Elsevier

The Lancet

Volume 394, Issue 10194, 20–26 July 2019, Pages 249-260
The Lancet

Series
Oral diseases: a global public health challenge

https://doi.org/10.1016/S0140-6736(19)31146-8Get rights and content

Summary

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Introduction

Oral health matters. The teeth and mouth are an integral part of the body, supporting and enabling essential human functions, and the mouth is a fundamental feature of personal identity. Building on existing definitions,1, 2 oral health can be defined as being multidimensional in nature, including physical, psychological, emotional, and social domains that are integral to overall health and wellbeing. Oral health is subjective and dynamic, enabling eating, speaking, smiling, and socialising, without discomfort, pain, or embarrassment. Good oral health reflects an individual's ability to adapt to physiological changes throughout life and to maintain their own teeth and mouth through independent self care. Despite being largely preventable, oral diseases are highly prevalent throughout the life course and have substantial negative effects on individuals, communities, and the wider society. Oral diseases are a global public health problem, with particular concern over their rising prevalence in many low-income and middle-income countries (LMICs), linked to wider social, economic, and commercial changes.3, 4

Oral diseases are chronic and progressive in nature. For example, dental caries (tooth decay) affects very young children, but is a lifelong condition that tracks across adolescence and adulthood, and into later life. Oral conditions disproportionally affect impoverished and socially disadvantaged members of society. A strong and consistent social gradient exists between socioeconomic status and the prevalence and severity of oral diseases. In this way, oral diseases can be considered as a sensitive clinical marker of social disadvantage, being an early indicator of population ill health linked to deprivation.5 Oral diseases and oral health inequalities are directly influenced by wider social and commercial determinants, which are the underlying drivers of poor population oral health.6

Key messages

  • Oral health is an integral element of overall health and wellbeing, enabling essential daily functions

  • Oral diseases include a range of chronic clinical conditions that affect the teeth and mouth, including dental caries (tooth decay), periodontal (gum) disease, and oral cancers

  • Despite being largely preventable, oral diseases are highly prevalent conditions, affecting more than 3·5 billion people around the world; dental caries is the most common disease globally with increasing prevalence in many low-income and middle-income countries

  • Oral diseases disproportionally affect poorer and marginalised groups in society, being closely linked to socioeconomic status and the broader social determinants of health

  • Oral diseases have substantial effects, causing pain, sepsis, reduced quality of life, lost school days, family disruption, and decreased work productivity, and the costs of dental treatment can be considerable for both the individual and the wider health-care system

  • Oral conditions share common risk factors with other non-communicable diseases, which include free sugar consumption, tobacco use, and harmful alcohol consumption, as well as the wider social and commercial determinants of health

  • Of particular concern is the effect of free sugar consumption on the prevalence of caries and overweight or obesity, and associated conditions such as diabetes

  • Recognition is increasing of the influence, power, and effect of the global sugar industry as a threat to public health, which requires tighter regulation and legislation by governments

However, oral diseases are a neglected issue, rarely seen as a priority in health policy.7 Oral health and the dental profession have become somewhat isolated and marginalised from mainstream developments in health policy and health-care systems. The current model of dental care delivery and clinical preventive policy does not tackle the global burden of oral diseases. The so-called westernised model of modern dentistry (high technology and treatment focused) is unaffordable and inappropriate in many LMICs.8 Even in settings with resources, dentistry is not meeting the needs of large segments of the national population and is increasingly focusing on the provision of aesthetic treatments, largely driven by profit motives and consumerism.9 A radically different approach is needed to tackle the global challenge of oral diseases.

In this first paper of a two-part Series on oral health,10 we highlight the evidence for the global clinical and public health importance of oral diseases in terms of their prevalence, patterns of oral health inequalities, and effects on individuals, families, and society. Our analysis also highlights the underlying social and commercial determinants—the broad range of interacting biological, behavioural, psychosocial, economic, corporate, and political drivers that create the “conditions in which people are born, grow, live, work and age”11 that cause poor population oral health.6, 11 Furthermore, we present a unifying framework that places oral diseases in a broader context and directly links them to other non-communicable diseases (NCDs).

Section snippets

Clinical overview of oral diseases

A wide range of diseases and disorders affect the soft and hard tissues of the mouth, including an array of craniofacial disorders, congenital anomalies, injuries, and various infections. However, the key clinical conditions that are considered to be global public health priorities include dental caries (tooth decay), periodontal (gum) disease, and oral cancers.

Global epidemiological overview of oral diseases

According to the Global Burden of Disease (GBD) 2015 study, around 3·5 billion people worldwide live with dental conditions, predominantly untreated dental caries in the deciduous and permanent dentitions, severe periodontal disease, edentulism (complete tooth loss), and severe tooth loss (having between 1 and 9 remaining teeth).3 According to the International Agency for Research on Cancer, lip and oral cavity cancers were among the top 15 most common cancers in the world in 2018.26

Economic burden of oral diseases

Dental diseases impose a substantial economic burden on society.70 Their economic burden encompasses direct costs (treatment expenditures), indirect costs (productivity losses due to absence from work and school), and intangible costs (eg, pain, problems with biting, chewing and eating, tasting, speaking, and the expression of emotions such as smiling, all of which are involved in social and family activities). Worldwide in 2015, dental diseases accounted for US$356·80 billion in direct costs

Social and commercial determinants of oral diseases

The WHO conceptual framework for action on the social determinants of health126 highlights how structural determinants, such as economic, social, and welfare policies, can generate social hierarchies and influence the socioeconomic status of individuals within societies. Socioeconomic status can then influence health through the circumstances in which people live, work, and age, and their risks for disease. These intermediate determinants include housing and working conditions, social capital,

Conclusion

Oral diseases are a major global public health problem, having both high prevalence and major negative impacts on individuals, communities, and society. Globally, over 3·5 billion people have oral diseases that are chronic and progressive in nature, starting in early childhood and progressing throughout adolescence and adulthood and into later life. Oral diseases disproportionally affect poorer and marginalised groups in society, being very closely linked to socioeconomic status and broader

References (156)

  • GC Mejia et al.

