THE ORAL HEALTH ATLAS by Myriad Editions

Despite its importance for individuals and health systems, oral health is still a neglected area in both national and international health and politics. FINLAND NORWAY

The Oral Health Atlas highlights the extent of the problem worldwide and suggests realistic individual and populationwide solutions. This unique combination of short texts, fullcolour maps and graphics presents complex statistics and facts in an intuitive, easy-to-understand visual format.

SWEDEN

IRELAND

LATVIA LITHUANIA

DENMARK

RUSSIA

BELARUS

NETH. GERMANY BELGIUM

LUX. SWITZ.

FRANCE PORTUGAL

LEB. ISRAEL

MALTA

CZECH REP.

IRAQ

LIBYA

CHAD

UAE

YEMEN

GHANA TOGO BENIN

UGANDA

SOMALIA

KENYA RWANDA BURUNDI TANZANIA

SEYCHELLES COMOROS

ANGOLA ZAMBIA

MADAGASCAR

Cover design by Myriad Editions ZIMBABWE

Front cover photograph: young boy with NAMIBIA BOTSWANA missing tooth, Shaolin, China © Justin MOZAMBIQUE

BackSOUTH cover (from top): girl, Benin © Peeter LESOTHO AFRICA Viisimaa / istock; dental inspection © Tjerrie Smit / istock.

2:1 ALGERI A When tooth emerges

BRAZIL

Upper Teeth

BOLIVIA CHILE

PARAGUAY

Lateral incisor

7 to 8 years GUINEA-BISSAU 8 to 9 years

Canine

11 to 12 years

First premolar

10 to 11 years

Second premolar

10 to 12 years

First molar

6 to 7 years

Second molar

12 to 13 years

Third molar (wisdom tooth)

17 to 21 years

ARGENTINA URUGUAY

2:1 5:1

www.fdiworldental.org www.oralhealthatlas.org

1:1 MAURITANIA

MALI

2:1 NIGER

GAMBIA GUINEA SIERRA LEONE

CÔTE D’IVOIRE

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Central incisor

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GABON EQUATORIAL GUINEA CONGO

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Guariglia / National Geographic Collection / Getty Images. SWAZILAND

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ETHIOPIA CENTRAL AFRICAN REP.

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1:1 SWAZILAND

WHO Collaborating Centre for Oral Health, Faculty of Dentistry, University of the Western Cape

ISBN: 978-0-9539261-6-9

9 780953 926169

Beaglehole, Benzian, Crail and Mackay

COLOMBIA

GREECE

ETHIOPIA

DEMOCRATIC REPUBLIC OF CONGO

VENEZUELA

PANAMA

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SUDA N

CENTRAL AFRICAN REP.

SAO TOME & PRINCIPE

• dental decay and other major oral diseases • major risk factors for oral diseases • prevention • treatment • oral health workforce • strategies • major international stakeholders • history and future • research and education • global oral health scorecard

AFGHANISTAN

DJIBOUTI

Complemented by an extensive table of globalSIERRA oral health NIGERIA LEONE LIBERIA CAMEROON data and a reference section, The Oral Health Atlas coversEQUATORIAL GUINEA GABON a wide range of topics, including: CÔTE D’IVOIRE

MACEDONIA IRAN

SAUDI ARABIA

BURKINA FASO

GUINEA

MOLDOVA

KUWAIT

BAHRAIN QATAR

EGYPT

CAPE VERDE

GUINEA-BISSAU

UKRAINE

SLOVAKIA

ALB.

JORDANITALY

SPAIN

The Oral Health Atlas is a valuable resource for dentalALGERI A practitioners, public health experts, students, policy MAURITANIA MALI NIGER makers, and anyone interested in oral health. SENEGAL

POLAND

AUSTRIA HUN. SLOV. ROMANIA CRO. B-H SERBIA BULGARIA

ANDORRA

MOROCCO

GAMBIA

ESTONIA

THE ORAL HEALTH ATLAS

Oral health is an integral part of general health and wellbeing, yet more than 90% of the world’s population experience oral or dental problems in their lifetime.

ORAL HEALTH

The

Atlas

Mapping a neglected global health issue

Roby Beaglehole Habib Benzian Jon Crail Judith Mackay

blank page

The

ORAL HEALTH Atlas

MAPPING A NEGLECTED GLOBAL HEALTH ISSUE

Now set the teeth, and stretch the nostril wide; Hold hard the breath, and bend up every spirit ... William Shakespeare, Romeo and Juliet, Act III, scene 1

The

ORAL HEALTH Atlas

MAPPING A NEGLECTED GLOBAL HEALTH ISSUE

Roby Beaglehole Habib Benzian Jon Crail Judith Mackay

With contributions from:

WHO Collaborating Centre for Oral Health, Faculty of Dentistry, University of the Western Cape

International Federation of Dental Educators and Associations

First published by FDI World Dental Federation in 2009 Text and illustrations copyright © FDI World Dental Education 2009 Maps, graphics and original concept copyright © Myriad Editions 2009 All rights reserved The moral rights of the authors have been asserted ISBN: 978-0-9539261-6-9 Produced for the FDI World Dental Federation by Myriad Editions 59 Lansdowne Place Brighton, BN3 1FL, UK www.MyriadEditions.com Edited and coordinated by Jannet King, Candida Lacey and Elizabeth Wyse Designed by Isabelle Lewis and Corinne Pearlman Maps and graphics created by Isabelle Lewis

Printed on paper produced from sustainable sources. Printed and bound in Hong Kong through Lion Production under the supervision of Bob Cassels, The Hanway Press, London

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the written permission of FDI World Dental Federation. Requests for permission to reproduce any material and other enquiries should be directed to FDI World Dental Federation, Tour Cointrin, Avenue Louis Casaï 84, 1216 Cointrin, Switzerland, info@oralhealthatlas.org The views expressed in this document do not necessarily represent the official views of the FDI World Dental Federation or any other organisation mentioned. The authors have done their utmost to ensure accuracy of all information; however, the inclusion of links and references does not entail recognition or endorsement of information given under these links nor can they be held liable for any wrong information. The use of specific product names does not imply endorsement or recommendation of these products in any way. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The terms “low-income”, “middle-income” or “high-income” country used in this report follow the definitions of the World Bank Group.

CONTENTS 9 HIV/AIDS HIV/AIDS can cause serious oral diseases. Oral health professionals can help in early detection of HIV/AIDS from oral signs.

10 Birth Defects Birth defects require early intervention to avoid serious impact on quality of life.

11 Trauma Head and tooth trauma are important public health problems worldwide.

12 Economics Dental care is both an important industry and unaffordable for most countries.

13 Impact of Oral Diseases Oral diseases and oral pain have great impact on individuals, populations, health systems and society at large.

Part 3: RISK FACTORS

14 Risk Factors A range of oral and other chronic diseases can be reduced, or even prevented, when the key risk factors responsible are addressed.

15 Sugar High sugar consumption is a key risk factor for dental decay and many other health problems.

6 Gum Diseases Gum (periodontal) diseases are widespread and are the leading cause of tooth loss.

16 Tobacco Tobacco use in all forms is dangerous for health and oral health. Dentists and their teams can help patients to quit.

7 Oral Cancer Oral cancer is among the ten most common cancers worldwide and can be largely prevented by reducing alcohol and tobacco consumption.

17 Socio-economic Status Socio-economic status is a key risk factor for many oral diseases, and significantly determines both general and oral health.

8 Noma Noma is a neglected, deadly and disfiguring disease of poverty, affecting mainly children.

Foreword â&#x20AC;&#x201C; Dr. Burton Conrod The Authors Preface Acknowledgments Contributing Authors

7 8 9 10 11

PART 1: INTRODUCTION

1 Oral Health Oral health is essential to general wellbeing. Oral diseases have a significant impact on individuals, communities and health systems.

2 Teeth for Life Primary and secondary teeth are both important for a healthy mouth throughout an entire lifetime.

3 Oral Health and General Health The mouth can reflect the state of general health. Conversely, oral diseases can have an impact on general health.

PART 2: BURDEN AND INEQUALITIES

4 Tooth Decay Dental decay (caries) is the most common chronic disease on the planet, yet it is preventable.

5 Mapping Dental Caries Dental decay remains largely untreated and there are widespread inequalities both between and within countries.

PART 4: SOLUTIONS – TAKING ACTION

PART 6: ACTORS AND ORGANISATIONS

18 Behaviour and Choices Oral diseases are preventable by appropriate behaviour, which is reinforced and encouraged by public health policies and health promotion.

27 Dental Education Dental education should ensure that oral health professionals are equipped with the necessary skills to meet the needs of their patients and populations.

