eight goals. poverty
well-being for all at all ages’, which includes • Mobilize resources through vertical
Oral diseases are linked, directly and indirectly, 13 health targets. Of these 13 targets, at least to achieve programmes “Oral
to all eight MDGs; however, this advocacy seven are of direct concern to the oral health prioritized targets • Segmented by age diseases are an obstacle
group, instead of
opportunity was not systematically used to community. • Create platforms to development. Something
adopting a
improve prioritization and integration of oral for as preventable as tooth decay
life-course approach
It will therefore be important to relate oral multi-stakeholder
health on international public health agendas. • Monitored only can impair people’s ability to eat,
health systematically to the goals of the SDGs, partnerships
national aggregate to interact with others, attend
With the MDGs expiring by the end of 2015, • Strengthen global
their indicators and targets from the outset. This indicators; did not school, or work. These
monitoring systems
the UN has put a global consultative process in will provide a framework for the systematic measure gaps in
and accountability health equity
consequences all detract from
place to take stock of the MDG achievements inclusion of oral healthcare in strengthening human wellbeing, economic
• Measured mortality
and to develop a set of Sustainable Develop- health systems, to promote oral healthcare but not morbidity potential, and development
ment Goals (SDGs) for the period 2015 to and prevention in the context of NCDs and progress.”
2030. The SDGs set new global priorities universal health coverage; and to make strong
to promote sustainable and equitable develop- advocacy arguments for cross-cutting and Helen Clark,
ment across the world. They carry forward multi-sectoral integration of oral health in Administrator of the UNDP,
3 2011
some of the unfinished MDG commitments, sustainable human development.
ORAL HEALTH SELECTED SUSTAINABLE
IS INTEGRAL TO DEVELOPMENT GOALS
R INTEGRATING ORAL HEALTH
SUSTAINABLE ES FO AND
NITI

CHAPTER 7 ORAL HEALTH AND THE GLOBAL AGENDA

T U Universal Health Coverage DEV 4 WITH A RELATION TO HEALTH
DEVELOPMENT P POR I n cl uding primary ELO
PM Status April 2015
G O H Ensure
IN ors o ra l h ea lthc ar e eal EN
US k fact r NCD
s th T healthy lives and
is e r s i a n
r t h to Cr n a d o promote 6
on and sk fac
o oss
-se ll po ral
o mm ases me ri cto
ral licie eal
h well-being for all
C ise
d e sa int s th at all ages 17
h LL RELIEVE BURD e 10
l
ra re t E A LTH WI E N ON
gr
at
Ensure
O ha H io
s RAL Economic burden DE n inclusive and
N GO di tio n s inc u r co sts to
VE
LO equitable quality
VI l co n pub li P
O Ora lth systems and economie c, O ME education and promote
Su ollec f disea rating evidence

PR NT
e s

hea s
the s enera nant
min socia alth

Ensure
rve

IM ral lifelong learning

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84 85
 7.3 v.2

Universal Health Coverage

Basic oral healthcare The concept of Universal Health Coverage LEVEL OF BASIC ORAL
should be an integral (UHC) has gained increasing attention since NORWAY HEALTHCARE COVERAGE
ICELAND
part of Universal the first related WHO resolution in 2005. In OECD countries
FINLAND 2008
Health Coverage, an WHO defines UHC as a system in which ‘all
increasingly people have access to services and do not CANADA SWEDEN 100% coverage
UK
recognized concept suffer financial hardship paying for them’. The DENMARK
51% – 99% coverage
IRELAND
aiming to ensure goal of UHC is thus to guarantee access to NETH. POLAND 1% – 50% coverage
healthcare for all and to provide financial BELGIUM GERMANY
access to basic CZECH REP.
LUX. SLOVAK REP. 0% no coverage
primary health protection. FRANCE AUSTRIA HUNGARY
SOUTH KOREA JAPAN no data
services for all. UHC alone does not eliminate inequalities, SWITZERLAND
PORTUGAL
but it is a major step towards that goal, ITALY
SPAIN TURKEY
especially when combined with other meas- MEXICO
GREECE
ures addressing determinants of health. Truly
‘universal’ health coverage will only be
achieved when promotive, preventive, curative
and rehabilitative oral healthcare are fully
integrated in the wider health system context.
Moreover, appropriate financing mechanisms
must cover all population groups, including
the most disadvantaged such as the poor,
disabled, immigrants and others.
“Universal
To date, there is no generally agreed concept Health Coverage is AUSTRALIA

or solution for the variety of national contexts, the single most

needs and resources. Countries across the powerful concept
world include dental services with varying public health has
levels of coverage, depending on their to offer.”
economic resources and political priorities. NEW ZEALAND

CHAPTER 7 ORAL HEALTH AND THE GLOBAL AGENDA

Most high-income countries are implementing Margaret Chan,
WHO Director-General, 2015
reforms to contain costs, particularly by
increasing co-payment for services deemed
non-essential, such as eye and dental care.
“Every TOWARDS UNIVERSAL COVERAGE
On the other hand, many low- and middle- member of a society Financial protection
should have healthcare Universal health coverage aims at:
income countries are trying to address health What do people
coverage. Because oral health • ‘Health for All’ – reaching have to pay
needs by providing minimum primary care Reduce cost Include
people with healthcare services out-of-pocket?
services to the majority of people covered by is integral to overall health and sharing other
who are not currently served
oral healthcare is an essential and fees services
health insurance systems and other financing • Including as many services as
mechanisms. At present a global picture of type of primary healthcare, possible, but at least basic Extend to
access to oral healthcare primary care non-
the extent of inclusion of oral healthcare
coverage should be • Reducing cost sharing and fees,
covered Coverage
services is not available. Increased focus on mechanisms
universal.” providing maximum financial
implementation and health-service research Services
protection
Which services
is required to evaluate existing Universal Scott Tomar, Professor at the University of Florida,
Population are covered?
Oral Health Care models and to guide College of Dentistry, and Lois Cohen,
Who is covered?
evidence-based policy decisions for new ones. Ambassador for Global Health Research, 2010

86 87
 7.4

Amalgam and the Minamata Convention ICELAND

INTERNATIONAL SUPPORT
ESTONIA
FOR THE MINAMATA
The Minamata Minamata disease, named after the Japanese CONVENTION
Convention on city where the neurological condition bearing As of March 2015
Mercury provides its name was discovered in 1956, is caused by UKRAINE
signed and ratified/
challenges to current severe mercury poisoning. Extreme symptoms accepted/
LIECHT.
approved/
dental practice, but it include mental retardation, paralysis, coma, SAN MARINO B-H acceded
is also an opportunity and even death. A congenital form of the PORTUGAL ANDORRA signed
for innovation and disease can also affect the unborn foetus. KAZAKHSTAN
not signed
better prioritization To address the health and environmental KYRGYZSTAN
NORTH
UZBEK. KOREA
AZERBAIJAN
of oral disease threats of mercury use, the United Nations TURKMEN.
TAJIKISTAN

prevention. Environment Programme (UNEP) initiated LEBANON AFGHANISTAN

MICRONESIA, FED. STATES OF
MARSHALL ISLANDS
NAURU
the process in 2009 to develop the Minamata BAHAMAS
GAZA
WEST BANK BHUTAN PALAU
KIRIBATI
WESTERN ALGERIA BAHRAIN QATAR
Convention on Mercury. This global, legally CUBA
SAHARA EGYPT TUVALU

HAITI ANTIGUA & SAUDI ARABIA

binding convention was adopted in 2013 and BELIZE
ST KITTS & NEVIS
BARBUDA CAPE
VERDE OMAN
MYANMAR LAOS SAMOA

DOMINICA
opened for signature. EL SALVADOR
ST VINCENT & GRENAD.
ST LUCIA ERITREA THAILAND
VANUATU
GRENADA BARBADOS FIJI
TRINIDAD & TOBAGO
The Convention’s impact on dentistry is and disposal of dental SOUTH
SUDAN TONGA
SURINAME BRUNEI
considerable because it requires the gradual amalgam; researchers to EQUATORIAL
GUINEA
SOMALIA
MALDIVES

phase-down of dental amalgam, a mercury- accelerate research and SÃO TOME DEM. REP. RWANDA
& PRINCIPE OF CONGO
containing, cost-effective metal-alloy filling development of alternative PAPUA
NEW
GUINEA
material used in restorative dentistry for products with equivalent EAST TIMOR SOLOMON
well over 150 years. Global consumption of solidity and durability, and ISLANDS

mercury for dental use reached about 8 percent dental practitioners to reduce NAMIBIA
BOTSWANA
of overall mercury consumption in 2000. While their environmental impact
amalgam use accounts for less than 1 percent through installation of amalgam SWAZILAND

of global mercury emissions, there are concerns separators and proper recycling of
that mercury can escape during manufacture, amalgam waste.
storage, disposal or recycling, from crematoria
However, the Convention also MINAMATA CONVENTION (2013)
or from dental practices, though inappropriate
provides unique opportunities for

CHAPTER 7 ORAL HEALTH AND THE GLOBAL AGENDA

disposal. Article 4 Paragraph 3 Measures to be taken by a Party to phase down the use of dental amalgam shall
atmosphere
oral health professionals to advocate for take into account the Party’s domestic circumstances and relevant international guidance and shall
50–70 The provisions of the Convention effective prevention strategies against tooth include two or more of the measures from the following list:
set challenges to: governments decay; and for policy makers to prioritize
1 Setting national objectives aiming at dental 6 Discouraging insurance policies and
for effective implementation prevention and control of oral diseases as part caries prevention and health promotion, thereby programmes that favour dental amalgam use
through regulation of of primary healthcare, so that the long-term minimizing the need for dental restoration; over mercury-free dental restoration;
total supply, import, use need for dental fillings is reduced. 2 Setting national objectives aiming at minimizing 7 Encouraging insurance policies and programmes
260–340 its use; that favour the use of quality alternatives to
tonnes/year dental amalgam for dental restoration;
3 Promoting the use of cost-effective and clinically
effective mercury-free alternatives for dental 8 Restricting the use of dental amalgam to its
restoration; encapsulated form;
recycling of 4 Promoting research and development of quality 9 Promoting the use of best environmental
dental amalgam mercury-free materials for dental restoration; practices in dental facilities to reduce releases of
sequestered, 40–50 mercury and mercury compounds to water and
secure disposal MAJOR PATHWAYS OF MERCURY 5 Encouraging representative professional
40–50 organizations and dental schools to educate and land. Dr Moryama with Mr
RELEASE INTO THE ENVIRONMENT Hannaga – a congential
train dental professionals and students on the use
surface water
DUE TO DENTAL AMALGAM USE of mercury-free dental restoration alternatives Minamata disease
soil Metric tonnes per year
groundwater 75–100 35–45 and on promoting best management practices; patient at Meisui-en
20–25 Hospital, 1991.

