It’s all political: Why oral health has yet to become a global health priority
By James Coughlan, EDSA Vice President Public Relations, UK
EDSA VPPR James Coughlan discusses the issues in getting oral health recognised as a major global problem with Dr David Alexander, former FDI CEO and a world-renowned expert in global oral health.
Neglect is a strong word. It implies a wilful ignorance, an ability to look at something serious and turn the other way. Neglect of children is classified as child abuse, while medical neglect by a practitioner can result in the loss of their licence.
Big Issue, No Progress
Yet neglect is the exact right word to describe the inaction at a global level in managing oral diseases. 3.5 billion people, half of the world’s population, suffer from untreated oral diseases and dental caries in permanent teeth is mankind’s most prevalent disease. The Global Burden of Disease studies, funded by the Gate Foundation, found that overall the burden of oral diseases had not improved in the last 25 years – instead the burden has increased by over one billion people in that timeframe. The authors of the report tentatively mused that “maybe a different strategy is needed”. Maybe indeed.
On the surface of it, oral diseases have a perfect cocktail of traits favourable to successful advocacy, sharing many common risk factors (sugar, tobacco, hygiene, etc) with a number of other chronic and life-threatening diseases. The data above clearly demonstrate the scale of the health problem, while a large global study estimated the indirect costs of oral diseases to the global economy (for example through missed school and work) at $187.6 billion, enough to make any economist sit a little straighter in their chair. By this number, the indirect costs of oral diseases rank among the indirect costs of the top 10 causes of death. Toothache is also a relatable pain that many have either suffered from themselves or have seen those close to them suffer.
Political Recognition of Oral Diseases
Despite this, oral diseases enjoy a small fraction of the recognition on the political stage that other non-communicable diseases (NCDs), such as diabetes, cancer, cardiovascular disease, chronic respiratory diseases, and mental illnesses do. In the recent United Nations High Level Meeting 3 (HLM3) on NCDs lobbying from a number of dental organisations, such as the FDI and IADR, failed to get oral diseases included in the final declaration, or even mentioned in the presentations at the meeting attended by heads of state and ministers of health. This is significant because without the explicit and constant reminder at the international stage, national governments will continue to see oral health as an adjunct to general health, rather than the integral part it is. There were other disappointments too; after opposition earlier in the year from the Trump administration, the inclusion of a call to implement sugar sweetened beverage (SSB) tax was also omitted.
David Alexander, the UN representative of the Academy of Dentistry International, an NGO with Special Consultative Status to the UN, puts this failure to recognise oral disease down to two key aspects, the overwhelming efforts from of the “big five” NCDs, alongside ineffective advocacy. “The big five were so loud that a number of other chronic diseases, such as kidney and eye, were side-lined. Contributing factors for low-level of advocacy for oral diseases are inadequate financial resources and the lack of leaders highly-trained and experienced in advocacy at the global level. Advocacy efforts for oral diseases are out-witted, outsmarted and outspent by the other causes that take home the winnings while oral diseases pick over the crumbs left behind. A further example of this is the position of oral health at the WHO. In the 1980’s there was an oral health division staffed by some 30 or more experts. Since then, the numbers have been allowed to dwindle into the low single digits. One should also note that the role of the WHO has also changed a lot since the 80’s – they have moved towards reacting to international crises such as infectious diseases, which they do remarkably effectively, rather than disease prevention and health promotion”.
Successful political advocacy relies not only on statistics, but also on ideas. There is a reason that charity adverts have tragic images of death and poverty accompanied by sad music; emotion parts people with their money. Ministers of Health share the same propensity to be swayed by emotion, yet Dr. Alexander thinks that as dentists we avoid ‘going emotional’ and talk in terms of our own chairside language that no one else understands or cares about. He goes further, “We go into meetings with Ministers of Health or funding agencies with 2 or 3 dentists to the exclusion of anyone else... where is the angry parent of the child who had all their teeth extracted under general anaesthetic? Where is the angry granddaughter of the elderly patient who choked to death because they couldn’t chew their food properly? Too often in these meetings we talk in DMFT scores or mm of attachment loss – you can just see their glaze over as they recall the other competitive causes – diabetes, cardiovascular disease or cancer – who brought all stakeholders to the meeting, including patients, family and caregivers, funders, policy experts, and of course the health professionals. Other causes learned many years ago, health professionals alone never win anything – it’s the emotion around the suffering that wins it”.