19 Fluoride Universal access to fluoride for dental health is part of the basic human right to health.

28 Dental Research Research is the cornerstone of sound and effective policy and practice – from the personal to the political.

20 Fluoride Toothpaste The widespread use of fluoride toothpaste has been recognised as the single most important reason for the decline of dental caries.

29 FDI World Dental Federation FDI is a federation of over 190 dental associations whose vision is to lead the world to optimal oral health.

21 Treatment Modern dental treatment can restore almost all functions and aesthetics of a healthy dentition.

30 World Health Organization The WHO is the UN agency in charge of international health. Its Global Oral Health Programme provides policy guidance and technical assistance to member states.

Part 7: PAST, PRESENT AND FUTURE

22 Oral Health and Primary Health Care 60 Basic oral care and prevention are possible even in low-resource settings, using cost-effective and evidence-based interventions. 23 Advocacy and Integration International policies and the UN Millennium Development Goals support the integration of appropriate oral health services in health systems worldwide.

PART 5: ORAL HEALTH WORKFORCE

24 The Dental Team Dental teams function in a variety of settings, ranging from high-tech clinics to simple community or field settings.

25 Dentists There are more than a million dentists worldwide – but unequally distributed, leaving many of the world’s poorer countries with a shortage of qualified dentists.

26 Workforce Challenges The global oral health workforce is in constant change. Innovative solutions are required.

31 History: Dentistry 7000 BCE – AD 1699 84 32 History: Dentistry 1700–1899

33 History: Dentistry 1900–2009

34 The Present: A Scorecard Oral diseases are a neglected issue in global health, particularly in low- and middle-income countries.

35 The Future Despite advances in science and technology, the challenge of inequalities in oral health status will remain.

Part 8: ANNEX – WORLD TABLE

World Table Comments on Data References Photo Credits Glossary Index

96 104 107 115 116 118

FOREWORD

ore and more people realise the importance of good oral health and how negative the impact of oral diseases can be on daily performance, social participation and general well being. Oral diseases are to a very large extent preventable, yet when they occur they can be among the most expensive to treat or cure. Despite the central role of the mouth as gateway to, and mirror of, the body, general knowledge about prevention of oral disease is limited. Health planners and politicians are often unaware of the magnitude and impact of oral diseases and believe dental treatment and preventive services are an optional luxury. Others think that oral care is just too costly for their health care system, and often no budgets are allocated to this sector. Yet simple, effective and evidence-based interventions exist that can help, in rich and poor countries alike, to reduce the burden of oral diseases significantly. “Oral health is a neglected area of international health” – these words of the Director-General of the World Health Organization, Dr. Margaret Chan, expressed during the landmark 120th session of the WHO’s Executive Board in 2007, were a wake-up call for the international health community. They were also tremendous encouragement for us to continue the long-standing advocacy work of the FDI World Dental Federation. Dental caries is the most common chronic non-communicable disease in the world, but few people, even in public health, know about this fact. This Oral Health Atlas is intended to draw attention, in a graphic manner, to the huge burden of oral disease around the globe, highlighting the key risk factors, workforce issues, stakeholders and solutions. It is hoped that it will be used as a tool to both demonstrate the problems and motivate health care providers, governments and the public to take action. Oral health is subject to a number of key risk factors. Fortunately, avoidance of risk factors such as high sugar consumption, poor nutrition, poor basic hygiene and tobacco use will also prevent many other serious health problems. Good oral health is not something that we should take for granted. The recognition of oral health as a basic human right commits all of us, particularly the dental profession, to do everything possible to improve access to quality care and preventive programmes – for every citizen of the world. This Atlas provides a snapshot of the status and challenges of oral health globally. Its maps clearly highlight the lack of current data in many areas important to oral health. I see it as the first edition of an important publication that will be updated periodically to capture and communicate the ever-changing picture of global oral health. I encourage FDI member associations and other organisations to translate the Oral Health Atlas into other languages to facilitate the dissemination of information. The FDI World Dental Federation, with its vision of “leading the world to optimal oral health”, is proud to present this Atlas to the global audience. Please study and use it to help make the dream of “(Oral) Health for All” become a reality.

Dr. Burton Conrod, Canada President, FDI World Dental Federation, 2007–09

THE AUTHORS Dr. Roby Beaglehole (co-author) is based in Nelson, New Zealand and works as a public health consultant and as a clinical dentist. Dr. Beaglehole graduated from Otago University, New Zealand in 1997 and gained an MSc in Dental Public Health from University College London, UK in 2003. He has previously worked as a consultant to the Department of Health in the UK and as a political advisor to the New Zealand Government. He is co-author of the FDI/WHO publication Tobacco or Health, as well as several other guidelines, conference reports and publications.

Dr. Habib Benzian (co-author & project leader) is based in Berlin, Germany, and was the first Associate Director for Development and Public Health at the FDI World Dental Federation’s head office in Geneva, Switzerland (from 2002–09). He is an experienced oral surgeon and recognised expert in international dental public health. Dr. Benzian graduated in 1987 at Free University of Berlin/Germany and holds an MSc in Dental Public Health from King’s College, London. Joining the FDI in 2002, he helped in developing and reshaping the FDI’s Public Health activities. He has organised several international conferences and symposia on oral health, among them the first-ever ministerial meeting on oral health in Africa. He is lecturer in dental public health at the University College London and other European universities; as well as speaker at oral health conferences worldwide.

Mr. Jon Crail (co-author) is the Manager, Public Health and Advocacy Projects at the FDI World Dental Federation in Geneva, Switzerland. He holds a university degree from Kalamazoo College in political science and an MSc in Health, Community and Development from The London School of Economics and Political Science. He has developed, managed and evaluated public health and development projects in partnership with Central American governments and a variety of national and international NGOs. Mr. Crail is also the founder and director of Digital Roots, an NGO that empowers communities to investigate, document, and share their culture and history through the use of digital technologies to create physical and virtual museums.

Dr. Judith Mackay (co-author) is a medical doctor based in Hong Kong. She is Senior Advisor to the World Lung Foundation; Senior Policy Advisor to the World Health Organization; and Director of the Asian Consultancy on Tobacco Control. She holds professorships at the Department of Community Medicine at the University of Hong Kong and at the Chinese Academy of Preventive Medicine in Beijing. She is a Fellow of the Royal Colleges of Physicians of Edinburgh and of London. After an early career as a hospital physician, she moved to preventive and public health. In 2007, she was selected as one of the TIME 100 World’s Most Influential People, and in 2009 she received the first-ever Lifetime Achievement Award from the British Medical Journal Group. She has authored or co-authored several Myriad atlases: The Tobacco Atlas, The State of Health Atlas, The Penguin Atlas of Human Sexual Behaviour, The Atlas of Heart Disease and Stroke, and The Cancer Atlas.

PREFACE

he Oral Health Atlas is intended for readers interested in global health issues, and serves as an invaluable resource for health professionals and policy makers, and for those interested in how better to look after their own oral health. The Atlas demonstrates that oral health has all the ingredients of a fascinating public health story: it is both personal and political, encompassing total health, political will, economics, big business (sugar, tobacco and personal care), allocation of resources, poverty, children and human development, and it will be crucially important in the future. There are several surprises for most general readers and even, we suspect, for many health professionals: • The first is that oral health problems and rudimentary treatments have been identified and described for many thousands of years. • Secondly, oral health is not limited to teeth – there are many intriguing parts of the mouth, with surprising functions, which also need to be cared for. • Oral health does not just involve the mouth but is intertwined with the health of the whole body. Thus, modern oral health care is far removed from the traditional “drill, fill and bill” concept of dentistry, but rather involves caring for the health of the complete body. • Perhaps more expected, but utterly regrettable, the Atlas maps the huge gap in oral health between rich and poor countries, high- and low-income populations. The little boy on the cover exemplifies the high-risk child: from a low- or middle-income country, probably without access to adequate dental care, who already has serious tooth decay – a path towards life-long oral health problems. The Oral Health Atlas maps the history, documents the current situation and challenges, as well as predicts the future of oral health. There is a marketing maxim “If you can’t measure it, you can’t manage it” and the Atlas emphasises the urgent need for better data on oral health. We encourage you to read our comments on the data sources where the problems and shortcomings of current global oral health data are highlighted. The Atlas also looks at solutions and reflects the importance of multiple approaches to improving oral health, requiring action by the World Health Organization, governmental and non-governmental organisations (NGOs), the private sector and individuals. Integration and collaboration are the key words here; oral health initiatives require that efforts be made both to alter personal behaviour and inform population policy. We hope that a future edition of the Atlas will be able to map the broad landscape of other stakeholders, such as the dental industry, dental NGOs and others. In the last few decades we have seen developments and improvements which have had a global impact, ranging from the introduction of fluoride toothpaste in 1955 to the reduction of one of the major risk factors – tobacco – by the 2005 WHO Framework Convention on Tobacco Control. The good news is that nearly all oral diseases are preventable and most are also treatable. Unlike our colleagues in other fields of health, we are lucky enough to have both the knowledge and the tools to significantly improve oral health worldwide, drastically improving both the quality of life and economic productivity of nations. The Atlas is thus a challenge, an opportunity and a “call to action” to be bold and improve oral health now, so that within our lifetime millions of people will be able to benefit from better health and human development. Roby Beaglehole, Nelson, New Zealand Habib Benzian, Berlin, Germany Jon Crail, Geneva, Switzerland Judith Mackay, Hong Kong SAR, China