88 89
A Call for Global Action Chapter 8

The Challenge of Oral Disease – A call for the ability of governments to implement public
global action provides a brief account of the health planning and the development of appro-
global challenge that the burden of oral disease priate preventive and curative programmes.
presents to all countries. It also makes
It is now time for governments and policy
recommendations for action to address this
makers to respond to the global oral health
unacceptable burden and reduce the impact of
crisis and act to reduce the burden of oral dis-
these largely preventable diseases.
ease, through the implementation of evi-
The challenges associated with a rapidly grow- dence-based policies and strategies. The
ing global population, particularly in mid- current momentum in the prevention and con-
dle-income countries, exacerbated by rising trol of NCDs provides a unique opportunity for
exposure to common NCD risk factors, lead to the integration of measures to improve oral
increasing pressures on already strained health health and general health. This book outlines
systems. Despite progress and advances in some of the possible approaches to achieve
some areas, the state of the world’s oral health better recognition, integration and prioritiza-
is still characterized by neglect, low prioritiza- tion of oral diseases at the community, national,
tion and inadequate responses of governments regional and international level.
and national health systems.
All chapters of The Challenge of Oral Disease
Even in high-income countries, large segments – A call for global action provide practical rec-
of the population have limited access to oral ommendations and guidance for action. The
healthcare, so that much of the oral disease following presents the key points in a summa-
burden remains untreated. Moreover, there is a rized style, in order to facilitate advocacy and
paucity of good country-level data on the prev- ready access to the most important aspects.
alence of oral disease, especially in low- and This section may thus be used as a blueprint for
middle-income countries, which handicaps addressing challenges related to oral diseases.

91
Oral and general health – the life-course approach
screening is not recommended, but there is good evidence Cleft lip and/or palate are the most common congenital defects
Healthy primary and permanent teeth – important for Oral health and general health – closely related and to be for the screening of patients with risk factors. of the face and mouth, creating a heavy burden in terms of
health and wellbeing throughout life considered holistically • Appropriate specialist care should be part of universal health mortality, disability, quality of life and financial cost.
Oral diseases have a major adverse impact on general health The global improvement in life expectancy, and the resulting coverage, particularly in countries with high prevalence, in • Primary prevention and essential surgery services for birth
and on quality of life. A healthy and well-functioning dentition increase in the population of older people, makes a life-course order to improve patient survival rates and quality of life, as defects such as cleft lip and/or palate must be part of
is important during all stages of life to support essential human approach to oral health very important. well as to avoid catastrophic health expenditures for patients integrated health-system strengthening in low- and middle-
functions, such as speaking, smiling, socializing and eating. • The close bi-directional relationship between oral and and families affected. income countries.
• Good oral hygiene practices and professional oral care, general health provides a strong conceptual basis for the • Integrating oral cancer prevention and control into
combined with a healthy lifestyle and avoiding risks such integration of oral healthcare into general healthcare. prevention and control of cancer in the context of NCDs Trauma to orofacial structures and teeth is common and can
as high sugar consumption and smoking make it possible to • Knowledge and awareness of the close associations is required to reduce incidence and improve treatment be prevented by improving public health policies and raising
retain a functioning dentition through life. between oral and general health, and the collaboration outcomes. awareness of risks related to violence, sports and road safety.
between oral and general health professionals is important • Policies and approaches to increase road-traffic safety,
for holistic care. Other oral conditions – high combined burden and reduce violence and bullying at school, increase safety for
impacts contact sports, as well as improve post-trauma response
HIV infection may be associated with important symptoms in through appropriate emergency care are important.
the mouth, which impact the quality of life and nutrition of
those affected. The involvement of oral health professionals in Improving oral disease surveillance and data collection
The burden of oral diseases – a largely neglected reality effective multi-disciplinary care is essential. The persisting gaps in data on the prevalence of oral diseases,
• Dentists and oral healthcare professionals have an obligation and their burden and severity in different populations, means
Tooth decay – addressing the most common chronic • Implementing population-wide strategies to maintain a to provide ethical, equitable care to all patients, irrespective that awareness of the significance of these diseases is poor.
disease worldwide healthy lifestyle, with low exposure to risk factors such of their HIV status. Lack of good information creates a barrier to prioritizing their
Untreated tooth decay is the most common chronic disease as tobacco or alcohol use, along with good oral hygiene • Patients with oral manifestations should be referred for prevention and treatment, and limits the development of
and a major global public health problem, with significant and regular check-ups, are important approaches in the testing for HIV/AIDS, have appropriate medical follow-up, effective public health responses. There is thus a need for:
impacts on individuals, health systems and economies. Tooth prevention of periodontal disease. and be monitored for compliance with Highly Active Anti- • Oral health and disease indicators to be included
decay is a complex multifactorial disease, but the main reason • Early detection through regular visits to the dentist can help Retroviral Treatment. systematically in regular disease surveillance and
for its high prevalence is high sugar consumption, coupled to address the progression from mild to severe forms of epidemiological monitoring, including data on the related
with the lack of effective preventive strategies and limited periodontitis. Noma is a disease of poverty and neglect, disfiguring and killing risk factors.
access to appropriate oral healthcare. • Management and prevention of periodontal disease should mainly children in Sub-Saharan Africa. • Cancer registries to be strengthened to cover oral cancer
• Tooth decay can largely be prevented by reducing sugar be integrated into strategies for addressing other oral • Early detection, simple emergency primary healthcare effectively.
consumption, increasing appropriate fluoride use and by diseases and NCDs. This will also require increased inter- and referral to specialist care are essential to prevent rapid • Monitoring of noma, orofacial trauma and congenital
maintaining good oral hygiene. professional collaboration between oral and general health disease progression. Measures addressing poverty and malformations to be improved.
• Early detection and care may reduce the progression of the professionals. nutrition, basic healthcare and immunization of children, • Collected data to be made universally accessible and
disease to more severe forms. together with better awareness of this condition, may reduce compiled in repositories, so that they are available for
• In order to reduce the disease burden, full integration of Oral cancer – a challenge to public health in many the number of cases. research and informed policy decision making.

CHAPTER 8 A CALL FOR GLOBAL ACTION

oral health into population-wide prevention and health- countries
promotion strategies for NCD reduction is necessary, along Oral cancer is among the 10 most common cancers worldwide
with universal access to affordable fluoride and inclusion of and shows considerable regional variation. Survival rates are
primary oral healthcare in universal health coverage. low compared to other cancers due to late detection and the
complexities of appropriate care. The impacts on quality of life
Periodontal disease – a common but preventable oral for those who survive the disease can be high.
condition • Reducing the main risk factors (tobacco use and excessive
Periodontal disease is among the most common diseases of alcohol consumption) is effective in addressing the high
humankind, with close associations to general health. It is incidence of oral cancer.
largely preventable through good oral hygiene and preventive • Early detection can improve treatment outcomes through
policies addressing common determinants. timely referral for specialist care. General population-wide

92 93
Social determinants and common risk factors – the main drivers of oral diseases Inequalities in oral health – disease burden, impact and access to care
Both the general and oral health of whole populations are Tobacco use Socioeconomic status is a fundamental determinant of • Public health action on the broader determinants of health,
largely determined by social factors and their interaction with Tobacco use in all forms is harmful to health, including oral both oral and general health. Action to reduce oral health with particular emphasis on the younger generation, where
a set of common risk factors, namely sugar, tobacco, alcohol health. Dentists and their teams can effectively help patients inequalities needs to address the underlying causes of disease. inequalities in quality of life seem to be more pronounced.
and poor diet. to quit and address tobacco-related oral diseases; policies to Oral conditions have considerable impact on the quality of • Extending coverage of health insurance, and improving
• Policies and approaches aimed at reducing poverty, strengthen tobacco control include, but are not limited to: life of individuals and societies, particularly among younger the availability of oral healthcare services targeting
increasing social inclusion and improving the general levels • Protecting people from tobacco smoke, offering help to quit population groups and those with lower socioeconomic disadvantaged population groups.
of education and employment, combined with reducing tobacco use and warning about the dangers of tobacco. position. Oral diseases have considerable impact in terms • Working in partnership across relevant sectors, agencies and
barriers to healthcare, promoting affordable housing, safe • Raising taxes on tobacco products to reduce consumption. of treatment costs and productivity losses; equitable access professions, using upstream, midstream and downstream
water and sanitation, and protecting minority and vulnerable • Enforcing bans on tobacco advertising, promotion and to oral healthcare is a major public health challenge, and strategies.
groups have the greatest potential to deliver sustainable sponsorship. substantial inequalities persist between population groups and
improved health and oral health status. countries. Dental teams and their national professional bodies
• Systematically including health and oral health in all Harmful use of alcohol have an important advocacy role in promoting policies to
policies can help to reduce negative effects on health Harmful use of alcohol is a major risk factor for more than reduce health inequalities in the populations they serve. Policy
equity of policy decisions in other sectors and can 200 diseases, including oral cancer and periodontal disease, measures include, but are not limited to:
contribute to increasing synergies for better health status and must be addressed as part of a comprehensive approach to
of populations. NCDs; measures include but are not limited to: Providing oral health care and prevention
• Working effectively across disciplines and sectors has • Raising taxes on alcoholic beverages to reduce
significant potential to reduce inequalities. consumption. Dentists and the dental team – key providers of oral care • Including the dental profession in the planning,
• Tackling inequalities requires action across the whole social • Implementing and enforcing effective measures that in the wider healthcare system development and implementation of oral healthcare
gradient to deliver the greatest population-wide benefit. regulate alcohol availability as well as strict zero-tolerance Oral healthcare is best delivered by a team led and supervised services, thus ensuring the provision of equitable and
• Effective measures to reduce exposure to risk factors policies for drink driving. by dentists, and composed of oral health professionals with appropriate oral healthcare for all.
to health and oral health are a key responsibility of • Regulating, reducing or banning alcohol advertising and different skills and training, thus ensuring quality care for all.
governments in the context of protecting populations and promotion. Dentists are the principal providers of oral disease treatment Self-care and prevention through fluorides and fluoride
improving their quality of life. and prevention. Their role is changing in response to changing toothpaste
Unhealthy diet risk factors, evolving disease burdens, demographic changes, The use of fluorides for the prevention of tooth decay is safe,
Sugar consumption A healthy diet, low in sugar, salt and fat, contributes to reducing and broader health system and socioeconomic pressures. efficient and highly cost-effective. Consequently, increased
Sugar is a leading risk factor for tooth decay. Population-wide the risk of oral diseases, obesity, diabetes and other NCDs. efforts are required to promote access and use of appropriate
strategies and policies to reduce sugar consumption as part of Measures include, but are not limited to: Access to basic oral care is mandatory for everyone in all fluorides, particularly of fluoride toothpaste, in order to achieve
a healthy diet have the highest potential to promote better oral • Restricting sales, limiting serving sizes and availability, countries. It is possible even for resource-poor health systems, universal access. Among other measures, this calls for:
health. At the same time they also address diabetes, obesity and increasing taxation on unhealthy food products; and through the use of cost-effective, evidence-based interventions • Evidence-based selection of the most appropriate delivery
and other NCDs. Such policies include, but are not limited to: banning unhealthy food from the school environment. that emphasize prevention and self-care. An ideal primary method of fluorides for dental health, depending on local
• Higher taxation on sugar-rich food and sugar-sweetened • Regulation of advertising and sponsorship of food (oral) healthcare system should provide universal coverage, be contexts and resources.
beverages. manufacturers and implementing systematic consumer- people-centred, have demand-led policies and programmes, • Improving the monitoring and evaluation of population-

