A Plea to Reform Dental Care Policy
Brian L. Mealey, DDS, MS
Oral health is not merely a physical construct, an absence of defect or disease. Poor oral health affects physical, psychosocial, and emotional well being through the resultant potential for pain; infection; inability or unwillingness to smile; and alteration in biting, chewing, and speaking. In addition, direct financial costs for treatment of oral conditions place a large burden on patients.
The two referenced articles1,2 address the global span of oral diseases, their prevalence and its relationship to socioeconomic factors and availability of care, and their impact on the individuals who have them and on the families and communities in which those individuals live. The articles lay out the failures of current healthcare education and delivery systems to actually improve oral health around the world.
There is a clear social gradient in oral health, with marked inequalities among residents of communities and countries with lower socioeconomic status. For example, dental caries is the most prevalent health condition in adults, and while the prevalence of dental caries has decreased slightly in high-income countries over the past few decades, this has not occurred in middle- and low-income countries. The articles strongly suggest that oral disease management strategies used in high-income countries, approaches that focus on treatment of oral conditions through use of high technology and on preventive tactics that take place within a healthcare setting such as a dental office or community health clinic, are not affordable or appropriate in lower-income countries. Such approaches generally are not applicable even to lower-income communities within high-income countries.
The most striking conclusion of the articles is the authors' recommendation that management of the global scope of oral health conditions requires radical changes in healthcare policy and in dentistry as a whole. Rather than policies that focus on oral disease treatment, the authors recommend strategies aimed at reducing major risk factors for oral disease, such as tobacco use, alcohol consumption, and especially sugar consumption. In particular, the articles target the "global sugar industry" and recommend policies that the authors believe will result in decreasing sugar consumption, especially in at-risk communities. The authors indict multinational sugar-producing corporations and associated downstream industries for promoting consumption of their products worldwide and recommend "bold action" against these industries to block their efforts to "lessen the effect of any public health efforts attempting to reduce free sugar consumption."
Such actions would inherently be government-centric in nature and include population-wide policies such as regulation of sugared product advertising directed at children, taxation of sugared drinks, limitations on lobbying by corporate sugar interests, and restrictions on corporate participation in governmental or nongovernmental organizations dealing with health policy. Similar actions to decrease tobacco use and overconsumption of alcohol are recommended.
The second article tackles issues related to current dental practice models. In high-income countries, dentists tend to concentrate in wealthy urban areas, while poorer rural settings have limited access to care. Lack of mid-level providers may also limit availability of basic dental prevention and treatment. In lower-income countries, the problem is magnified exponentially. The authors provide a series of recommendations to change the global oral healthcare delivery system, including recognition of oral health as a right guaranteed by the government, universal oral healthcare coverage, incentivization of preventive approaches to oral conditions, changing dental education and practice away from a dentist-centered model toward a team approach that would include other oral healthcare practitioners such as mid-level providers, and dissemination of oral healthcare providers into underserved communities, among others.
The first article concludes, "Dental treatment alone cannot solve this problem. A radically different approach is now needed to tackle this global health challenge." Indeed, the approaches offered by these articles would be a radical shift, especially in countries with limited-government philosophies and free-market economies.
1. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral diseases: a global public health challenge. Lancet. 2019;394(10194):249-260.
2. Watt RG, Daly B, Allison P, et al. Ending the neglect of global oral health: time for radical action. Lancet. 2019;394(10194):261-272.