ACKNOWLEDGMENTS The authors would like to thank the following people for their help and encouragement, without which this book would not have been possible: The FDI World Dental Federation and the Executive Director David Alexander, who wholeheartedly supported the development of this publication after taking office, for constant support and vision in developing this publication; and the World Lung Foundation for generously covering Judith Mackay’s and Ellie Rampton’s time during the drafting and editing process. We thank Unilever Oral Care Ltd for an educational grant which helped to make this atlas possible. We thank all organisations that support this publication by lending their logos to it: The International Association for Dental Research (IADR) in Alexandria, USA, the International Federation of Dental Educators and Associations (IFDEA) in Washington DC, USA and the WHO Collaborating Center on Oral Health at the University of the Western Cape, Cape Town, South Africa. We are indebted to Lois Cohen and Wim van Palenstein Helderman for reviewing the atlas content and for sharing their unique experience, wisdom and insight. The authors are grateful to all members of the FDI’s World Dental Development & Health Promotion Committee (WDDHPC), in particular to the chairman George Weber, for providing support and guidance. Special thanks go to Christopher Holmgren, appointed expert to the WDDHPC for his critical eye, constant availability and cordial friendship. Some colleagues at the FDI Head Office were involved in various aspects of putting this atlas together. We are grateful to Djerdana Ivosevic for her attention to detail and general support; Sylvie Dutilloy for her help with FDI membership information; Christina Thorsen and the former staff member Charlotte Nackstad, for their outstanding proofreading skills. Furthermore, we would like to thank: The Executive Director Nathan Grey and Rennie Sloan from the American Cancer Society, for allowing us to use data on global tobacco consumption; The International Agency for Research on Cancer (IARC), Lyon, France, for permission to use their data on oral cancer; Newell Johnson, Foundation Dean, School of Dentistry and Oral Health, Griffith University, Southport, Australia, for his advice on presenting oral cancer data; Sudeshni Naidoo, University of the Western Cape, for her spontaneous commitment to the atlas project and for drafting the spread on HIV/AIDS; Charlotte Faty Ndiaye, WHO/AFRO, for her friendship and leadership on noma and other aspects of the atlas relating to the African content; Richard Watt, Department of Epidemiology and Public Health, University College, London, UK, for his contributions to several spreads; Sheila Jones, the British Fluoridation Society, and George Gillespie, former PAHO Regional Advisor for Oral Health, for their help with the fluoride data; Ann Goldman, George Washington University, and Robert Yee, National University of Singapore, for data on affordability of fluoride toothpaste; Jo Frencken from the Centre for Global Oral Health, Radboud University, Nijmegen, Netherlands for advising on content and sharing images for the Basic Package of Oral Care (BPOC); Bella Monse, Department of Education, Philippines, for allowing us to use photos and data from the Fit for School Programme; Dairmuid Shanley, Majella Giles, both from Trinity College, Dublin, and the Executive Director Richard Valacovich of the International Federation of Dental Educators and Associations (IFDEA) for their help with the dental education spread; Sarah Hodges, Uganda, for allowing us to quote her on birth defects; Eduardo Ortiz from the University College London for helping with the socio-economic data; Martin Hobdell, University College London, for contributing to the spread on socio-economic risk factors and his good advice on many other aspects of the atlas; Ingrid Thomas and the Executive Director Christopher Fox of the International Association for Dental Research (IADR) for their help with the dental research spread; Poul Erik Petersen, Global Oral Health Programme, WHO Geneva, for providing input from the World Health Organization and for helping with the spread on the WHO; Robert Yee for allowing us to use data on impact of oral diseases from his PhD thesis; Stanley Gelbier, Professor Emeritus for Dental Public Health, King’s College London, and Ilona Marz, Institute for History of Medicine, Charité University, Berlin, Germany, for reviewing the historical facts. Particular thanks go to the GIS Laboratory of Xavier University, Cagayan de Oro, Philippines and its leader Mark Alexis Sabines for meticulous checking of map data, and to Rafael Oclarit for managing this process. A very special thanks to our spouses and partners, Erika Anderson, Sam Loe, Martin Lack and John Mackay, who were patient and supportive when we put in the extra hours, nights, weekends and travel necessary to complete this book. We were privileged to work with the experienced team at Myriad Editions; we admired their patience and creativity and hope that they like the result of the work as much as we do! And finally, we, the authors, would like to thank each other for a unique journey and wonderful team spirit. We hope that the passion and dedication that went into this book will make a difference to oral health worldwide.

CONTRIBUTING AUTHORS The following authors (listed in alphabetical order) contributed to the coverage of specific topics: Dr. Christopher Fox is the Executive Director of the International and American Associations for Dental Research. He earned a dental degree and a doctorate in oral biology and oral epidemiology from Harvard University. He also completed residencies in periodontology and dental public health. (28 DENTAL RESEARCH) Prof. Jo Frencken lived for 14 years in three African countries as a lecturer, researcher and practitioner. He pioneered the ART approach, lectures and undertakes research in multi-country and multi-cultural settings. He is Director of the Department of Global Oral Health, Radboud University Nijmegen, Netherlands. (22 ORAL HEALTH AND PRIMARY HEALTH CARE) Prof. Martin Hobdell was Professor, Community & Preventive Dentistry at Trinity College Dublin; Dean, Faculty of Dentistry at University of the Western Cape, South Africa; Chair, Department of Dental Public Health & Dental Hygiene at University of Texas Health Science Center, Houston. He is currently Visiting Professor in Dental Public Health, University College London, and Co-Director of the Master’s programme in Dental Public Health, University of Health Sciences, Lao PDR. (17 SOCIO-ECONOMIC STATUS) Dr. Christopher Holmgren is visiting Professor to the Department of Global Oral Health, Radboud University Nijmegen, Netherlands. He works as consultant to international health organisations, including the FDI. He is co-author of Atraumatic Restorative Treatment for Dental Caries and the WHO Basic Package of Oral Care. He is currently working on the promotion of the appropriate use of fluoride for the prevention and control of caries in developing countries and disadvantaged communities, including the development of Arresting Caries Treatment approaches. (19 FLUORIDE, 20 FLUORIDE TOOTHPASTE) Prof. Sudeshni Naidoo is a Professor and Specialist in the Department of Community Oral Health, Faculty of Dentistry University of the Western Cape. She is the Director of the WHO Collaborating Centre for Oral Health. Her main focus of research are infectious diseases and infection control. She is member of the Health Professions Council of South Africa, is President-elect of the SA Division of the IADR and past National Vice-President of the South African Dental Association. (9 HIV/AIDS) Prof. Charlotte Faty Ndiaye is the Regional Advisor for Oral Health in WHO/AFRO. Expert in oral pathology and public health, she was member of the oral health expert group developing the WHO Regional Strategy for Oral Health and is leading the Global WHO Noma programme. (8 NOMA) Ellie Rampton, who has a Master’s Degree from the University of Exeter, UK, divides her time between freelance writing projects and working for the World Lung Foundation, alongside Dr. Judith Mackay, in Hong Kong. She has been involved in the development of three atlases. In this Atlas, she was delighted to contribute research, creative ideas and editing support. Prof. Richard Watt is Professor of Dental Public Health at UCL. He was co-founder and Past President of the Oral Health Promotion Research Group and is the Immediate Past President of the British Association for the Study of Community Dentistry. He currently sits on a variety of expert working groups for the Department of Health, NICE, WHO and European Union. (3 ORAL HEALTH AND GENERAL HEALTH, 14 COMMON RISK FACTORS, 18 BEHAVIOUR AND CHOICES) Reviewers: Dr. Lois Cohen is consultant to the National Institute of Dental & Craniofacial Research (NIDCR), National Institutes of Health, USA, and the Canadian Institute for Health Research, as well as a number of global health agencies, associations and universities. Named in 2006 as a Paul G. Rogers Ambassador for Global Health Research, she is a research sociologist by education whose most recent position was Associate Director for International Health, NIDCR. Before her retirement in 2006, she also served as the Director of the WHO Collaborating Center for Dental & Craniofacial Research and Training. Prof. Wim van Palenstein Helderman is professor in education and research on oral health care for deprived communities at the College of Oral Science, Nijmegen, the Netherlands. Previously he was chair for community and preventive dentistry as well as co-ordinator of the establishment of the dental school in Dar es Salaam, Tanzania. He also serves as Co-Editor of the journal Nederlands Tijdschrift voor Tandheelkunde; was member and co-chair of the FDI’s World Dental Development and Health Promotion Committee; and was consultant for the WHO and other international and national agencies in developing countries.