CHAPTER 8 A CALL FOR GLOBAL ACTION

• Transparent food labelling for informed consumer choices. friendly food-labelling regulations to facilitate informed and be integrated with general health in all policies, including wide fluoridation interventions to strengthen the
• Limiting the marketing and availability of sugar-rich foods food choices in every country. labour, environment and education. Among other measures, evidence-base for effective programme planning.
and sugar-sweetened beverages to children and adolescents. • Promoting breastfeeding following WHO recommendations this calls for: • Removal of taxation and tariffs on fluoride products, mainly
• Simplified nutrition guidelines, including sugar intake, to to improve nutrition and growth. • Embedding strategic oral health workforce planning in fluoride toothpaste in order to increase affordability;
promote healthy eating and drinking. • Promoting natural and indigenous products with good overall planning for human resources in health in order to taxation of oral health products without fluoride should be
• Strong regulation of sugar in baby foods and sugar- nutritional values over the use of processed food through reduce crucial service and access gaps. increased to discourage the use of such products.
sweetened beverages. integrated nutrition counselling. • Addressing the gap between the burden of disease and the • Improvement of capacities of national food and drug
availability of care by creating dentist-led oral healthcare administrations for better monitoring of toothpaste quality,
teams that include a flexible mix of complementary mid- as well as strengthening and enforcing the regulations of
level providers and others in the context of primary health ISO 11609, which defines the minimum standards for
care, as required by local needs and determined by local toothpaste quality and labelling.
legislation.

94 95
Challenges in dental education, care and research Oral health and the global agenda
Contemporary dental education aims at producing oral • Adequate public investments in oral and health professional The context of the international policy environment • This will provide a framework for the systematic inclusion of
health professionals equipped with the required mix of skills education are required, together with curricular and provides challenges and opportunities for better recognition, oral healthcare in strengthening health systems, to promote
and competencies to meet the needs of their patients and institutional reforms, in order to create an effective global prioritization and integration of oral health. Linking to and oral healthcare and prevention in the context of universal
populations; yet commercialism and the rapidly changing oral health workforce. using these opportunities may accelerate the process of health coverage; and to make strong advocacy arguments
context for education is challenging. Moreover, migration • Implementation of existing codes of practice for stepping-up responses on all levels to the growing global for cross-sectoral integration of oral health in sustainable
and mobility of oral health professionals and of patients pose international recruitment alongside policy options for burden of oral diseases. Relevant international developments human development.
challenges and result from complex push and pull factors. countries to facilitate effective national workforce planning, include, but are not limited to:
The positive and negative impacts on sending and receiving mitigate possible negative effects of international migration, Universal Health Coverage
countries need to be balanced through appropriate policies and monitor workforce flows more effectively. Prevention and control of NCDs Basic oral healthcare should be an integral part of Universal
and regulations. Therefore, oral health research, encompassing • Developing and coordinating international collaborative NCDs are a growing global threat. Oral diseases are integral Health Coverage, an increasingly recognized concept aiming
the full range of basic, clinical, translational and applied research priorities in order to fill essential knowledge gaps to prevention and control of NCDs. The global momentum for to ensure access to basic primary health services for all.
health-system research is essential to understand, address and in oral health. NCDs is a window of opportunity to improve oral health on a • Increased focus on implementation and health-service
evaluate the multitude of approaches needed to improve oral • A particular focus on evaluating social and behavioural global scale. This requires, among others: research is required to evaluate existing Universal Oral
health worldwide. interventions, implementation and delivery will be required • Continued advocacy for the integration of oral diseases into Health Care models and to guide evidence-based policy
• The integration of dental education with general health if the major global oral health inequalities are to be reduced. action plans for prevention and control of NCDs. decisions for new ones.
professional education is a crucial element in shaping the • Comprehensive inter-sectoral action and inter-professional
scope of practice, and scaling up the number and impact of collaboration to achieve improvements in health and oral The Minamata Convention on Mercury
oral health professionals worldwide. health. The Minamata Convention on Mercury aims at a complete
elimination of mercury from the environment, including
Oral health and global development the use in dentistry through dental amalgam fillings. The
Linking and integrating oral health with the Sustainable convention includes provisions for increased investments in
Development Goals is crucial for better prioritization of oral health promotion and prevention to reduce the need for
oral diseases in the context of global public health and restorative care. Depending on circumstances this may provide
development. for major opportunities to prioritize prevention and control of
• It will be important to relate oral health systematically to the oral disease.
objectives of the SDGs, their indicators and targets from the
outset.

CHAPTER 8 A CALL FOR GLOBAL ACTION

96 97
 Milestones in Dentistry 7000 BCE – AD 1699

7000 BCE Pakistan Stone-age cultures in Baluchistan (‘In- 659 BCE China Su Kung mentions amalgam for filling a
dus Culture’) use bow drills with flint burs to remove de- decayed tooth in his Materia Medica.
cayed tooth substance.
600 BCE – AD 400 Italy/Europe
5000 BCE Iraq A Sumerian text describes ‘tooth worms’ as The Etruscans and Romans be-
the cause of dental decay. This may be the earliest observa- come experts in restorative den-
tion of the dental pulp. tistry and make gold crowns
and fixed bridgework. Full and
2700 BCE China Acupuncture is used to treat toothache.
partial dentures are not uncom-

Annex 2660 BCE Egypt The Third Dy-

nasty tomb of Hesy-Ra, describ-
mon.
500 BCE China/India Recipes are described for a paste to
ing him as ‘the greatest of those
clean teeth.
who deal with teeth, and of phy-
sicians’, and the tombs of three 450 BCE India The process of crystallizing sugar-cane juice
other named Fifth Dynasty den- is invented.
tal specialists, all at Saqqara, re-
450 BCE Italy The Roman laws of the 12 tables bans plac-
veal early specialization.
ing gold in tombs except for gold in teeth. Bones, eggshells
and oyster shells mixed with honey are used to cleanse the
1750 BCE Mesopotamia Law 200 teeth. Aristocrats employ special slaves to clean their teeth.
of the famous code of Hammurabi states that ‘if someone
460–322 BCE Greece Scientist and philosopher Hippo-
knocks out the tooth of an equal, his own tooth is knocked
crates describes disposition, saliva and nutrition as the
out’.
causing factors for caries, contradicting the prevailing be-
1700–1550 BCE Egypt The Ebers Papyrus, a 21-metre-long lief that tooth worms are causing disease. Aristotle writes
text, describes extensively the knowledge and treatment of about dentistry, including the eruption pattern of teeth,
dental diseases of the time. treating decayed teeth and periodontal disease, extracting
teeth with forceps, and using wires to stabilize loose teeth
900–300 BCE Americas The Ma-
and fractured jaws. However, he wrongly believes that
yans implant semi-precious stones
male humans, sheep, goats and pigs have more teeth than
such as jade in teeth for cosmetic
females.
and cultural reasons. Front teeth
are filed into different shapes to re- 50–25 BCE Italy Roman medical writer Aulus Cornelius
semble sharp animal teeth. Celsus summarizes contemporary knowledge of medicine
and writes about oral hygiene, stabilization of loose teeth,
treatment for toothache and tooth replacement. He stresses
the great care needed when extracting teeth, and describes
the method to reset a dislocated mandible still used today.
700 BCE Myanmar Teeth 174 AD Italy Galen, the personal physician to Emperor
found in the Halin area show Marcus Aurelius, collects all knowledge and his own re-
gold-foil fillings probably search about medicine, including oral diseases. He states
made for cultural or ceremoni- that ‘Soon there will be more doctors than parts of the body
al reasons. and each disease will have its own doctor.’