    An introduction to oral health inequalities among Indigenous and non-Indigenous populations

    Int Dent J

    (2010)
  • CM Vargas et al.

    Oral health status of rural adults in the United States

    J Am Dent Assoc

    (2002)
  • SR Nagarkar et al.

    Early childhood caries-related visits to emergency departments and ambulatory surgery facilities and associated charges in New York state

    J Am Dent Assoc

    (2012)
  • TV Macfarlane et al.

    Orofacial pain: just another chronic pain? Results from a population-based survey

    Pain

    (2002)
  • PE Petersen

    The World Oral Health Report 2003: continuous improvement of oral health in the 21st century–the approach of the WHO Global Oral Health Programme

    (2003)
  • NJ Kassebaum et al.

    Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990–2015: a systematic analysis for the global burden of diseases, injuries, and risk factors

    J Dent Res

    (2017)
  • PE Petersen et al.

    The global burden of oral diseases and risks to oral health

    Bull World Health Organ

    (2005)
  • RG Watt et al.

    Integrating the common risk factor approach into a social determinants framework

    Community Dent Oral Epidemiol

    (2012)
  • ACL Holden

    Consumer-driven and commercialised practice in dentistry: an ethical and professional problem?

    Med Health Care Philos

    (2018)
  • RG Watt et al.

    Ending the neglect of global oral health—time for radical action

    Lancet

    (2019)
  • Commission on social determinants of health. Closing the gap in a generation: health equity through action on the social determinants of health

    (2008)
  • O Fejerskov et al.

    Dental caries: the disease and its clinical management

    (2003)
  • Guideline: sugars intake for adults and children

    (2015)
  • JM ten Cate et al.

    Mechanistic aspects of the interactions between fluoride and dental enamel

    Crit Rev Oral Biol Med

    (1991)
  • NB Pitts et al.

    Dental caries

    Nat Rev Dis Primers

    (2017)
  • H Klein et al.

    Studies on dental caries: X. A procedure for the recording and statistical processing of dental examination findings

    J Dent Res

    (1940)
  • IL Chapple

    Time to take periodontitis seriously

    BMJ

    (2014)
  • H Löe et al.

    Experimental gingivitis in man

    J Periodontol

    (1965)
  • MS Tonetti et al.

    Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: a call for global action

    J Clin Periodontol

    (2017)
  • PB Lockhart et al.

    Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?

    Circulation

    (2012)
  • IL Chapple et al.

    Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

    J Periodontol

    (2013)
  • B Daly et al.

    Evidence summary: the relationship between oral health and dementia

    Br Dent J

    (2017)
  • S Awano et al.

    Oral health and mortality risk from pneumonia in the elderly

    J Dent Res

    (2008)
  • F Bray et al.

    Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries

    CA Cancer J Clin

    (2018)
  • S Warnakulasuriya

    Causes of oral cancer–an appraisal of controversies

    Br Dent J

    (2009)
  • D Winn et al.

    The INHANCE consortium: toward a better understanding of the causes and mechanisms of head and neck cancer

    Oral Dis

    (2015)
  • H Mehanna et al.

    Prevalence of human papillomavirus in oropharyngeal and nonoropharyngeal head and neck cancer–systematic review and meta-analysis of trends by time and region

    Head Neck

    (2013)
  • DI Conway et al.

    Estimating and explaining the effect of education and income on head and neck cancer risk: INHANCE consortium pooled analysis of 31 case-control studies from 27 countries

    Int J Cancer

    (2015)
  • TM Marthaler

    Changes in dental caries 1953–2003

    Caries Res

    (2004)
  • JE Frencken et al.

    Global epidemiology of dental caries and severe periodontitis— a comprehensive review

    J Clin Periodontol

    (2017)
  • W Marcenes et al.

    Global burden of oral conditions in 1990–2010: a systematic analysis

    J Dent Res

    (2013)
  • NJ Kassebaum et al.

    Global burden of untreated caries

    J Dent Res

    (2015)
  • NJ Kassebaum et al.

    Global burden of severe periodontitis in 1990–2010

    J Dent Res

    (2014)
  • NJ Kassebaum et al.

    Global burden of severe tooth loss: a systematic review and meta-analysis

    J Dent Res

    (2014)
  • Y Matsuyama et al.

    Are lowered socioeconomic circumstances causally related to tooth loss? A natural experiment involving the 2011 great east Japan earthquake

    Am J Epidemiol

    (2017)
  • F Schwendicke et al.

    Socioeconomic inequality and caries

    J Dent Res

    (2015)
  • S Costa et al.

    Socioeconomic factors and caries in people between 19 and 60 years of age: an update of a systematic review and meta-analysis of observational studies

    Int J Environ Res Public Health

    (2018)
  • B Klinge et al.

    A socio-economic perspective on periodontal diseases: a systematic review

    J Clin Periodontol

    (2005)
  • DI Conway et al.

    Socioeconomic inequalities and oral cancer risk: a systematic review and meta-analysis of case-control studies

    Int J Cancer

    (2008)
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