The job of a citizen is to keep his mouth open. G端nther Grass, German Nobel Laureate for Literature, 1999

Part 1 INTRODUCTION 13

THE MOUTH IN ACTION

Every tooth in a man’s head is more valuable than a diamond. from Don Quixote by Miguel de Cervantes, Spanish author, 1547–1616

ral health is an important international public health issue; oral diseases have a significant impact on individuals, communities, health systems, economies and society at large. Oral health refers to the entire mouth, not just the teeth. It includes the gums, the hard and soft palate, the linings of the mouth and throat, the tongue, lips, salivary glands, chewing muscles, and the upper and lower jaws. The World Health Organization defines oral health as “a state of complete physical, mental and social wellbeing, not merely the absence of tooth decay, oral and throat cancers, gum disease, chronic pain, oral tissue

ORAL HEALTH 1 Oral health is essential to general wellbeing. Oral diseases have a significant impact on individuals, communities and health systems. THE ADULT MOUTH lip

fraenum gum

incisors canine premolars

palate

molars uvula

tonsil

floor of mouth

gum

tongue

molars premolars canine incisors

fraenum

SOME OF THE THINGS THE MOUTH CAN DO breathe speak express

lip

attract taste drink bite

lesions, birth defects … and other diseases and disorders that affect the oral, dental and craniofacial tissues”. Oral health is an essential and integral component of overall health. Oral diseases impact on general health and systemic diseases show symptoms in the oral structures. An unhealthy mouth and teeth may limit people’s ability to take in food, thereby affecting their capacity to study or work. It may also affect their social interactions. Tooth decay (dental caries) and gum diseases (periodontal diseases) affect virtually every human being during their lifetime, although both diseases are almost entirely preventable.

eat lick suck spit kiss whistle make music

The “tooth fairy” is a popular western myth about a fairy who gives children a present in exchange for a baby tooth that has fallen out.

When tooth erupts

PRIMARY TEETH

Upper teeth

One in every 2,000 infants is born with one or more teeth already present.

Lower teeth

Adam and Eve had many advantages, but the principal one was that they escaped teething. Mark Twain, US author, 1835–1910

In some Asian countries there is a tradition of throwing lost baby teeth on the roof or putting them under floorboards for luck.

When tooth falls out

Central incisor

8 to 12 months

6 to 7 years

Lateral incisor

9 to 13 months

7 to 8 years

Canine

16 to 22 months

10 to 12 years

First molar

13 to 19 months

9 to 11 years

Second molar

25 to 33 months

10 to 12 years

Second molar

23 to 31 months

10 to 12 years

First molar

14 to 18 months

9 to 11 years

Canine

17 to 23 months

9 to 12 years

Lateral incisor

10 to 16 months

7 to 8 years

Central incisor

6 to 10 months

6 to 7 years

he development of the human dentition is a complex process, with a primary set of 20 teeth and a permanent set of 32 teeth. Occasionally, there are extra (supernumerary) teeth. Primary teeth (baby teeth, milk teeth or deciduous teeth) start to form between the sixth and eighth week in the womb, and permanent (secondary) teeth begin to form in the twentieth week in the womb. Babies get their first teeth at around six to eight months of age, usually starting with the lower two front teeth. The remaining baby teeth erupt at regular intervals and usually all 20 teeth have erupted by the age of two-and-a-half. Like adult teeth, primary teeth are important for both eating and appearance, but they also act as a stimulus for the jaws and face

Eight muscles are needed for chewing – their maximum force is 200 kg/cm2 (the force of a lion’s bite is about 350 kg/cm2).

Normal saliva production can vary from between 0.75–1.5 litres per day.

TEETH FOR LIFE 2 Primary and secondary teeth are both important for a healthy mouth throughout an entire lifetime.

PERMANENT TEETH When tooth erupts

Upper teeth

Every dentition is unique and characteristic – it can even be used to identify an individual after a serious accident or death.

Lower teeth

Central incisor

7 to 8 years

Lateral incisor

8 to 9 years

Canine

11 to 12 years

First premolar

10 to 11 years

Second premolar

10 to 12 years

First molar

6 to 7 years

Second molar

12 to 13 years

Third molar (wisdom tooth)

17 to 21 years

Third molar (wisdom tooth)

17 to 21 years

Second molar

11 to 13 years

First molar

6 to 7 years

Second premolar

11 to 12 years

First premolar

10 to 12 years

Canine

9 to 10 years

Lateral incisor

7 to 8 years

Central incisor

6 to 7 years

to grow and maintain spaces for the permanent teeth to erupt from underneath. Early loss of baby teeth as a result of accidents or tooth decay often leads to overcrowding of the permanent teeth. The permanent teeth start to erupt around the age of six to eight and again, the front teeth (incisors) on the lower jaw are usually the first to appear. While the outer coating of the tooth (enamel) is the hardest tissue of the human body, teeth have a soft-tissue interior (pulp) with nerves and blood vessels. Throughout life, tooth wear causes loss of enamel or underlying dentin. In the absence of gum diseases or other reasons for tooth loss it is possible to retain a functioning full dentition for a lifetime.

SOME IMPACTS OF ORAL CONDITIONS ON GENERAL HEALTH HIV/AIDS often manifests in the mouth.

Diabetes can result in delayed wound healing and the worsening of gum disease.

Low blood sugar level can be detected by a characteristic odour.

Leukaemia may result in oral ulcers. Syphilis during pregnancy can result in characteristic tooth and palate malformation in the child.

Tetracycline antibiotic use by pregnant mothers or children can result in an enamel malformation and staining of the children’s teeth.

Stress and psychological disorders can lead to grinding, clenching and TMJ joint problems.

Measles is usually detected by characteristic spots on the inner cheeks.

Down Syndrome often includes an enlarged tongue.

Tuberculosis may show as a characteristic ulcer of the tongue surface or other oral tissues.

Drug abuse is often associated with severe caries and tooth loss.

Xerostomia (dry mouth due to lack of saliva) results in rapid dental decay.

Bulimia often causes characteristic tooth erosions (from gastric acid).

Tetanus infection may result in lockjaw.

Various genetic syndromes cause malformation of teeth and jaws.

Scurvy, a vitamin C deficiency, can result in swollen, bleeding gums and tooth loss.

In the past half-century, we have come to recognise that the mouth is a mirror of the body, it is a sentinel of disease, and it is critical to overall health and well-being. David Satcher, US Surgeon General, 1998–2002

he mouth is a gateway to the body and can be used as an early warning system for health practitioners. Signs in the mouth can indicate trouble in other parts of the body. For example, mouth lesions and other oral conditions may be the first sign of HIV infection and can be used as indicators to follow its progression to AIDS. An oral examination can also reveal other diseases, general health status and habits such as tobacco and other drug use. Oral diseases share common determinants with many other chronic diseases, such as diabetes and heart disease. The mouth should be seen as an interrelated part of the body. Patterns of oral disease mirror those of many other chronic diseases. Inequalities in both general and oral health

ORAL HEALTH AND GENERAL HEALTH 3 Dental treatment is required before heart surgery to avoid complication from dental infections.

SOME IMPACTS OF SYSTEMIC DISEASE ON ORAL HEALTH

Edentulousness (loss of teeth) within the elderly population results in impaired ability to chew and can lead to malnutrition. Dental infections have been associated with higher increased risk for pneumonia. The mouth may be a reservoir for bacteria associated with stomach ulcers. Saliva and oral swabs are used to detect compounds, genes, diseases and conditions, as well as to identify individuals through their DNA.

Gum disease can complicate diabetes. Oral bacteria are associated with infective arthritis.

The mouth can reflect the state of general health. Conversely, oral diseases can have an impact on general health.

Gum disease can be the starting point for noma. Oral bacteria are associated with infective endocarditis (inflammation of the heart's inner lining). Gum disease has been associated with higher risk of cardiovascular disease.

Gum disease has been associated with higher risk of pre-term babies. Gum disease has been associated with higher risk of low-birthweight babies.