99
 Milestones in Dentistry 1700–1899

650 India Indian author Vagbhata describes 75 oral 1500 The Caribbean Sugar-cane plantations are established 1728 France Dentist Pierre Fau- 1776 UK Joseph Priestley synthe-
diseases. in the new colonies, particularly in the Canaries and the chard, credited as the father of sises nitrous oxide, later known as
West Indies. modern dentistry, describes in his laughing gas. By the 1840s its nar-
500–1000 Europe During the Middle Ages, medicine, sur-
book Le Chirurgien Dentiste, ou cotic and pain-numbing properties
gery, and dentistry are generally practised by monks, the 1530 Germany The first book devoted entirely to dentistry,
Traité des Dents a comprehen- are used by dentists and surgeons
most educated people of the period. While knowledge The Little Medicinal Book for All Kinds of Diseases and In-
sive system for the practice of in particular.
from Roman and Greek times has been lost, new folk med- firmities of the Teeth, is published. It covers practical topics
dentistry, including basic oral
icine emerges with many doubtful practices, such as blood- such as oral hygiene, tooth extraction, drilling teeth, and
anatomy and function, operative
letting. placement of gold fillings. It is a standard textbook for more
and restorative techniques, and
than 200 years. The last edition of the book is published in
963–1013 Spain Abù I-Qàsim (Abulcasis), an Arab surgeon denture construction. He also
1756.
from Spain, recovers the dental knowledge of the Gre- opposes the contemporary belief
co-Roman world, and editions of his work circulate widely 1533–1603 England Queen Elizabeth I fills the gaps in her in tooth worms as the cause of
in Europe, some carrying fine illustrations of dental instru- dentition with cloth to improve her appearance in public. caries. His work is translated into 1780 UK William Addis starts semi-mass production of the
ments for scaling, cautery of the pulp, and extraction. English only in 1946.
1575 France Ambrose Paré, known as the Father of Surgery, modern toothbrush
980–1037 Iran/Uzbekistan Physi- publishes his Complete Works, which includes practical in- 1746 France Claude Mouton describes a gold crown and 1783 UK Robert Woofendale links sugar consumption to
cian and philosopher Ibn Sinà, formation about surgery, such as tooth extraction, the treat- post to be retained in the root canal. decay in the second teeth of children.
also known as Avicenna, de- ment of tooth decay and jaw fractures. He also performs the
1756 Germany Philipp Pfaff, the dentist of the Prussian King 1790 USA One of George Washington’s dentists, John
scribes medical knowledge of the first cleft-lip surgery.
Frederick II, introduces to Paris the use of wax and plaster Greenwood, constructs the first known dental foot engine.
time and covers dental diseases
1664 onwards UK/Italy/Holland At Oxford, and in London to take an impression. This greatly improves the fitting of
and treatment as well. His writ- He adapts his mother’s foot treadle spinning wheel to rotate
in the new Royal Society, the discoveries of the innervations dentures. Like Pierre Fauchard, he establishes standards for
ings influence European medical a drill.
of the teeth and jaws by Willis, of the microscopic appear- dental care and pushes dental practice to new levels.
thinking throughout the Middle 1790 USA Josiah Flagg, a dentist, constructs the first chair
ance of the teeth and of the living and inanimate bodies to
Ages. 1760 onwards France/UK/USA Dentists commence school made specifically for dental patients.
be observed in dental calculus by van Leeuenhoek, and of
visits and are appointed to orphanages and public health
the capillaries by Malphigi and more were published, as 1791 France Nicolas Dubois de Chemant receives the first
institutions. They are listed under ‘dentist’ or ‘dentiste’ in
true science came to dentistry. Van Leeuwenhoek identifies patent for porcelain teeth.
public registers and directories.
1258 France A Guild of Barbers is established. Barbers some ‘tooth worms’ sent to him as cheese mites.
eventually evolve into two groups: surgeons, who are edu- 1768 UK Thomas Berdmore noted the clear link between 1795 USA Increased cancers of the lip are reported in pipe
1685 UK Charles Allen publishes his book The operator for smokers by Samuel Thomas von Soemmering.
cated and trained to perform complex surgical operations, sugar, eating sweet things, and dental decay.
the teeth which goes into three editions and incorporates
and lay barbers, or barber-surgeons, who perform more 1815 USA Levi Spear Parmly, a New Orleans dentist, is
the recent discoveries, and some of his own, setting UK 1771 UK John Hunter’s Natural History of the Human Teeth
routine hygiene services, including shaving, bleeding and credited as the inventor of modern dental floss (a piece
dentistry on a scientific theoretical base. is published, together with A Practical Treatise on the Dis-
tooth extraction. of silk thread); although threads used as floss have subse-
eases of the Teeth. One experiment appeared (incorrectly)
1687 France King Louis XIV undergoes an extraction of an quently been found in prehistoric sites.
1280 China Medicine is divided into 13 specialisms, to validate transplanting teeth. This practice, supported by
upper molar that results in a jaw fracture and perforation of
among them dentistry. Fauchard, had been condemned by Allen in 1685 as ‘rob- 1815 UK Teeth from the 50,000 sol-
the maxillary sinus. The subsequent infection and further
bing Peter to pay Paul’; and by Pfaff in 1756 and Berdmore diers killed in the battle of Waterloo

ANNEX MILESTONES IN DENTISTRY

1400s France A series of royal decrees prohibits lay barbers treatments leave the king without upper teeth for the rest
in 1768 for the transmission of disease, especially venereal. are taken out and used to fabricate
from practising all surgical procedures except bleeding, of his life.
cupping, leeching, and extracting teeth. 1776 USA In one of the first known cases of post-mor- dentures, known as ‘Waterloo teeth’.
1690 USA Sugar-cane cultivation begins. Even though the use of porcelain
tem dental forensics, Paul Revere, a dentist and patriot of
1498 China A toothbrush with bristles is first described. teeth and new materials become
the independence wars, verifies the death of his friend by
identifying the bridge he constructed for him. more widespread, extracted human teeth are used until the
1860s to make dentures.

100 101
 Milestones in Dentistry 1900–2004

1817–21 UK/USA Levi Spear Parmly, in a move away from 1872 USA The first pedal-powered dental engine, manu- 1900 France The Fédération Dentaire Internationale (FDI) is 1921 New Zealand Training for what became Dental Ther-
traditional apprenticeship, advertises his Dental Institution factured by James B. Morrison, is sold at a dental meeting formed in Paris by French dentist Charles Godon. apists started in New Zealand.
in London to young men and women wishing to train as in Binghamton, New York. Morrison’s inexpensive, mech-
1901 France The FDI Commission on Public Dental Hy- 1926 USA William J. Gies publishes a report on the state
dentists. anized tool supplies dental burs with enough speed to cut
giene is established. of dental education in the USA, criticizing poor standards
enamel and dentine smoothly and quickly, revolutionizing
1832 USA James Snell invents the first reclining dental and calling for an academic, university-affiliated dental
the practice of dentistry. 1903 USA Charles Land devises the porcelain jacket crown.
chair. education.
1873 USA Colgate mass-produces toothpaste in jars. 1905 Germany Alfred Einhorn, a chemist, formulates the
1839 USA The American Journal of Dental Science is pub- 1926 USA During the FDI Annual World Dental Congress
local anaesthetic procain, later marketed under the trade
lished as the world’s first dental journal. 1874 UK The British government, under prime minister in Philadelphia, a resolution is adopted recommending all
name Novocain and commonly used in dentistry.
Gladstone, abolishes taxation on sugar, thus making it af- governments to establish the position of a Chief Dental
1839 USA Based on an earlier
fordable by the general population. 1905 USA Irene Newman be- Officer.
German discovery, Charles
Goodyear develops vulcanized 1875 USA The first electric dental drill is patented by comes the first dental hygienist 1937 USA Alvin Strock inserts the first Vitallium dental
rubber, a material that allows for George Green. and engages in oral health pro- screw implant.
cheap and well-fitting dentures. motion for children.
1884 Austria The first local anaesthetic used in dentistry, 1938 USA The nylon toothbrush, the first made with syn-
This material was replaced by
cocaine, is introduced by the ophthalmologist Carl Koller. thetic bristles, appears on the market, leading to the grad-
acrylic resin in the 20th century.
ual replacement of animal hair in toothbrushes.
1890 Germany American scientist Wil-
1839 USA The world’s first dental school, the Baltimore
loughby Miller establishes the microbial 1908 USA G.V. Black publishes his monumental two-vol- 1938 USA The DMFT index is first used for a large pop-
College of Dental Surgery, opens. Dental schools are
basis of dental decay and initiates discus- ume treatise Operative Dentistry, which remains the essen- ulation study on caries in the USA by Klein, Palmer and
opened in Berlin in 1855, London in 1858, Paris in 1880,
sion of what was to become the ‘focal tial clinical dental text for 50 years. Black later develops Knutson.
Geneva in 1881, Stockholm in 1888 and Vienna in 1890.
infection’ debate with his description of techniques for filling teeth, standardizes operative proce- 1940s USA Trendley Dean determines the ideal level of
1840 USA The American Society of Dental Surgeons, the bacteria in the dental pulp. Belief in den- dures and instruments, develops an improved amalgam, fluoride in drinking water to substantially reduce decay
world’s first dental society, is founded. tal sources of infection being responsible and pioneers the use of visual aids for teaching dentistry. without mottling.
for diseases elsewhere in the body reached excessive levels
1841 UK John Tomes publishes the principles of anatom- 1910 USA The first formal training programme for dental
in the 1920s, but is now the subject of rational investiga- 1945 USA The water fluoridation era begins when the cities
ic forceps design for tooth extraction. Surgical instruments nurses is established. The programme is discontinued in
tion, particularly in association to periodontal disease. of Newburgh, New York, and Grand Rapids, Michigan, add
based on his concepts are still used today. 1914, mainly due to opposition by dentists. sodium fluoride to their public water systems.
1895 UK Lilian Lindsay becomes the first British woman to
1846 France/USA The collapsible tube, made out of lead 1914 USA Dental hygienists are introduced and named
gain a Licence in Dental Surgery (LDS). 1949 Switzerland Oskar Hagger, a chemist, develops the
or tin, is invented in both countries. It is only in 1896 that by Dr Fones. The first class graduates in Bridgeport first system of bonding acrylic resin to dentin.
toothpaste starts to be sold in collapsible tubes in the USA 1896 Germany/USA Wilhelm Roentgen, a physicist, dis- Connecticut.
and Germany. covers the x-ray. The first x-ray images of teeth and jaws 1949 New Zealand John Patrick Walsh patents a dental
are taken in Germany only three months later. In the USA, 1919 USA/Germany The company Rit- drill driven by compressed air, thereby reaching very high
1847 Hungary Ignaz Semmelweiss identifies the risk of ter presents a dental unit, combining
C. Edmond Kells takes dental x-rays eight months later. He speed.
cross-infection between patients. drill, pressurized water, air, cauteriza-
develops recurring cancer on his fingers and arm due to
tion and light. Other companies fol- 1951 France FDI passes its first resolution supporting fluo-
1866 USA Lucy Beaman Hobbs gradu- the constant exposure to radiation. After enduring 42 oper-
ride for caries control.

