The case for universal oral health coverage, according to the WHO

HeOn Friday, oral health advocates around the world got an early holiday gift from their long-term wish list. They had been waiting their entire careers — as some STAT spoke to, as long as half a century — for oral health to be folded into conversations that called for access to health care for all. The World Health Organization’s new Global Oral Health Status Report took this first step.

“This merger […] is really something that has never happened before,” said Lisa Simon, a dentist at Brigham and Women’s Hospital and one of the STAT 2022 Wunderkinds.

The WHO report includes data on oral disease incidence and mortality in 194 countries, highlighting differences in the prevalence of oral health problems in different regions. It also focuses on the most common oral health problems, such as tooth decay, tooth loss, severe gum disease and oral cancer. The report highlights barriers to access, including cost and the need for specialist providers, and opportunities to address disparities, all in support of the goal set by the World Health Assembly earlier this year: Universal Oral Health Coverage by 2030.

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Universal oral health coverage does not necessarily mean free services or advanced dental care — such as implants or braces — for everyone, said Habib Benzian, who worked on the WHO report and is a research professor and co-director of the WHO Collaborating Center in New York. York College of Dentistry. Rather, universal coverage aims to ensure that all people have access to quality essential oral health care, no matter where they live or how poor they are. Essential services include oral disease prevention, pain relief, fillings and dental restorations.

The report shows that nearly half of the world suffers from some form of oral disease, with three out of four people affected living in low- and middle-income countries. But one of its most striking findings may be that a country’s income level doesn’t determine its overall oral health picture, said Benjamin Chaffee, associate professor of preventive and restorative dentistry at the University of California, San Francisco School of Dentistry.

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Among high-, middle-, and low-income countries, the prevalence of major oral diseases, excluding oral cancer, was not high, based on 2019 Global Burden of Disease data. Those numbers speak to how global the problem is, Chaffee said.

The data also reinforces the importance of preventive aid, no matter how rich a country is. “By the time a person goes to the dentist, it’s often late and the oral problem is already there,” Benoit Varenne, the WHO’s lead for all oral health, told STAT in an email.

For Varenne, the spark that ignited what would become a 99-page, multi-year effort came through Burkina Faso more than 20 years ago. He was then a young WHO consultant working in remote areas of West Africa, where the nearest dentist was almost 500 kilometers away. There were no dental schools to train a new workforce, so Burkinabé had to go to Senegal for oral health training.

Faced with these access problems, schools of public health in Burkina Faso began training nurses to double as dental nurses. On stage, it didn’t matter if they had gone through some fancy schooling. The only thing that mattered to the patients was that the nurses had the right training to extract a tooth or provide pain relief for an infection.

Watching this workforce training play out in rural areas gave Verenne important insight into how to bridge access gaps. Inequalities facing rural and poor communities exist around the world, so solutions to oral health care should work regardless of a particular community’s access to technology, he said. The report’s authors highlight less invasive dental practices as an important step toward universal coverage: Think fewer extractions or gum procedures, more fluoride products, and flossing education.

But things like fluoride toothpaste are still out of reach for many low-income people. A WHO action plan in the works to guide governments to initiate oral health reforms could help. It was announced on Friday that the World Health Organization’s Executive Committee will publish the action plan in January 2023 and at the World Health Assembly in May 2023.

Relying on a less specialized workforce could also help improve access – perhaps by training doctors in oral health care, Burkina Faso-style. It is cheaper and takes less time to train people who are already working in healthcare in dentistry than to train new people.

“I think the entire health and public health community needs to increase their technological knowledge when it comes to oral health,” Benzian told STAT via email. “Even our doctors or nursing colleagues often know very little about oral health and how to respond to common diseases.”

The approach also makes it easier to secure oral health workers in remote areas where dentists are less likely to work.

“It’s a big, slow challenge, because most models have been built on specialized providers with high-tech equipment,” Verenne said. “And of course all these things cost a lot.” Making oral health care less expensive could ease government concerns about putting oral health under the same umbrella as general medical access talks, laws and initiatives, Verenne said.

Collaborations outside the medical-dental field may also better serve patient needs. Simon, a dentist and physician, was excited by the report authors’ call for greater collaboration among researchers in health economics, policy and medicine. But it would be “nice” to see a similar call for the WHO report to work with community members on research, she said. The case studies—from people in India who chew betel nuts, a known carcinogen, to Nigerian survivors of noma, a form of gangrene—include a variety of voices, but don’t risk promoting subject-centered participatory research.

Even experts collaborating with the WHO agree. It’s important to include people from the informal sector, said Brittany Seymour, global health director at the Harvard School of Dental Medicine, which contracts with the WHO’s African regional offices. Patients and advocates are often left out of research on the issues that most affect them, she said.

She and other researchers were less impressed by the bleak picture of global oral health care – and more by the fact that the report was launched last. Seymour cited a side session on oral health at the 2011 United Nations Summit on Noncommunicable Diseases as one turning point in advocacy.

“The information here [in the 2022 report] — it’s been building toward this for years,” Seymour said. The WHO report is noteworthy because it reflects “the growing global priority of oral health and the increasing political visibility it is gaining with each of these events.”

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