FICTION

Early intervention using the Castillo-Morales Manual Orofacial Therapy and a specially designed palatal plate can improve orofacial function and facial growth in children with Down Syndrome.

are also very similar. These similarities highlight the close association between oral and general health. Oral and general health are linked and jointly influenced by psychosocial factors such as stress, behaviours such as diet and smoking, and broader socio-environmental factors. The evidence to date highlights the need for future oral health preventive programmes to be more integrated with general health-promotion activities.

Every baby costs the mother a tooth. FACT Hormonal changes during pregnancy are unlikely to result in tooth loss if good oral hygiene is maintained.

Health Action â&#x20AC;˘ If any oral problem (sores, swelling, bleeding, pain, etc.) persists longer than two weeks, consult a health professional.

No matter how we may attempt to rationalise it, profound disparities in oral health and disparate effects of oral diseases have been documented on our watch and during our time of leadership and stewardship for oral health! The range and magnitude of these disparities should trouble us all. Caswell A. Evans, College of Dentistry, University of Illinois at Chicago, 2006

Part 2 BURDEN AND INEQUALITIES 21

MAJOR FACTORS BEHIND TOOTH DECAY

• poor oral hygiene • low fluoride presence • harmful bacteria

BACTER

IAL

BI O

FIL

• age • low fluoride presence • poor nutrition • lack of essential trace elements • tooth shape

The number of bacteria in one mouth can easily exceed the number of people who live on Earth – more than 6 billion.

I M

P L A Q UE

L TA

CARIES

A tooth that was removed due to a large carious cavity.

• poor oral hygiene • low saliva flow • frequent and/or high sugar intake

The man with a toothache thinks everyone happy whose teeth are sound. from Man and Superman by George Bernard Shaw, Irish playwright, 1856–1950

ental decay (caries) is a major global public health problem. Caries is the most common childhood disease worldwide and the most common non-communicable disease on the planet. Caries is a multi-factorial disease for which at least three main factors must come together: dietary sugars (including carbohydrates), oral bacteria and time. Put simply, bacteria metabolise sugars and produce acids, which over time break down tooth enamel. The consequences of this process, if left untreated, are the destruction of the tooth’s hard tissues, pain, abscess and possible tooth loss. Caries can be diagnosed by sight, by using a probe, via x-ray (radiograph) or other advanced technology. Caries usually starts, often hidden from view,

TOOTH DECAY 4 Dental decay (caries) is the most common chronic disease on the planet, yet it is preventable.

EARLY CHILDHOOD CARIES As soon as a child’s teeth appear, at around 6 months of age, they are susceptible to a specific and rapidly progressing form of tooth decay called Early Childhood Caries (ECC). Frequent bottle-feeding with liquids containing sugars, particularly during the night, can be an important cause of what is sometimes referred to as “baby-bottle syndrome”. Where possible, breastfeeding instead of bottle-feeding is recommended.

Parents should give their babies and toddlers only water between meals and brush their teeth twice a day with a smear of fluoride toothpaste.

Toothache is the number one reason for absenteeism from schools in the Philippines and many other countries.

Tooth decay in the USA is five times more common than asthma and seven times more common than hay fever.

In 2000, 51 million hours of school were lost in the USA due to dental problems.

in the fissures of a tooth or in the tight spaces between teeth. Root caries are more frequent among adults. Caries is treated by removing the decayed tissue and then placing a filling in the cavity to restore the tooth function. On a global scale, most dental decay remains untreated due to unavailable or inappropriate oral-care services. Caries can be prevented by twice-daily toothbrushing with fluoride toothpaste, by applying fluorides, sealing the pits and fissures of molars, reducing the frequency of consuming sugars and carbohydrates, and by removing dental plaque (a film of bacteria that builds up on the teeth). Interventions related to personal behaviour and population-wide strategies must complement each other to effectively address the global burden of dental decay.

DENTAL PLAQUE

Dental plaque is a biofilm consisting of approximately 10,000 different types of bacteria, but only a few cause problems, and only one is mainly related to dental decay – Streptococcus mutans. Saliva can protect against caries by dilution and elimination of bacteria and sugars, by buffering bacterial acids, and remineralisation of damaged tooth surfaces. Patients with dry mouth (xerostomia) usually suffer from severe caries.

Health Actions • Cut down on sticky, sugary foods and soft drinks. • Avoid unhealthy snacks between meals. • Brush twice a day with a fluoride toothpaste. • Chew sugar-free gum after snacks. • Visit the dentist regularly.

WORLDWIDE DENTAL DECAY

The nation’s morals are like its teeth, the more decayed they are the more it hurts to touch them. George Bernard Shaw, Irish playwright, 1856–1950

Average number of Decayed, Missing and Filled permanent Teeth (DMFT) in 12-year-olds 2008 high; more than 3.5 moderate; 2.6 – 3.5 low; 1.2 – 2.5

CANADA

very low; 0.0 –1.1 no data USA

World average: 2.0 Highest: Croatia 6.7 Lowest: Rwanda, Tanzania, Togo 0.3

BERMUDA

BAHAMAS

MEXICO

CUBA CAYMAN IS.

BELIZE JAMAICA

Dental treatment accounted for only 3% of the reduction in tooth decay in 12-year-olds in industrialised countries during the last 40 years. The main factors were fluoride toothpaste and general socio-economic development.

HAITI

DOMINICAN REP. PUERTO RICO

ST KITTS & NEVIS

HONDURAS GUATEMALA ST VINCENT & THE GRENADINES EL SALVADOR NICARAGUA GRENADA COSTA RICA PANAMA

VENEZUELA

ANGUILLA ANTIGUA & BARBUDA DOMINICA MARTINIQUE ST LUCIA BARBADOS TRINIDAD & TOBAGO

53%

20%

SENEGAL GAMBIA GUINEA-BISSAU

GUYANA

COLOMBIA

CAPE VERDE

SURINAME

ECUADOR

PERU

BRAZIL

7% BOLIVIA CHILE

95%

ANATOMY OF TOOTH DECAY

Proportion of Decayed, Missing and Filled Teeth (DMFT) in children aged 11–14 years by nation grouping 1991–2004

73%

PARAGUAY

ARGENTINA URUGUAY

44%

teeth treated with filling teeth missing due to caries untreated decayed teeth

Caries is a disease of social deprivation, just as it is a disease of bad diets. Ole Fejerskov & Edwina Kidd, 2008

highincome

middleincome

lowincome

ooth decay (dental caries) is an ancient disease. Levels of caries rose during the 17th century and reached epidemic proportions in the 19th and 20th centuries. The FDI and WHO set Global Goals for Oral Health by the Year 2000, and over the last three decades caries rates dropped in high-income countries. Scientists believe that this improvement was mainly the result of the widespread use of fluoride. As populations of low-income countries adopt a more affluent lifestyle, high in sugar consumption, dental decay rates rise. Generally, caries rates are highest in middle-income countries where sugar consumption is high but access to prevention and care is low. Since 1938, tooth decay has been measured using an index known as

MAPPING DENTAL CARIES 5 Dental decay remains largely untreated and there are widespread inequalities both between and within countries.

ICELAND

FINLAND

NORWAY

SWEDEN

ESTONIA

RUSSIA

LITHUANIA

DENMARK IRELAND

PORTUGAL

BELARUS POLAND BEL. GERMANY UKRAINE CZ. SL. REP. LIECHT. LUX. MOLDOVA AUS. HUN. ROM. FRANCE SWITZ. SL. B-H SERB. S. M. CRO. BUL. MONT. NETH.

ALB.

MAC.

ITALY

SPAIN TUNISIA

ISRAEL

ALGERIA

LIBYA

ARMENIA

MONGOLIA NORTH KOREA

KYRGYZSTAN

CHINA

AFGHANISTAN

IRAN KUWAIT

PAKISTAN

NEPAL

BAHRAIN SAUDI ARABIA

UAE

IN DIA

BHUTAN

NIGER

ERITREA

SUDA N

Hong Kong SAR

LAOS

MYANMAR

KIRIBATI

PHILIPPINES

THAILAND

YEMEN

VIETNAM CAMBODIA

DJIBOUTI

GHANA TOGO BENIN

FED. STATES MICRONESIA

Macau SAR

BANGLADESH

OMAN

MALI

JAPAN

SOUTH KOREA

TURKMENISTAN TAJIKISTAN

IRAQ

JORDAN

EGYP T

BURKINA FASO

CÔTE D’IVOIRE

UZBEKISTAN

GEORGIA

CYPRUS SYRIA LEB.