ANNEX MILESTONES IN DENTISTRY

ates from the Ohio College of Dental Sur- ations, resulting in arm and shoulder amputation, he com- low, and standards for dental surgery
gery, becoming the first woman in the mits suicide in 1928. equipment are established. 1951 Switzerland The World Health Assembly of the World
world to earn a dental degree. Health Organization (WHO) decides to incorporate a den-
1898 USA Johnson & Johnson is the first company to patent 1920s France The cord-driven Doriot tal programme in WHO activities.
dental floss. arm, developed by the Parisian dentist Constant Doriot, be-
comes the standard to transfer the power of the electrical 1954 Switzerland The first electrical toothbrush is manufac-
1870 Japan The practice of blackening 1899 USA Edward Angle classifies the various forms of
engine to the drill and bur. It is joined by the high-speed tured. In the early 1960s, cordless models are developed.
the teeth of women of higher classes as a malocclusion. His classification system is still used to de-
sign of marital fidelity, known since the 4th century AD, is scribe how crooked teeth are. air-rotor drill of Walsh and Borden in 1957, and replaced by 1955 USA The first fluoride toothpaste is introduced.
banned. Some caries protection may have resulted from the the Siemens micro-electric motor and air motors from 1965.
painting of the teeth.

102 103
 Milestones in Dentistry 2005–2015

1957 USA At the FDI’s Annual World Dental Congress 1990s USA New tooth-coloured restorative materials, plus 2005 Switzerland The WHO Framework Convention on To- celebrated every year on 12 September (birthday of FDI’s
in Rome, the American John Borden introduces his high- increased usage of bleaching, veneers and implants inau- bacco Control (FCTC) comes into force, using international founder Charles Godon and date of the historical Alma-Ata
speed air-driven handpiece. gurate an era of aesthetic dentistry. law to improve public health by requiring governments to conference on Primary Health Care). In 2013 the com-
implement proven methods of reducing tobacco use. memorative day was moved to 20 March.
1957 USA Dentsply introduce the ultrasonic scaler. 1990 Canada The phrase ‘Evidence-Based Dentistry’ (EBD),
adopted from evidence-based medicine (‘the integration of 2005 France The joint FDI/WHO 2009 France First edition of the Oral Health Atlas is pub-
1960s Sit-down, four-handed dentistry (dentist and assis-
best research evidence with clinical expertise and patient publication Tobacco or Oral Health lished by FDI.
tant), with the patient lying almost flat, becomes popular.
values’ is adopted as a synthesis of rational and scientific is published in six languages.
This technique improves productivity and shortens treat- 2011 USA The UN adopts the Political Declaration of the
practice of dentistry.
ment time. High-Level Meeting of the General Assembly on the Pre-
1994 Switzerland/UK WHO and FDI declare the year 1994 vention and Control of Non-communicable Diseases, rec-
1960s Europe Lasers are developed and approved for
the ‘International Year of Oral Health’, dedicating World ognizing the major health burden oral disease poses for
soft-tissue procedures.
Health Day on 7 April to oral health. many countries.
1961 USA/USSR Space dentistry is established as a disci-
1997 USA FDA approves the Erbium-YAG laser, the first for 2012 Switzerland FDI publishes its guidance document Vi-
pline. During extended stays in a zero-gravity environment,
use on dentin, to treat tooth decay. sion 2020: Shaping the future of oral health.
astronauts rapidly lose bone density, which can lead to 2006 France/Switzerland An expert consultation convened
tooth loss. 2000 France During the FDI’s Annual by WHO, FDI and IADR recognizes access to appropriate 2013 Switzerland The Minamata Convention on Mercury is
World Dental Congress in Paris the fluoride as a human right. adopted by UNEP to reduce mercury pollution.
1962 USA Rafael Bowen develops a thermoset resin com-
centennial of the organization is cele-
plex used in most modern composite resin restorative 2007 Switzerland The Ministers of Health of 193 countries 2015 Switzerland WHO publishes the Guideline: Sugars
brated; France’s President Jacques
materials. adopt the first resolution on oral health for 26 years during intake for adults and children.
Chirac receives the FDI Council on
the 60th World Health Assembly in Geneva, calling for re-
1965 Germany The first micromotor handpiece is presented this occasion at the Elysée Palace. 2015 Switzerland FDI publishes
newed attention to oral health worldwide.
by Siemens, finishing the era of the Doriot arm. The Challenge of Oral Disease: A
2008 Switzerland The first World Noma Day is celebrated call for global action, the second
1971 Germany Based on an earlier suggestion of the Ger-
in Geneva on the occasion of the World Health Assembly. edition of the Oral Health Atlas.
man Professor Joachim Viohl, the FDI two-digit tooth nota-
WHO, FDI and other organizations alert the world to this
tion is introduced as a worldwide standard. 2001 France FDI establishes the World Dental Develop-
forgotten disease of poverty.
ment & Health Promotion Committee in order to respond
1975 Germany Articain is introduced as a standard sub-
to the growing disparities in oral health worldwide. 2008 France FDI declares World Oral Health Day, to be
stance for local anaesthesia in dentistry.
2002 USA The landmark report Oral Health in America: A
1980s Sweden Per-Ingvar Brånemark describes techniques
report of the Surgeon General is published.
for the osseointegration of dental implants and lays the
foundation for dental implantology. 2003 Switzerland/France/USA Global Goals for Oral
Health by 2020 are established jointly by WHO, FDI and
1980 Europe The first European Union Dental Directive
IADR.
harmonizes training in European schools, enabling dental
graduates to work anywhere in the EU. 2004 Kenya The first Conference for Oral Health in Africa is
organized by FDI and WHO in Nairobi. The Nairobi Decla-

ANNEX MILESTONES IN DENTISTRY

1981 Switzerland/UK WHO and FDI jointly declare
ration on Oral Health in Africa recognizes oral health as a
‘Global Goals for Oral Health by the Year 2000’.
basic human right for the first time.
1980s World Concern about the spread of new infections
leads to an intensive review of dental procedures, equip-
ment, disposables and sterilization protocols, all designed
to eliminate the possibility of cross infection.

104 105
Comments on data and sources since the information on periodontal disease in the WHO Oral 3. Oral Diseases and Risk Factors
Health Country/Area Profile Programme is even more limited and
outdated than the data for tooth decay. 42–43 Sugar
Collecting data on health is a complex undertaking that requires 2 Oral Diseases and Health The map data are based on statistics published by FAO. These sta-
an appropriate and agreed indicator framework, as well as a health 26–27 Oral cancer tistics show the availability for human consumption of each food
system that includes reliable surveillance systems and is able to 16–19 Tooth decay Age-standardized incidence for oral cancer was sourced from item. The map data includes both, sugars and sweeteners, which,
report data regularly. Moreover, political support to allocate suffi- the International Agency for Research on Cancer, which is a sub- according to FAO’s definition, comprise the following: fructose
Despite tooth decay being the most widespread chronic disease
cient resources to statistical analysis and commitment to transpar- sidiary agency of WHO. Their GLOBOCAN database developed chemically pure, maltose chemically pure, maple sugar and syr-
on the planet, the lack of reliable data is striking. Data used for
ency for open access is required. Much progress has been made in the latest available estimate figures for the year 2012. Full de- ups, sugar crops, other fructose and syrup, sugar, glucose and dex-
the map is drawn from the WHO Oral Health Country/Area Profile
collecting data on general health and health systems performance. tails of GLOBOCAN data sources and methods are available at: trose, lactose, isoglucose, beverage non-alcoholic; nutrient data
Programme, which is, to date, the only available international re-
Yet, all areas of data collection related to oral health, oral health http://globocan.iarc.fr/Pages/DataSource_and_methods.aspx only: molasses. These figures thus include both table sugar (added
pository of data for epidemiological data on oral health, especially
systems and oral health programme performance are significantly by the consumer on home-cooked products) and sugars used by
tooth decay. However, the data available are often out of date: only The GLOBOCAN 2012 database uses the ICD10 code C00-C08
lagging behind. the industry and added to processed foods.
15% of countries around the world have published new data in the to define oral cancer. This definition includes the following cancer
Initiatives from WHO, the European Union and others to integrate last 5 years; 20% in the past 5–10 years; 35% more than 10 years localizations: lips, tongue and floor of the mouth, gingiva, palate, The Sugar facts infographic has statistics on sugar consumption
appropriate oral health indicators in routine health data surveys ago, and almost 1 in 3 countries worldwide has no reliable data salivary glands and other oral mucosa areas. which are estimates based on the FAO statistics cited above.
are welcome steps in the right direction that have yet to be im- available. More information on available oral health data, includ- WHO-recommended daily sugar intake for children and adults is
plemented at a national level in many countries. Including key ing maps and tables, can be found at the FDI Data Hub for global based on the WHO Guideline: Sugars intake for adults and chil-
30–31 HIV/AIDS and oral health
oral health data in international health statistics is a task still to be oral health (www.fdiworldental.org/data-hub) – FDI’s online plat- dren published in 2015. Sugar content per 100g of various foods
form collating all available oral health data into a single resource. The map is based on the latest available data from the WHO Global
tackled on a broader scale. is based on information available from the UK National Health
Health Observatory and shows the estimated%age of the popula-
Furthermore, many datasets do not rely on a national survey and Service. It is important to note that sugar content of different prod-
Most maps and graphics in this atlas reflect averages from disparate tion aged 15–49 who were HIV-positive in 2011. However, the data
are thus not representative for an entire country, but rather pres- ucts can vary between countries, as well as between brands. Sugar
datasets of varying coverage and quality. Averages, unfortunately, from following the following countries did not come from WHO,
ent data from only one region, city or village. Differences within amounts presented are thus only indicative.
obscure significant differences from the mean and may paint a ros- but from the 2011 UNAIDS AIDSinfo database: Bangladesh, Czech
ier picture for some countries than may exist for significant portions countries, i.e. between rural and urban or different socioeconomic Republic, Egypt, India, Maldives, Mongolia, Serbia, Sri Lanka, Tuni-
of their respective populations. Those averages may consequently strata, are not reflected at all in this data. The focus of the data is sia and Uzbekistan. These countries were included to complete the 44–45 Tobacco
also obscure existing inequalities, needs for future data collection, on children aged 5–6 or 12–15 years; data for other age groups are latest available information for the world map. Data on global cigarette consumption and facts of the infographic
as well as associated recommendations for action. not comprehensively gathered or reported. Despite WHO’s defi- were used from The Tobacco Atlas (fourth edition) with permission
nition of survey standards in its publication Oral health surveys: 32–33 Noma of the American Cancer Society.
Some of the data sources used throughout this atlas are outdated, Basic Methods, its fifth edition published in 2013, researchers and
unreliable or not comprehensive in coverage. Yet, they are still the Currently, there are no reliable global data on noma and there-
governments are free to follow all or some of the guidance, or 48–49 Diet
best available. Is it better to have no data than information that is fore no map presenting prevalence or incidence could be devel-
do things differently all together. This makes comparison between
more than 10 years old? This question is difficult to answer. Re- oped. Available estimations are generally based on the number of Data on Body Mass Index (BMI) were chosen to illustrate one of
studies challenging.
searching the data revealed astonishing gaps in data availability noma cases referred for treatment, which are dependent on reli- the main consequences of an inappropriate diet. The data are from
and quality, ignorance of existing oral health indicators when de- The figure illustrating the number of people affected by common able systems of medical records and health facility reporting. It the WHO Global Health Observatory and present the percentage
veloping national surveillance frameworks, or simply absence of diseases used data from the Global Burden Disease Study (2010), has previously been estimated that only 10%–15% of noma cases of people aged 20 years or more with body mass index of 25 or
any data at all. On the other hand, for many countries, generally as well as information obtained from the International Diabetes are referred for treatment and that the mortality rate was 80–90%. more, including the categories of overweight and obesity.
high-income countries, data with acceptable quality exist. In order Federation. Untreated decay of primary and permanent teeth was Based on these assumptions, WHO estimated the total number of
for this gap to be addressed, significant conceptual, political and calculated as follows: prevalence of untreated decay of primary cases worldwide per year to be at 140,000 in 1994 and about 4. Oral Diseases and Society
financial efforts are required. However, despite the shortcomings teeth was obtained by dividing the estimated number of children 42,000 in 2006. More recent figures are not available.
of some underlying data, the sources used are generally the best affected, as per GBD study (dental caries of deciduous teeth), by 52–53 Inequalities in oral health – Oral health status
available; and the maps highlight key issues in oral health that the number of children aged 0–12 years according to 2010 world 34–35 Congenital anomalies The London map is based on the UK’s index of multiple depriva-

