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

ohn Friday, oral health advocates around the world got an early holiday gift from their longtime wish lists. They’ve waited their entire careers — for some, up to nearly half a century, speaking with STAT — for oral health to be folded into conversations calling for access to health care for all. The World Health Organization’s new Global Oral Health Status report has taken that first step.

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

The WHO report provides data on 194 countries’ oral disease caseload and mortality rates, highlighting differences in the prevalence of oral health problems across different regions. It also highlights the most common oral health issues, such as tooth decay, tooth loss, severe gum disease and oral cancer. The report highlights barriers to access, including cost and the need for specialized providers, and opportunities to tackle inequalities, all in service 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 prosthetics – for everyone, says Habib Benzian, who worked on the WHO report and is research professor and associate director of the WHO Collaborating Center at New York University’s College of Dentistry. Rather, universal coverage aims to ensure that all people have access to essential, quality oral health services, regardless of where they live or how poor they are. Essential services include prevention of oral disease, pain relief, fillings and some dental restoration.

The report shows nearly half the world suffers from some form of oral disease, with three in four people affected in low- and middle-income countries. But one of its most striking findings may be that a country’s income level does not determine its overall picture of oral health, said Benjamin Chaffee, associate professor of preventive and restorative dental science 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 cancers, did not differ much, based on 2019 Global Burden of Disease data. These numbers speak to how global the issues are, Chaffee said.

The data also confirm the importance of preventive care, regardless of how wealthy a country is. “When a person goes to the dentist, it’s often late and the oral problem is already there,” Benoit Varenne, head of oral health at the WHO, told STAT via 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 adviser working in remote regions of the West African country, where the nearest dentist was almost 500 kilometers away. There were no dental schools to train a new workforce, so Burkinabes had to go to Senegal for oral health care training.

Faced with these access issues, public health schools in Burkina Faso began training nurses to double as dental nurses. In the field, it didn’t matter if they went through a fancy schooling. All that mattered to the patients was that nurses had the right training to pull a tooth or provide pain relief for an infection.

Watching this workforce training play out in rural areas gave Verenne an important perspective on how to bridge access gaps. Disparities facing rural and poor communities exist globally, so oral health care solutions must work regardless of a given community’s access to technology, he said. The report authors highlight less invasive approaches in dentistry as an important step towards universal coverage: Think less extractions or gum surgery, more fluoride products and education around flossing.

But items like fluoride toothpaste remain out of reach for many low-income people. A WHO action plan in the works to guide governments to launch oral health reforms may help. The WHO’s Executive Committee, announced on Friday, will roll out 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 medical providers in oral health care, Burkina Faso-style. It is cheaper and takes less time to train people already working in healthcare in dentistry than to train beginners.

“I think the entire health and public health community needs to raise its technical expertise levels when it comes to oral health,” Benzian told STAT via email. “Even our medical or nursing colleagues often know very little about oral health and how to address common conditions.”

The approach also makes it easier to guarantee an oral health care workforce in remote areas where dental professionals are less likely to work.

“It’s a big, slow challenge because most of the models are built based on specialized suppliers with high-tech equipment,” Verenne said. “And of course all these things cost a lot.” Making oral health coverage cheaper could ease governments’ concerns about putting oral health under the same umbrella as universal medical access conversations, laws and initiatives, Verenne said.

Collaboration beyond the medical and dental divide can also better serve patients’ needs. Simon, the dentist-physician, was excited by the report authors’ call for broader alliances between health economics, policy and medical researchers. But it would be “nice” to see a similar call on the WHO report to collaborate with community members on research, she said. The case studies—ranging from people in India who chew betel nut, a known carcinogen, to Nigerian survivors of noma, a type of gangrene—include diverse voices, but stop short of promoting subject-centeredness in participatory research.

Even experts working with the WHO agree. It is essential to include people from the informal sector, said Brittany Seymour, the global health discipline director for the Harvard School of Dental Medicine, which contracts with the WHO Africa regional offices. Patients and advocates are often left out of research on the issues that affect them most, she said.

She and other researchers were less struck by the bleak snapshot of global oral health care — and more by the fact that the report was finally launched. Seymour cited a side session focused on oral health at the 2011 United Nations Summit on Noncommunicable Diseases as one early advocacy milestone.

“The information here [in the 2022 report] – it’s been building here for many years,” Seymour said. The WHO report is noteworthy because it “reflects the increasing prioritization of oral health at the global level and the growing political visibility it gains with each of these events.”

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