MALTA

SIERRA LEONE

KAZAKHSTAN

TURKEY

GREECE

MOROCCO

MAURITANIA

RUSSIA

LATVIA

TUVALU

TOKELAU

SOLOMON ISLANDS SAMOA

NIGERIA CAMEROON

ETHIOPIA

CENTRAL AFRICAN REP.

LIBERIA

VANUATU

BRUNEI

UGANDA

DEMOCRATIC REPUBLIC OF CONGO

GABON

SRI LANKA MALDIVES

SOMALIA

MALAYSIA

NIUE FR. POLYNESIA

SEYCHELLES

I N D O N E S I A

TANZANIA ANGOLA ZAMBIA

BOTSWANA

PAPUA NEW GUINEA

MALAWI MADAGASCAR

ZIMBABWE MOZAMBIQUE SWAZILAND

SOUTH AFRICA

TONGA

RWANDA

BURUNDI

NAMIBIA

NEW CALEDONIA

SINGAPORE

KENYA

COOK ISLANDS

FIJI

LESOTHO

DECLINING DECAY?

Changing rates of caries (DMFT) amongst 12-year-olds 1980–98 developed countries all countries developing countries

MAURITIUS RÉUNION

5 AUSTRALIA

4 3 2

NEW ZEALAND

1 0 1980

1985

1990

DMFT, which records the number of decayed (D), missing (M) and filled (F) teeth (T). While DMFT is not the only measure and has limitations, the oral health status of populations is often summarised as a DMFT score (usually of 12-year-olds). A DMFT score of 1.0 means that one of the 32 adult teeth is either decayed, missing or filled. Scores for individuals are full numbers, for populations they can have decimal values. The WHO maintains a global database for caries levels; the data collection, however, is incomplete and not up to date due to the complexity of undertaking national surveys or different health-system priorities. Accurate data about dental decay is important for projecting the future disease burden.

1995

1998

Health Action • Reducing frequency and quantity of sugar consumption, and appropriate exposure to fluorides are the best ways of preventing dental caries.

TOOTHLESSNESS

Percentage of people aged 65 years and over who are edentulous latest available 1986–2008 50% or more 30% – 49% 10% – 29% C A N A D A

fewer than 10% no data

Calculus (tartar) is a hard deposit on the tooth surface, typically on the inner surfaces of the lower incisors, but also on other teeth. It develops from dental plaque that hardens through minerals from saliva and becomes so hard that it cannot be removed with a toothbrush. Calculus itself does not cause gingivitis, but the bacteria living in and on it can do so. Calculus accumulation can be controlled and prevented by regular brushing, but once formed it can be removed only by an oral health professional.

People who have chronic infections – and gum disease is one of the major chronic infections – are at increased risk later in life for [hardening of the arteries] and coronary heart disease. Richard Stein, Spokesperson, American Heart Association, 2005

Totally toothless (edentulous) Gum disease is the leading cause of tooth loss worldwide. Losing all the teeth has serious consequences for an individual: • loss of chewing capacity • difficulty in speaking • loss of support for lips and cheeks • loss of supporting jaw bone.

U S A

MEXICO

Measuring gum disease and oral hygiene There are several ways of measuring the prevalence, severity and impact of gum diseases, including the assessment of: • bleeding • pocket depths • whether or not teeth are loose • the presence and severity of dental plaque. The Community Periodontal Index of Treatment Needs (CPITN), developed by the World Health Organization (WHO), is one of the indices used to measure these aspects in population surveys. However, many other indices are used as well, making comparisons between different surveys difficult.

PANAMA

BRAZIL

um (periodontal) diseases include a range of inflammatory diseases of the tissues that support the teeth (periodontium). When the gums are involved, the disease is called gingivitis. If the deeper connective tissues and supporting bone are involved, it is called periodontitis. Gingivitis, showing as swollen, red and bleeding gums around the teeth, heals with good oral hygiene and removal of dental plaque. Periodontitis and loss of attachment (“pockets”), however, can only be stopped but not restored. Left untreated, the disease can lead to increased tooth movement, abscess or even tooth loss. The bacteria in dental plaque are the leading cause of gum disease. Other common factors of gum disease include smoking, diabetes, leukaemia and

GUM DISEASES 6 In this map, total toothlessness is used as a marker for gum disease, as no simple and comparable global data on gum disease are available. ICELAND

Gum (periodontal) diseases are widespread and are the leading cause of tooth loss.

FINLAND NORWAY SWEDEN DENMARK

UK IRELAND

NETH. BEL. FRANCE

GERMANY SWITZ.

PORTUGAL

POLAND

BELARUS

CZ. REP. AUS. HUN.

SL. B-H CRO. ITALY

SPAIN

ESTONIA LITHUANIA

BULGARIA

ALB.

GEORGIA

UZBEKISTAN

KYRGYZSTAN

TURKEY

GREECE

CHINA

LEBANON

PAKISTAN

EGYPT

Hong Kong SAR

SAUDI ARABIA

INDIA

Cats, dogs and other animals are prone to calculus and gum disease as well; appropriate diet and regular tooth cleaning can help.

THAILAND

GAMBIA

CAMBODIA NIGERIA

Between 5% and 20% of populations suffer from severe forms of gum disease, with formation of deep pockets.

FIJI

SRI LANKA MALAYSIA SINGAPORE

I N D O N E S I A

AUSTRALIA SOUTH AFRICA

If a patient cannot clean his teeth, no dentist can clean them for him. Martin H. Fischer, Scientist, 1879–1962

HIV, hormonal changes associated with pregnancy, stress, and socioeconomic factors. Factors predisposing to plaque accumulation, such as calculus (tartar), defective dental fillings and crooked teeth also play a role. Gingivitis is a very common disease, present in four out of five adults worldwide. Gum diseases include a number of distinct diseases with specific characteristics. In general, the link between gum disease and systemic health is the strongest of all oral diseases. Subject to intensive worldwide research, gum diseases have been linked to an increased risk for heart disease, premature and low-weight birth, and can influence the severity of diabetes.

Health Actions • Brush your teeth twice a day with a fluoride toothpaste. • Reduce or quit smoking. • Visit your oral health professional at regular intervals.

ORAL CANCER

In 2002 there were more than 400,000 cases of oral cancer diagnosed worldwide.

Male and female incident rates per 100,000 people 2002

The risk for oral cancer is 15 times higher when the two main risk factors, tobacco use and alcohol, are combined.

10.0 or more 7.5 – 9.9 5.0 – 7.4

FINLAND

ICELAND NORWAY SWEDEN

IRELAND

NETH. BELGIUM

FRANCE

POLAND

GERMANY

CZECH REP. AUSTRIA SLOV.

SWITZ.

BELARUS UKRAINE

SLOVAKIA

MOLDOVA

HUNGARY

RUSSIA

ROMANIA

B-H SERBIA CROATIA BULGARIA MONT. MACEDONIA ALBANIA

PORTUGAL

SPAIN

ITALY

KAZAKHSTAN

GREECE

U S A

UZBEKISTAN

GEORGIA

CUBA

HAITI BELIZE JAMAICA GUATEMALA HONDURAS EL SALVADOR NICARAGUA

COSTA RICA PANAMA

MEN

BAHAMAS

MOROCCO ALGERIA

DOMINICAN REP.

VENEZUELA COLOMBIA

BARBADOS TRINIDAD & TOBAGO

GUYANA SURINAME

SENEGAL GAMBIA GUINEA-BISSAU GUINEA

MALI

QATAR UAE SAUDI ARABIA OMAN

NIGER CHAD

SUDAN

CENTRAL AFRICAN REP. EQUAT. CAMEROON DEM. REP. GUINEA CONGO GABON RWANDA BURUNDI CONGO

UGANDA

ARGENTINA

MALAWI

MADAGASCAR ZIMBABWE BOTSWANA MAURITIUS MOZAMBIQUE

SOUTH AFRICA

URUGUAY

BANGLADESH MYANMAR

SWAZILAND LESOTHO

LAOS VIETNAM THAILAND

MICRONESIA

PHILIPPINES

SRI LANKA BRUNEI MALAYSIA SINGAPORE

KENYA

COMOROS ZAMBIA

PARAGUAY

JAPAN

BHUTAN

CAMBODIA

SOMALIA

TANZANIA

ANGOLA

NAMIBIA

INDIA

ETHIOPIA

BRAZIL

CHILE

NEPAL

DJIBOUTI

NIGERIA

BOLIVIA

SOUTH KOREA

C H I N A

ERITREA YEMEN

B. F.

CÔTE SIERRA LEONE D’IVOIRE LIBERIA

ECUADOR PERU

MAURITANIA

NORTH KOREA

BAHRAIN

LIBYA EGYPT

CAPE VERDE

MONGOLIA

KYRGYZSTAN

AZER. TURKMEN. TURKEY TAJIKISTAN ARMENIA CYPRUS SYRIA IRAN AFGHANISTAN LEB. IRAQ ISRAEL JORDAN KUWAIT PAKISTAN

TUNISIA MALTA

GHANA TOGO BENIN

MEXICO

Male oral cancer incidence rates World average: 6.3 Highest: Papua New Guinea 40.9 Lowest: El Salvador 0.4

RUSSIA

LUX.