ANNEX COMMENTS ON DATA AND SOURCES

require international attention and action. After all, even the ab- population statistics. Prevalence of untreated decay of permanent tion, which integrates seven aspects of deprivation: income; em-
The incidence rates of orofacial clefts per world regions were
sence of data constitutes information and is a fact worth noting. teeth was calculated by dividing the estimated number of adoles- ployment; health deprivation and disability; education skills and
sourced from Mossey et al, 2012. Incidence rates for different ethnic
Where no data was available, the country’s name on maps is not cents and adults affected, as per GBD study (dental caries of per- training; barriers to housing and services; crime; living environ-
groups were taken from Gundlach K et al, 2006. The incidence data
displayed. manent teeth), by the number of people aged +12 years according ment. It is used with permission of The Guardian’s Data Blog. The
are expressed as average number of birth defects per 100,000 live
to 2010 world population statistics. World population statistics map was merged with data called ‘Lives on the Line’, created by
Although all possible efforts were made to present the most recent births. Some terminology relating to ethnic groups was modified.
were obtained from the United States Census Bureau. the University College London, displaying how life expectancy dif-
and reliable data, errors and omissions will occur. We welcome The ‘Asian’ group does not include data from Japan or Mongolia.
fers from tube station to tube station. The data showing the caries
suggestions and comments on specific data aspects and accuracy,
22–23 Periodontal disease 36–37 Oral trauma prevalence of 5-year-old children of selected London boroughs is
but encourage all to read the following remarks first, outlining the
The map on severe chronic periodontitis is based on data from the based on NHS data from 2012 (Muirhead V et al, 2013).
source and limitation of specific data. After all “No one loves the Statistics for the main causes of oral trauma were sourced for Eu-
messenger who brings bad news”! (Antigone, Sophocles, Greek Global Burden of Disease Study and shows estimates of prevalence
rope from: Boffano P et al, 2015; and for Rwanda from: Majambo Data on edentulousness is drawn from Guarnizo-Herreño et al,
tragedian, 496–406 BCE). for the year 2010 (Kassebaum et al, 2014). This study relies on
M et al, 2013. Although both studies differ in methodology and 2013. Countries were grouped according to Ferrera’s welfare re-
an extensive systematic literature review which includes a total of
scope, they provide a revealing comparison as to the proportion of gime typology (Scandinavian, Anglo-Saxon, Bismarckian, and
72 studies, covering 291,170 individuals aged 15 or more in 37
different causes of oral trauma. Southern) and the additional Eastern regime. The Scandinavian
countries (from 16 of the 21 regions and all 7 super-regions). This
regime includes Sweden, Finland, and Denmark; the Anglo-Saxon
recent and large-scale study was selected as source for the map,
includes the UK and Ireland; the Bismarckian regime includes

106 107
Austria, Belgium, France, Germany, Luxembourg, and the Neth- WHO about the density of oral health personnel (called dental per- countries participating in the World Health Survey 2002–2004. 7. Oral health on the global agenda
erlands; the Southern regime includes Greece, Italy, Portugal, and sonnel by WHO, and including dentists, auxiliaries and lab tech- The information is based on a questionnaire survey that was part
Spain; and the Eastern regime includes Czech Republic, Estonia, nicians for some countries). These are the professionals available of a bigger survey. 80–81 Oral health and NCDs
Hungary, Poland, Slovakia, and Slovenia. Social policy in each of to address the burden of oral disease. For simplicity the burden is
The data for the map showing deaths due to NCDs – age-standard-
these five social models has different characteristics in terms of ex- expressed in DALYs and calculated using data for untreated decay 66–67 Prevention of tooth decay – Fluorides ized death rate (per 100 000 population), both sexes, 2012 – were
penses on social support, employment, principal source of financ- of deciduous and permanent teeth, as well as severe periodontal
Information on global fluoride use was based on estimations made taken from the WHO Global Health Observatory. Estimates of the
ing, levels of poverty, re-distribution and private provision of social disease, thus capturing the oral diseases with the highest burden
for the year 2000 by Rugg-Gunn, 2001, but was updated where cost of action versus inaction in low- and middle-income countries
support (for more information see Popova & Kozhevniova, 2013). (Kassebaum et al, 2014 & 2015).
more recent estimations had been made. Care should be taken were retrieved from a report commissioned by WHO and issued
The graphic presented shows that levels of edentulousness have
This metric particularly highlights areas with high disease burden in interpreting this data, since populations might be benefiting si- by the World Economic Forum in 2011. An additional report pub-
similar patterns in people with similar professional and education
and low provider numbers. A given value should be seen in rela- multaneously from multiple sources of fluoride. Thus, for example, lished at the same time estimates that the global cost of NCDs,
background, irrespective of the type of healthcare system in place
tion to other countries and to other indices. The ratio also shows the majority of those who are exposed to fluoridated water are including mental illness, will amount to US$ 47 trillion in the time-
in the country they live in.
the importance of curbing the disease burden, rather than increas- probably also benefiting from the use of fluoride toothpaste. A sim- span 2010–2030 (Bloom et al, 2011).
ing the provider levels, as the only realistic way of addressing oral ple summation of the number of people using different modes of
54–55 Inequalities in oral health – Impact of oral diseases The timeline synthesizes milestones and other NCD-related events
disease. Full details of the new metric, including methodology, fluoride delivery therefore cannot provide a reliable estimate of the
from different sources and is not intended to be comprehensive.
What is meant by ‘Disability Adjusted Life Years (DALYs)’? As per interpretation and application will be available in a forthcoming number of people globally benefiting from fluoride. The data for
WHO definition, one DALY can be thought of as one lost year of scientific paper. water fluoridation were used with permission of the British Fluori-
‘healthy’ life. The sum of these DALYs across the population, or the dation Society from their publication One in a Million, 2012. 84–85 Oral health and global development
burden of disease, can be thought of as a measurement of the gap The ratios of male/female dentists were provided by the respective The editorial deadline of the Oral Health Atlas was April 2015.
national member associations of the FDI World Dental Federation. Information on other methods of fluoridation are even scarcer and
between current health status and an ideal health situation, where At this point, the Sustainable Development Goals were still under
oftentimes rely on estimations (as indicated in the text – data on
the entire population lives to an advanced age, free of disease and negotiation and not finally approved. The wording was chosen ac-
62–63 Provision of healthcare – Dental team salt fluoridation from 2013, other fluoridation methods 2001). The
disability. DALYs for a disease or health condition are calculated cordingly to cover for possible reviews and changes.
lack of reliable usage information is in stark contrast to the impor-
as the sum of the Years of Life Lost (YLL) due to premature mor- Statistics on dentistry personnel stem from the WHO World Health
tance of fluorides in the prevention of tooth decay.
tality in the population and the Years Lost due to Disability (YLD) Statistics 2014, which covers the years 20062013. For countries 88–89 Amalgam and the Minamata Convention
for people living with the health condition or its consequences. for which no recent data is available, however, older data is pro- Data for the map illustrating the number of signatory parties to the
Data used for the map illustrating the burden of oral conditions vided as follows: Antigua and Barbuda 1997, Somalia 1997, Haiti
68–69 Prevention of tooth decay – Fluoride toothpaste
Minamata Convention was sourced from UNEP and reflects the
are taken from the Global Burden of Disease Study (Marcenes et 1998, United States of America 2000, Honduras 2000, Papua New Data about the toothbrushing habits are coming from a study in-
status as of April 2015.
al, 2013). Data for the figure illustrating the impact of household Guinea 2000, Greece 2001, Venezuela (Bolivarian Republic of) volving 20 countries (Honkala et al, 2015). Data on the annual
income on oral-health related quality of life is taken from Sanders 2001, Saint Kitts and Nevis 2001, Dominica 2001, Saint Vincent cost of fluoride toothpaste in terms of the number of days of house-
et al, 2009. Finally, data for the figure illustrating the effect of edu- and the Grenadines 2001, Paraguay 2002, Saint Lucia 2002, An- hold expenditure were based on a study conducted by Goldman
cation on perceived oral health is adapted from Guarnizo-Herreño dorra 2003, Portugal 2003, Spain 2003, Netherlands 2003, Dem- et al, 2009. Annual average consumption in their calculation was
et al. (2014) ocratic People’s Republic of Korea 2003, Nicaragua 2003, Lesotho based on 182 g/person.
2003, Ethiopia 2003, Seychelles 2004, Argentina 2004, Italy 2004,
56–57 Inequalities in oral health – Access to oral healthcare Philippines 2004, Ireland 2004, Mauritius 2004, Suriname 2004, 6. Oral Health Challenges
The figure ‘Price of neglect’ is based on data from Maiuro L, 2009. Sao Tome and Principe 2004, Gabon 2004, Comoros 2004, Equato-
rial Guinea 2004, Botswana 2004, Angola 2004, Nepal 2004, Mo- 72–73 Challenges in education
Data illustrating the cost of a range of diseases in 27 European zambique 2004, Eritrea 2004, Congo 2004, Democratic Republic The statistics of dental schools worldwide are based on the In-
countries were obtained from various sources and studies, all listed of the Congo 2004, Burundi 2004, Chad 2004, Barbados 2005, Iran ternational Federation of Dental Educators Association’s (IFDEA)
in the reference section. Data were obtained for cardiovascular (Islamic Republic of) 2005, Solomon Islands 2005, China 2005, datapool. In most countries, the number of dental schools has re-
disease (Nichols M et al, 2012); cancer (Luengo-Fernandez R et Uganda 2005, Guinea 2005. mained stable over the last 10 years, particularly in high-income Abbreviations used in book
al, 2013); Alzheimer’s disease (Wimo A et al, 2009); lung disease countries; whereas on specific countries, such as Brazil, India, DALYs Disability Adjusted Life Years
(European Respiratory Society, 2012); diabetes (IDF, 2013); brain Moreover, these WHO statistics include not only dentists, but also
Pakistan and others, the number of dental education institutions DMFT Decayed, Missing, Filled Teeth
disorders – including multiple sclerosis, neuromuscular disorders dental nurses, hygienists and dental laboratory technicians. Among
has increased significantly, mainly due to a boom in private dental
and stroke (Olesen J et al, 2012); and the cost of oral disease (Eaton all statistics for health professionals from the WHO World Health FDI FDI World Dental Federation
schools.
K, 2012). Statistics 2014, only the ‘dentist’ category uses such an undifferen- MDGs Millennium Development Goals
tiated approach, while figures for physicians, nurses and pharma-
74–75 Challenges of global migration NCDs Noncommunicable diseases
cists are well separated. The reason for this difference in statistical
5. Oral Diseases: Prevention and Management OECD Organisation for Economic Cooperation and
recording is unclear. Due to variability of data sources, the pro- There is virtually no data on international migration of dentists,
fessional-level and associate-level occupations may not be distin- despite considerable international effort to collect data on migra- Development
60–61 Provision of healthcare – Dentists
guishable for all countries since they were not reported separately. tion of other health professionals. This may be due to the overall