A shift in the framing of oral diseases might help. “We too often use treatment need as a diagnosis, we talk about people needing fillings, not that they have a sugar-related disease; we’re straight in there with treatment plans. With gingivitis – you have an inflammatory disease but we talk about cleanings. We have as a profession talked more of procedures than diseases”. This would require a concerted shift across the profession, but a 2011 paper by Benzian et. al. found that there was little cohesive external message portrayed by the oral health communities, with too many differing priorities and solutions. The presentation of oral diseases as a ‘neglected’ issue was also found to be inconsistent.
At what cost?
Part of the issue is that for most countries, the current model of dental care is financially unviable. Paying for treatment-based care carried out by a dentist is expensive and simply unaffordable for many countries, but there has been little impetus to move beyond this model of care towards a prevention first approach. Plenty of lip service is payed to prevention, while real investment in oral health prevention and promotion is stagnant or falling. Financial incentives are still largely based on paying for treatment rather than for health, as highlighted in a recent report by the Alliance for a Cavity Free Future (ACFF).
A growing number of voices have touted dental therapists (also known as mid-level providers) as part of the answer to this conundrum. Europe has seen a slow move towards partial access, whereby patients can see a dental therapist without prior seeing a dentist, with the Netherlands leading the way, and the UK and France not far behind. The idea is that the majority of routine work carried out by dentists could be done by hygienists or therapists for a much lower cost, potentially more appealing to less developed economies. “In advocacy, we go in saying we need more money, more dentists and more dental schools, it reeks of self-interest. We need to change the dialogue to childhood development and school absenteeism, the added costs of managing other diseases emerging in our understanding of the oral-general health bidirectional relationships. There is now good data showing significant medical savings due ot dental interventions.” says Dr Alexander.
Not everyone agrees. In their 2020 Vision paper, the FDI emphatically underlined their assertion that responsibility for diagnosis, treatment planning and treatment should be the sole responsibility of dentists: “delegation - yes, substitution – no”. Such a fundamental clash only underlines the disunity in the oral health community – a disunity that seeps through in the global political arena.
The Oral-Systemic Link
What all agree on is the need to emphasise the link between oral health and general health. The bidirectional link between the two has seen an increase in attention and research, with improved oral health posited as improving diabetes, Alzheimer’s disease, and cardiovascular disease. It is hoped that such findings will begin to “put the mouth back in the body” and reverse the historical split between dentistry and medicine. “When people from diabetes and heart disease are saying ‘until we sort the oral health out, my programmes are never going to be as effective. We need a comprehensive package for diabetes that includes oral health’ – then we’ll have won in terms of advocacy. A good first step therefore is simply to think ‘its not about us, its about them’.” says Dr Alexander.
Making the case in terms of country development is another avenue; “If we talk about a disease that is harming children’s education, it becomes an interest of the minister of education, the finance minister and the minister of commerce” explains Dr Alexander. Poor attendance at school and work ultimately reduces the productivity of the workforce, therefore targeting advocacy efforts beyond the traditional health channels can present an opportunity to make inroads where previously there were none.
Change to Come
There are tentative signs that things are changing. The ACFF Health Economics Consortium has been set up to collect policy relevant health economics data, while large research projects such as the European wide ADVOCATE have involved a wide array of stakeholders (including patients) to look at health system planning in relation to oral health. At a European level there is generally good relations between dentists, academia, advocacy groups and government representatives. EDSA collaborated with the European Pharmaceutical Students’ Association for this year’s World Oral Health Day, and our close relationship with other student healthcare organisations lays foundations for more interprofessional collaboration and respect in the future.
At a global scale, however, such collaboration remains elusive. There is still no single organisation that can unite all stakeholders and speak with a truly global voice, while attempts to permeate oral health throughout the NCD agenda are slow. As the UN HLM4 on Universal Health Coverage approaches, there is the strong likelihood that oral health will once again be overlooked. Furthermore, there is a risk that the buzz of activity in Europe and America, with many large, well-funded universities and research centres will distract attention from the higher burden elsewhere.
As student dental organisations, whether local, national, regional or global, we must ensure that we show and encourage leadership, using our connections with professional organisations to ensure that students’ voices are heard through the clamour. But after our short terms are done and we graduate, we should also consider how we can continue advocating for the pressing issues that continue to plague oral health. Dr Alexander muses, “It’s my generation who have screwed this all up, and it’s you guys who are left to fix it. You should have that voice now. The UN has a big push to include youth (age < 32) in most of its business. Oral health needs that too!”. As we progress from students to professionals we should take a concerted interest in the political landscape in which we will soon find ourselves.
Dr. Alexander can be found on Twitter at @DAGlobalHealth or on email at email@example.com