CA N A D A

ESTONIA LATVIA LITHUANIA

DENMARK

The average 5-year survival rate of oral cancer among white high-income males in Mumbai is 30%, whereas in the USA it is 70%.

SOLOMON ISLANDS VANUATU

SAMOA FIJI

I N D O N E S I A

PAPUA NEW GUINEA

AUSTRALIA

NEW ZEALAND

Similar incidence rates of oral cancer may result in dramatically different case numbers, depending on population size. In 2002, India: male incidence rate of 12.8 = 52,008 cases Turkmenistan: male incidence rate 12.9 = 172 cases

When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it. Louis Pasteur, French scientist, 1822–95

Paan is a highly carcinogenic mixture of betel leaf, lime, areca nut and tobacco. It is widely chewed in South-East Asia as a breath-freshener, as traditional medicine against a number of ailments, and for ceremonial purposes.

ral cancer is a malignant growth (tumour) on any part of the mouth. Oral cancer often first shows up as a visible or palpable lesion of the lip, tongue, throat (pharynx) or other oral soft tissues; there may be pain, difficulty in eating, swelling, bleeding or ulceration. Tobacco use, especially when combined with alcohol consumption, is the major risk factor for developing oral cancer, together with poor diet and vitamin deficiency, viral infections, genetic disposition and other factors. Smoking is associated with about 75 per cent of oral cancer cases. Oral cancers are predominantly squamous cell carcinomas.

ORAL CANCER 7 Oral cancer is among the ten most common cancers worldwide and can be largely prevented by reducing alcohol and tobacco consumption.

2.5 – 4.9 fewer than 2.5 no data FINLAND

ICELAND NORWAY SWEDEN

Female oral cancer incidence rates World average: 3.2 Highest: Papua New Guinea 26.3 Lowest: El Salvador, Egypt 0.2

NETH. BELGIUM

RUSSIA

CZECH REP.

SWITZ.

BELARUS UKRAINE

SLOVAKIA

MOLDOVA

HUNGARY

AUSTRIA SLOV.

RUSSIA

ROMANIA

B-H SERBIA CROATIA BULGARIA ITALY MONT. MACEDONIA ALBANIA

PORTUGAL

CANADA

POLAND

GERMANY

LUX. FRANCE

RUSSIA

LATVIA LITHUANIA

DENMARK

IRELAND

ESTONIA

SPAIN

KAZAKHSTAN

GREECE

U S A

UZBEKISTAN

GEORGIA AZER. ARMENIA

TURKEY

CUBA

GUATEMALA EL SALVADOR

DOMINICAN HAITI REP. BELIZE JAMAICA HONDURAS

NICARAGUA

COSTA RICA PANAMA

VENEZUELA COLOMBIA

CAPE VERDE

BARBADOS TRINIDAD & TOBAGO

GUYANA SURINAME

ECUADOR PERU

TUNISIA MALTA

MOROCCO ALGERIA

MAURITANIA

SENEGAL GAMBIA GUINEA-BISSAU GUINEA

MALI

CÔTE SIERRA LEONE D’IVOIRE LIBERIA

LEB. ISRAEL

LIBYA

SYRIA

BANGLADESH MYANMAR

UGANDA

MICRONESIA

LAOS VIETNAM THAILAND

PHILIPPINES

SOLOMON ISLANDS

CAMBODIA SRI LANKA

VANUATU

BRUNEI MALAYSIA SINGAPORE

SOMALIA

KENYA

SAMOA FIJI

I N D O N E S I A

TANZANIA

PAPUA NEW GUINEA

MALAWI

MADAGASCAR ZIMBABWE BOTSWANA MAURITIUS MOZAMBIQUE

SOUTH AFRICA

URUGUAY

BHUTAN

COMOROS ZAMBIA

PARAGUAY

INDIA

ETHIOPIA

ANGOLA

CHILE

NEPAL

DJIBOUTI

BRAZIL

NAMIBIA

PAKISTAN

ERITREA YEMEN

SUDAN

NIGERIA

BOLIVIA

C H I N A

AFGHANISTAN

QATAR UAE SAUDI ARABIA OMAN

B. F.

CENTRAL AFRICAN REP. EQUAT. CAMEROON DEM. REP. GUINEA CONGO GABON RWANDA BURUNDI CONGO

KUWAIT

JAPAN

SOUTH KOREA

BAHRAIN

EGYPT

CHAD

NORTH KOREA

TURKMEN. TAJIKISTAN IRAN

IRAQ JORDAN

NIGER

GHANA TOGO BENIN

MEXICO

WOMEN

BAHAMAS

CYPRUS

MONGOLIA

KYRGYZSTAN

AUSTRALIA

SWAZILAND LESOTHO

ARGENTINA

Cancer of the tongue. Quitting all tobacco products greatly reduces the risk of developing oral cancer. Dentists and other oral health professionals can help by offering tobaccocessation counselling.

Similar incidence rates of oral cancer may result in dramatically different case numbers, depending on population size. In 2002, India: female incidence rate 7.5 = 20,609 cases Namibia: female incidence rate 7.2 = 40 cases

In 2002, more than 400,000 cases of oral cancer were diagnosed worldwide. The risk for oral cancer is 15 times higher when the two main risk factors, tobacco use and alcohol, are combined.

NEW ZEALAND

Health Actions The clinical diagnosis is often confirmed by a biopsy of a suspected lesion and, if possible, the cancer is surgically removed. Radiation and chemotherapy can help in advanced cases. A dentist or other trained medical professional can perform a painless visual oral cancer screening in less than five minutes. If oral cancer is found at a very early stage there is a high chance of survival. However, as it is often diagnosed at a later stage, the average 5-year survival rates of oral cancer patients are only around 50 per cent.

• Reducing tobacco and alcohol use keeps your oral cancer risk low. • If you have sores, white or dark patches, unusual bleeding or pain in your mouth or neck that persists for more than two weeks, see your dentist. Early detection will increase your chance of survival.

NOMA WORLDWIDE Reported cases 1981–2006

countries reporting one or more cases of noma 1981–2000

Estimation of new noma cases for 2006 based on reported numbers from 21 African countries 10,000 or more 1,000 – 5,200 fewer than 1,000 no data

Two Swiss foundations contribute significantly to the WHO’s Global Noma Programme: the Winds of Hope Foundation and the Gertrud Hirzel Foundation.

Niger was the first country to establish a national noma programme in 1999.

PORTUGAL

U S A

ITALY

JAPAN

PAKISTAN

MEXICO

DOMINICAN REP.

CUBA

MOROCCO

ISRAEL

ALGERIA

JAMAICA

INDIA

EGYPT

SURINAME COLOMBIA

MAURITANIA SENEGAL GAMBIA

MALI

NIGER CHAD

BURKINA FASO

GUINEA GUINEACÔTE BISSAU D’IVOIRE

TOGO BENIN

GUYANA

PERU

GHANA

SUDAN

NIGERIA

CAMEROON

UGANDA DEM. REP. OF CONGO

KENYA

TANZANIA

ANGOLA

URUGUAY ARGENTINA

ZAMBIA

MALAWI

ZIMBABWE NAMIBIA

BOTSWANA

SOUTH AFRICA

SOMALIA

RWANDA

BURUNDI

PARAGUAY

DJIBOUTI

ETHIOPIA

CENTRAL AFRICAN REP.

BOLIVIA

In the 21st century, when there have been significant scientific and technological breakthroughs in health sciences, the world has no excuse to remain passive about this disease. It is time to act and say no to noma. Luiz Gomez Sambo, Regional Director WHO/AFRO, World Noma Day, May 2008

MYANMAR

MADAGASCAR

MOZAMBIQUE

LESOTHO

Noma affects mainly children up to six years old, often when they are being weaned at around the age of three.

oma is a rapidly spreading gangrene that starts in the mouth and disfigures the face, sometimes within days, consuming both soft tissue and bone. The disease affects mainly children and, if left untreated, as noma usually is, is fatal in 80 per cent of cases. Children with noma are often hidden by their families due to social stigmatisation or, if they survive, live a life of permanent extreme disfigurement and handicap. The World Health Organization estimates that 140,000 people, mostly in the poorest regions of Sub-Saharan Africa but also in Asia and South America, are affected. It is difficult to estimate the number of new cases, but a recent study by WHO/AFRO calculated about 42,800 new cases in one

PAPUA NEW GUINEA

NOMA 8 WHO, the NoNoma Federation and the FDI are aiming to eliminate the disease within a generation.