ANNEX ABBREVIATIONS
SDGs Sustainable Development Goals
The traditional way of assessing workforce levels in a country is to
Figures presented may thus overestimate the available workforce small volume of dentist migration, yet for smaller countries mi- UHC Universal Health Coverage
calculate the ratio of professionals per population. Such a map is
figures and may not be comparable with data about dentists from gration can be a significant problem. The available information
presented in the next section Provision of Healthcare – Dental UNDP United Nations Development Programme
other sources, particularly national statistics. on migration has been simplified and condensed; only the major
Team. UNEP United Nations Environment Programme
migration streams, source countries and destination countries are
This section presents a new approach, whereby the metrics is a 64–65 Provision of healthcare – Oral healthcare continuum represented on the map. WHO World Health Organization
ratio between the number of oral health professionals in a given Data on availability and use of dental care presented in the graphic
country and the burden of oral disease. This ratio uses data from comes from Hosseinpoor et al, 2012, who analysed data from 52

108 109
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Rugg-Gunn A, Banoczy J. Fluoride toothpastes and fluoride Williams D, 2014. Health in the context of sustainable development. Techical report
mouthrinses for home use. Acta Med Acad. 2013;42:168-178. political advocacy in the context of international migration of

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 for the post-2015 development agenda. New York: UNSDSN; 99–105 Milestones in Dentistry
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2014. Bishop M. The ‘Dental Institution’ in London, 1817-21. A proto-
Watt R, Sheiham A. Integrating the common risk factor approach type dental school: the vision of Levi Spear Parmly. Br Dent J.
into a social determinants framework. Community Dent Oral 2014;216 2, Jan 24. 83-87.
Epidemiol. 2012;40(4):289-296. Bishop M. Ars scientia mores: science comes to English dentistry in alcohol 11, 13, 14, 46–47, 94 toothpaste 10, 21, 65, 66, 68–69, 92, risk factors for 26, 39, 44, 46, 47
QUOTE CLARK the seventeenth century. 1. Medical publications and the Royal availability and pricing of 46 96, 104 oral conditions 13–38 see also specific
Miracle Corners of the World, 2011. Society. Br Dent J. 2013;214(4):181-184. 2. Charles Allen’s Trea- policies to reduce harmful use of 40, 46, affordability of 21, 64, 68, 69 conditions
tise of 1685/6. Br Dent J. 2013;214(5):239-242.
86–87 Universal Health Coverage Coppa A, Bondioli L, Cucina A, Frayer DW, Jarrige C, Jarrige JF, 81, 82, 94 policies on 68, 96 DALYs lost to 54
Giedion U, Andres Alfonso E, Diaz Y. The impact of universal Quivron G, Rossi M, Vidale M, Macchiarelli R. Palaeontology: risk factors for universal access to 21, 59, 66, 105 global burden of 9, 13, 84
coverage schemes in the developing world: a review of the exist- early Neolithic tradition of dentistry. Nature. 2006;440:755-756. congenital abnormalities 34 food labelling 48, 51 impact on quality of life 16, 21, 54, 56
ing evidence. Universal Health Coverage Studies Series. No. 25. Ennis J. The story of the Fédération Dentaire Internationale 1900-
Washington, DC: World Bank; 2013. NCDs 14, 25, 39, 40, 41, 59, 80 indirect cost of 56, 84
1962. 1967.
Mathur M, Williams D, Reddy K, Watt R. Universal Health Cov- Fischman SL. The history of oral hygiene products: how far have oral cancer 26, 27, 29, 39, 46, 47, 93 gingivitis 22 number affected by 16, 54
erage: a unique policy opportunity for oral health. J Dent Res. we come in 6000 years? Periodontol 2000. 1997;15:7-14. oral trauma 41, 46 Global Burden of Disease Study 13, 16 surveillance, monitoring and evaluation
2015;94(3 Suppl):3S-5S. Hoffman-Axthelm W. History of dentistry. Berlin: Quintessence; periodontal disease 22, 25, 41, 46, 92 of 21
Paris V, Devaux M, Wei L. Health systems institutional characteris- 1981.
tics: A survey of 29 Organisation for Economic Co-operation and tooth decay 46 HIV/AIDS 30–31, 93 oral health
Ring M. Dentistry. An illustrated history. New York: Harry N
Development (OECD) countries. OECD Health Working Papers Abrams; 1992. impact on oral conditions 13, 14, 26, 30 as human right 13, 84
No. 50. Paris: OECD Publishing; 2010. Ruel-Kellerman M, Baron P, Gana J. Musée Virtuel de l’art dentaire Basic Package of Oral Care 64 signs of in oral health 13, 30 challenges in 71–77
Somkotra T, Detsomboonrat P. Is there equity in oral healthcare [Internet]. Available from: www.biusante.parisdescartes.fr hypondontia 34 integral to sustainable development 84,
utilization: experience after achieving Universal Coverage. Com- Savage DK. A brief history of aerospace dentistry. J Hist Dent.
munity Dent Oral Epidemiol. 2009;37(1):85-96. cleft lip and/or palate see orofacial clefts 85, 96
2002;50:71-75.
Tomar S, Cohen L. Attributes of an ideal oral health care system. J Wynbrandt J. The excruciating history of dentistry - toothsome tales common risk factors see risk factors IADR-GOHIRA research priorities 77 integration into strategies for NCD
Pub Health Dent. 2010;70:S6-S14. & oral oddities from Babylon to braces. New York: St. Martin’s congenital anomalies 13, 34–35 inequalities 51–57, 95 reduction 21, 29, 79–83, 92, 96
United Nations Sustainable Development Solutions Network (UN- Press; 1998. in access to healthcare 39, 51, 56–57, 95 links with general health 13, 14–15,
SDSN). Health in the framework of sustainable development: Zillen PA. 1994 – the World Year of Oral Health. FDI World.
Technical report for the post-2015 sustainable development data see disease surveillance in disease burden 14, 52, 54–55, 95 84, 92
1994;3:13-15.
agenda. UNSDSN: New York; 2014. dental amalgam 88, 89, 99, 103 in education and impact on perceived research on 76–77
World Health Organization. The World Health Report: Health sys- dental education 71, 72–73, 96, 102 oral health 55 oral healthcare 60–66
tems financing: the path to universal coverage. Geneva: WHO; dental tourism 71, 75 in oral health status 51, 52–53 access to 21, 60, 64, 65
2010.
World Health Organization. 65th World Health Assembly closes dental treatment 11 in younger people’s oral health 54 Basic Package of Oral Care 64
with new global health measures. 2012. Available from: expenditure on 56, 57 policies to address 51, 52, 84, 95 continuum 64, 65
www.who.int take-up of 57 oral healthcare professionals 62–63, 95
LEVEL OF BASIC ORAL HEALTHCARE COVERAGE dentists 60–61 life-course approach to oral health 14 migration of 71, 74
Paros V et al, 2010. Photo Credits female/male ratio 61 ratio of personnel to population 62, 63
TOWARDS UNIVERSAL COVERAGE
Cover Tony Camacho/Science Photo Library; 10 iStockphoto. illegal 62, 63 malnutrition 48 see also diet role in addressing inequalities in oral
WHO, 2010.
QUOTE CHAN Top row, left to right: bmcent1; Zurijeta; GordonsLife; Bottom ratio to burden of DALYS lost to oral malocclusion 34 health 52, 60, 95
WHO, 2012. row: energy; acilo; monkeybusinessimages; yvdavyd; Hogie; disease 60, 61 mercury 88–89 oral hygiene 11, 18, 22, 23, 32, 62, 65,
QUOTE TOMAR & COHEN joecobbs; shironosov; Suze777; 13 G.M.B. Akash / Panos;
dentition 10–11, 92 Minamata Convention on Mercury (2013) 66, 68, 92, 96, 99
Tomar S et al, 2010. 15 comotion_design / iStockphoto; 18 Science Photo Library;
20 iStockphoto. Left to right: phildate; bowdenimages; jaroon; diet 48–49, 94 79, 88–89, 96, 105 oral trauma 13, 36–37, 93
88–89 Amalgam and the Minamata Convention 24 iStockphoto / jaroon; 28 © Kurt Krieger/Corbis; © Denis healthy-eating plate 48, 49 mouthguards 11 policies to prevent 36
FDI World Dental Federation. Dental restorative materials and the O’Regan/Corbis; 32 © Charlotte Faty Ndiaye: WHO/AFRO; impact on periodontal disease 22 risk factors for 36, 41, 46
Minamata Convention on Mercury. Guidelines for successful 33 Winds of Hope / Philippe Rathle; Winds of Hope / Philippe
implementation. Geneva: FDI; 2014. policies to promote healthy 48, 59 noma 13, 15, 32–33, 93 orofacial clefts 34–35, 93, 100
Rathle; iStockphoto / MShep2; iStockphoto / ranplett; iStockphoto
United States Environmental Protection Agency. EPA’s roadmap for / agafapaperiapunta; 34 Dr MA Ansary / Science Photo Library; risk factors for detection and management of 33, 93 policies to improve treatment of 34
mercury. Washington, DC: EPA; 2006. 37 Meinzahn / iStockphoto; urbancow / iStockphoto; 38 Sofie NCDs 14, 25, 39, 40 risk factors for 33, 48 risk factors for 34
United Nations Environment Programme. Minamata Convention Delauw / Cultura / Science Photo Library; 41 iStockphoto, starting oral diseases 34, 39, 41, 48, 59 noncommunicable diseases (NCDs) 9 treatment of 34, 35
on Mercury [Internet]. top right, clockwise: Twirl; PeopleImages; MotoEd; diane 39;
Available from: www.mercuryconvention.org disease surveillance 93 common risk factors with oral diseases Ottawa Charter for Health Promotion 39, 51
Inakiantonana; Sergey Nivens; jonya; Fertnig; 50 Chris Stowers /
World Health Organization. Future Use of Materials for Dental Panos; 58 4774344sean / iStockphoto; 70 kevinruss / iStockphoto; lack of 16, 22, 56, 84 13, 14, 25, 39, 41, 80, 81
Restoration. WHO: Geneva; 2009. 78 Sanjit Das / Panos; 90 Chris De Bode / Panos; 99 jade tooth, oral cancer 29 death rate from 80, 81 patient testimonies 20, 24, 28,
INTERNATIONAL SUPPORT FOR THE MINAMATA Mayan skull: Anything and Everything Blog; Halin teeth: Myanmar oral diseases 21 periodontal disease 11, 13, 22–25, 54,
CONVENTION Archaeology Students Blog; Bridge: What’s behind a smile?/
periodontal disease 29 obesity 48, 49 92, 99
UNEP. Discovery Museum, Newcastle, UK; 101 Laughing gas: David
MAJOR PATHWAYS FOR MERCURY RELEASE DUE TO USE OF Pearce, BLTC Research; Waterloo teeth: British Dental Association; DMFT Index 17, 103 risk factor for congenital anomalies 34 association with
DENTAL AMALGAM 102 Vulcanite dentures: British Dental Association; Beaman risk factor for periodontal disease 25 CVD 15, 22
WHO, 2009. Hobbs: Kansas Historical Society; 103 Irene Newman: Find A edentulousness 15, 51 older people’s health issues 14 diabetes 15, 22
MINAMATA CONVENTION (2013) Grave, Inc.; Ritter chair: Ritter Dental; FDI Paris: FDI World Dental
oral cancer 26–29, 93 gastrointestinal and pancreatic

