By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

“The status of global oral health is alarming.” That’s the conclusion of the first-ever Global Oral Health Status Report. Issued last November by the World Health Organization (WHO), the report documents a global population burdened by widespread oral disease.

• An estimated 2.5 billion people had untreated dental caries in 2019,
• Roughly 1 billion people had severe periodontal disease,
• 370 million people were missing permanent teeth, and
• 370,000 had oral cancer, a highly lethal disease that kills roughly 170,000 people globally each year.

“No other disease group affects humanity across the life cycle and across all countries in the way that oral diseases do,” the report declares.

How is it that policymakers throughout the world have paid so little attention to oral diseases when they affect so many? Part of the answer may be the tendency of public health officials to favor prevalence data when deciding where to focus their efforts. In comparing oral disease prevalence in 1990 with 2019 figures, the report’s authors found that the estimated age-standardized global prevalence of oral diseases had increased by 3.2% during the preceding three decades. That sounds like a modest increase, but the report’s startling case numbers lead to another conclusion. There are 1 billion more cases of oral disease today than in 1990. “Those are real people who are in pain and who need care because they have untreated disease,” says Habib Benzian, DDS, MScDPH, PhD, a research professor at NYU College of Dentistry who served on the team that produced the WHO report.

“You see a situation where the prevalence is stable and your conclusion is, our interventions seem to work,” Habib told me. “That view is a fallacy.” First, within the global prevalence statistics, modest decreases in high-income countries mask increases in prevalence in low- and middle-income countries, and even within countries, population groups are affected differently. Moreover, the persistent prevalence of oral diseases over 30 years — despite billions spent on dental care — constitutes an indictment of the status quo. As Habib put it, “We were not able to make a significant dent in oral disease using our current approaches.”

Universal Health Coverage

If the status quo is unacceptable, what should we be doing differently? In May 2022, the WHO adopted a global strategy, which put forth Universal Health Coverage (UHC) by 2030 as a means for enabling all people to enjoy the highest attainable state of oral health. To American ears, UHC may sound like dental insurance for all, but the WHO imbues the term “coverage” with a broader meaning. The WHO defines UHC as a state in which “all people have access to the full range of quality health services they need, when and where they need them, without financial hardship.” Applied to oral health, global UHC would mean all countries made health promotion, prevention, treatment, and rehabilitation services readily available to individuals and communities at an affordable cost.

In tandem with the recent report, the WHO released profiles of the oral health status of 194 WHO member countries. These profiles make clear that UHC is achievable, even in countries with emerging economies. Thailand stands out for having managed to provide essential oral health services to its population. Oral health benefits are integrated in all its insurance programs, and a school-based oral health program helps children develop good oral habits early in life.

Challenges at Home

In contrast, the report’s authors are openly critical of countries, including the United States, that they say “are embroiled in heated professional and political debates around offering limited oral health coverage for some disadvantaged population groups.” (See my recent posts on Medicaid dental benefits and care for veterans and people with disabilities for some specifics.) In a commentary, which appeared in The Lancet, the authors wrote that oral health is frequently viewed in these nations as “non-essential” and “a private matter,” with workforce shortages, unequal geographic distribution of oral health professionals, over-reliance on dentists, and little integration of oral health and primary care contributing to a lack of access.

I asked Habib if he thought the United States was on track to achieve UHC by 2030 as the report recommends. “I think the U.S. is heavily off track in many ways,” he said, noting the challenges inherent in changing policy in a nation with 50 largely autonomous states. He sees the focus on deriving profit from providing care as another barrier to reaching UHC. “We have a system that spends more on health care per capita than any country in the world with mediocre outcomes, so the situation of oral health is one symptom of bigger system issues,” he believes.

Where NYU Dentistry Fits In

Before joining NYU, Habib worked with the World Dental Federation (FDI) in Geneva, Switzerland, and then as a consultant for the WHO and other international agencies. This established relationship positioned NYU Dentistry’s Department of Epidemiology & Health Promotion, which I currently serve as interim chair, to become a WHO Collaborating Center for Quality Improvement, Evidence-based Dentistry in December 2016 with Professor Richard Niederman, DMD, as its first director. Habib and his colleague Eugenio Beltrán, DMD, DrPH, MPH, currently co-direct the Collaborating Center, which is the only one of its kind in the Americas.

Department faculty support the WHO’s oral health mission in a variety of ways. In addition to raising awareness and advocating for oral health and they work with colleagues internationally to determine which oral health interventions are most cost-effective. The Collaborating Center’s success in its early years led to a renewal of the WHO agreement in 2021.

Moving ahead, the Collaborating Center will continue to work with the WHO as it develops a comprehensive global oral health action plan and a framework for monitoring its implementation. The Global Oral Health Status Report presents a foundation for these efforts by providing baseline data that can be used to monitor progress. Although the report is not focused on policy solutions, its advocacy message is clear and strong: “Continuing with ‘business as usual’ is not an option,” it states, echoing a point Habib made when we spoke. “We need to move away from the idea that all diseases can be treated away because they cannot. We will never have enough oral health professionals to seal every tooth or treat every case of dental caries.”

I agree. Continuing to pour billions of dollars into established models of clinical care without also taking concerted steps to improve access and prevent disease will merely reinforce an unacceptable status quo. In showing that nearly half the world’s people have some form of oral disease, the WHO report reveals the magnitude of the problem. In sounding the alarm, its authors challenge us to muster the political will to move beyond the current state of global oral health and shift policy, both at home and globally.