ANNEX INDEX
UNEP. Federation.
FDI’s Vision 2020 9, 59, 62, 71, 105 early detection and timely referral 26, cancers 15
fluoride 18, 21, 66–67, 96 28, 29, 93 HIV/AIDS 14, 26
intervention 59, 66, 67, 96, 106 integration into strategies for NCD pre-term, low-birth-weight babies 15,
reduction 29, 93 22

118 119
 respiratory diseases 15, 22 sugar 42–43, 51, 99 UN Millennium Development Goals 79,
development of 23 benefits of reduction 21 84, 85
lack of standardized data on 22 free sugars 39, 42, 43, 46, 47, 48, 51 UN Sustainable Development Goals
risk factors for 22, 25, 41, 44, 46 impact on periodontal disease 25 (SDGs) 9, 79, 84, 85
sign of other conditions 14, 15 impact on tooth decay 10, 18, 19, 42, 66 UN Universal Declaration of Human
plaque 18, 19, 69 policies to reduce consumption 42, 48, Rights 13
policies to 82, 94 undernutrition 48 see also diet
address social determinants 40, 52 risk factors for
control tobacco 39, 44 NCDs 14, 25, 39, 40, 42, 59, 80 water fluoridation programmes 39, 51, 66,
improve fluoride toothpaste 68 oral diseases 39, 42, 101 67 see also fluoride
improve treatment of congenital WHO guidelines on 42, 43 World Health Organization (WHO) 82–83
anomalies 34 approved oral health system model 64
prevent oral trauma 36 tobacco use 11, 13, 14, 44–45 codes of practice for international
promote healthy diet 48 policies for tobacco control 39, 40, 44, recruitment 74
reduce harmful alcohol use 46 82, 94 definition of oral health 13
reduce sugar consumption 42 risk factors for estimate of cost of oral disease treatment
population-wide preventive interventions congenital anomalies 34 56
and health promotion strategies 9, 51, 59 NCDs 14, 25, 39, 40, 41, 59, 80 recommendations on cleft surgery 34
oral cancer 26, 27, 39, 45 diet 49
risk factors 39–50, 94 periodontal disease 22, 24, 25, 41, 45 fluoride 66
Common Risk Factor Approach 29, 40, smokeless tobacco use 44, 45 sugar consumption 42, 43, 82, 83, 105
59, 82, 94 smoking 44, 45 see also strategies About FDI
for NCDs including oral health 13, 14, tooth decay 10, 11, 16–21, 51, 54, 92 WHO Framework Convention on
25, 39, 41, 80, 81, 84 development of the disease 18–19, 42 Tobacco Control 44, 82, 105
DMFT average in 12-year-olds 16–17 WHO Global Action Plan for Prevention
saliva factors influencing development of 19 and Control of NCDs 79, 80, 81, 83 FDI World Dental Federation serves as the principal representative body for
lack of 13 impact on general health and well-being WHO Oral Health Action Plan (2007) more than 1 million dentists worldwide, developing health policy and con-
use to identify markers for HIV 15 16, 21 59 tinuing education programmes, speaking as a unified voice for dentistry in
smoking see tobacco use lack of standardized data 16 WHO Regional Programme for Noma
social determinants of health 39, 40, 41, prevention of 21, 66, 68, 69 Control 32, 33 international advocacy, and supporting member associations in global oral
84, 94 risk factors for 41, 42, 46, 99 health promotion activities. Over the years, it has developed programmes,
policies to address 40, 60, 94 toothbrushing 10, 68, 69 initiatives, campaigns, policies and congresses, always with a view to occu-
social gradient see inequalities toothpaste see fluoride
strategies to combat pying a space that no other not-for-profit group can claim.
harmful alcohol use 46 UN High-Level Meeting on the Prevention
oral cancer 26, 29 and Control of NCDs 59, 80, 82, 83
FDI works at national and international level through its own activities and
periodontal disease 25 Universal Health Coverage 79, 84, 86–87, those of its member dental associations. It is in official relations with the
tooth decay 21, 66 92, 96 World Health Organization (WHO), and is a member of the World Health
Professions Alliance (WHPA).

120
Oral conditions, such as tooth decay, periodontal disease and
oral cancer, are among the most common and widespread
diseases of humankind. They are generally related to the same
preventable risk factors associated with over 100 noncommu-
nicable diseases. Yet, international attention to oral diseases
does not match the high number of cases, nor the impact
these diseases have on individuals, populations and society.

The first edition of the Oral Health Atlas focused on ‘mapping

a neglected global health issue’. The new edition of this atlas
continues to highlight the extent of the problem worldwide and
reflects on policies and strategies addressing the global burden
of oral disease. The Challenge of Oral Disease – A call for global
action is a valuable resource for public health experts, policy
makers, the oral health profession and anyone with an interest
in oral health.

The wide range of oral health topics presented include:

• the impact and burden of oral diseases, such as tooth decay,
periodontal disease, oral cancer and more • major risk factors
and the common risk factor approach • inequalities in oral
health • oral disease prevention and management • oral health
challenges • ensuring oral health is on global health and
development agendas.

ISBN: 978-2-9700934-8-0