Noma is a neglected, deadly and disfiguring disease of poverty, affecting mainly children.

WHO STRATEGY AGAINST NOMA

The NoNoma Federation is a coalition of more than 30 nongovernmental organisations united in the fight against noma. Together with the WHO and the FDI, it organised the first World Noma Day on 22 May 2008 to raise awareness of the disease.

Prevention

Education and early detection by primary health care workers

Epidemiology and surveillance

Record and monitor disease trends

Research

Promote research to determine the causes of noma

Primary health care

Ensure emergency treatment and availability of necessary drugs

Surgery and rehabilitation

Referral of cases to specialised treatment centres; training of local health workers in treatment procedures

Left to right: acute case of noma; destruction resulting from noma; same patient after reconstructive surgeries.

year in 21 Sub-Saharan Africa countries as a worst-case scenario. Noma is a disease of extreme poverty and indicates general neglect, malnutrition, and lack of hygiene. Recently, eastern and southern African countries reported new cases of noma among HIV-infected children and adults, highlighting the significance of a compromised immune system in the disease process. In 1998, the WHO established a Global Action Programme against Noma, supporting countries in their fight against the deadly disease. Treatment of noma is possible but requires complex interventions, starting with rehydration and improved nutrition, followed by antibiotics and, if necessary, plastic surgery. Emphasis should therefore be put on prevention.

More than ever, the common risk factors approach is the key to the elimination of noma. Fighting noma means also fighting malnutrition, measles and other infections, improving hygiene and, most importantly, fighting poverty. Charlotte Faty Ndiaye, Regional Advisor Oral Health, WHO/AFRO

HIV: WORLDWIDE PREVALENCE

15.0% – 26.1%

Percentage of the population aged 15–49 years who are HIV-positive 2007 estimate

10.0% – 14.9% 5.0% – 9.9% 1.0% – 4.9% 0.9% or fewer

Highest: Swaziland 26.1%; Botswana 23.9%; Lesotho 23.2%

no data 4%

11%

74,000 Oceania

CANADA

230,000 18% Caribbean

FICTION There is a risk of HIV transmission during dental procedures. FACT All dental procedures are safe if standard infection control measures are taken, such as proper sterilisation and disinfection.

380,000 Middle East & North Africa

730,000 Western & Central Europe

740,000 East Asia

USA

A DEADLY PANDEMIC Regional impact of HIV estimated figures 2007 estimate

MEXICO

1.2 million North America 7%

number of people living with HIV

BAHAMAS

CUBA DOMINICAN

JAMAICA HAITI REP. BELIZE HONDURAS GUATEMALA EL SALVADOR NICARAGUA

BARBADOS TRINIDAD & TOBAGO

COSTA RICA PANAMA

new HIV infections as percentage of total number 8%

COLOMBIA

1.5 million Eastern Europe & Central Asia

GUYANA SURINAME

ECUADOR

PERU

BRAZIL

8% BOLIVIA

CHILE

PARAGUAY

ARGENTINA

22 million Sub-Saharan Africa

1.7 million Latin America

4.2 million South & South-East Asia

History will surely judge us harshly if we do not respond with all energy and resources that we can bring to bear in the fight against HIV/AIDS. Nelson Mandela, former president of South Africa, 2002

URUGUAY

For every two people put on antiretroviral drugs, another five become newly infected.

bout half of HIV-positive people develop oral fungal, bacterial or viral infections early in the course of the disease. Oral lesions such as candidiasis, herpetic ulcers and Kaposi’s sarcoma (a cancer often seen in association with HIV infection, but otherwise rare) are among the first symptoms of HIV infection. All these conditions cause pain, discomfort, eating restrictions and provide a constant source of opportunistic infection. Despite many promising developments and global efforts to address the HIV/AIDS pandemic, the number of people living with HIV continues to grow. The most striking increases are seen in East Asia, Eastern Europe and Central Asia. In many regions of the world, new HIV infections are concentrated on 15–24 year olds. Sub-Saharan Africa, where two-thirds of

HIV/AIDS 9

Due to HIV/AIDS, average life expectancy has decreased in 38 countries.

HIV/AIDS can cause serious oral diseases. Oral health professionals can help in early detection of HIV/AIDS from oral signs.

ICELAND

FINLAND

NORWAY

ESTONIA LATVIA

RUSSIA

LITHUANIA

DENMARK UK

IRELAND

RUSSIA

SWEDEN

BELARUS NETH. POLAND BEL. GERMANY UKRAINE SL. LUX. MOLDOVA AUS. HUN. FRANCE ROM. SWITZ. SL. CRO. B-H SERB.

MONGOLIA

GEORGIA

MAC. PORTUGAL

SPAIN

ITALY

LEBANON

MALTA MOROCCO

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN TAJIKISTAN

GREECE

TUNISIA

UZBEKISTAN

SOUTH KOREA

CHINA

IRAN

ISRAEL

PAKISTAN

ALGERIA

NEPAL

INDIA MAURITANIA

NIGER

CHAD

CÔTE SIERRA LEONE D’IVOIRE LIBERIA

MYANMAR

VIETNAM CAMBODIA

DJIBOUTI

NIGERIA CAMEROON

ETHIOPIA

CENTRAL AFRICAN REP.

EQUATORIAL GUINEA

UGANDA GABON

90% of the world’s 2 million HIVpositive children live in Sub-Saharan Africa.

FIJI

MALAYSIA

SOMALIA

RWANDA BURUNDI

CONGO

TANZANIA COMOROS

ANGOLA ZAMBIA

MALAWI MADAGASCAR

ZIMBABWE NAMIBIA

BOTSWANA

MOZAMBIQUE

“Patients with HIV ... should not be denied oral health care solely because of their infection.” FDI Policy Statement

By 2010 there will be 18 million orphans due to HIV/AIDS in Africa alone.

SINGAPORE

I N D O N E S I A

PAPUA NEW GUINEA

MAURITIUS

SWAZILAND

SOUTH AFRICA

LAOS THAILAND

ERITREA

SUDAN

BURKINA FASO

GHANA TOGO BENIN

SENEGAL GAMBIA GUINEABISSAU GUINEA

MALI

BHUTAN

AUSTRALIA

LESOTHO

NEW ZEALAND

Fungal infection (candidiasis) on the palate as sign of HIV/AIDS.

HIV-positive adults and children live, continues to bear the brunt of the global epidemic. Early detection of HIV-related oral lesions can be used to diagnose HIV infection, monitor the disease’s progression, predict immune status, and can result in timely therapeutic intervention. The treatment and management of oral HIV lesions can considerably improve wellbeing. Oral examination is quick and inexpensive. In addition, oral health services and professionals can contribute effectively to the control of HIV/AIDS through health education and health promotion, patient care, effective infection control, and surveillance. However, most of those with HIV do not have access to these services, if they are offered at all.

Health Action • Know your HIV status so that your dentist and physician can provide appropriate health care.

10 BIRTH DEFECTS Birth defects require early intervention to avoid serious impact on quality of life.

LOCATION OF CLEFTS bi-lateral clefts 24%

right-sided clefts 24%

left-sided clefts 52%

BIRTH DEFECTS

Average incidence rates for cleft lip/palate for different ethnic groups from 17 countries per 100,000 live births 2006 000

Multivitamin and folate supplements in early pregnancy can help to prevent facial birth defects, but more research is needed.

average range

Two-thirds of all facial birth defects are cleft lip and palate defects.

African Americans 50

Caucasians 152

Mongolians and American Indians 153

Asians

225

Lack of surgical provision commits otherwise healthy individuals to lifelong disfigurement and functional impairment, as well as educational and social exclusion. Sarah Hodges, Paediatric Anaesthesiologist, Uganda, 2009

If lip and palate clefts are properly treated by surgery, complete rehabilitation is possible.

left lip and cleft palate are the most common types of congenital birth defects. Factors such as genetic predisposition, poor nutrition, smoking, alcohol and obesity during pregnancy increase the risk of birth defects, which can result in many different forms of clefts. Treatment of the deformity is necessary to restore normal eating, speaking and appearance, and to avoid social stigma. If left untreated, serious complications and even death may result. Children affected require multiple surgeries, frequent follow-up and appropriate facilities, little of which is accessible or affordable for many children affected in low- and middle-income countries. Specialised NGOs sometimes assist in making such services available.

Every year, 5 million teeth are knocked out of the mouths of children and teenagers during sports in the USA.

TRAUMA 11 Boys are almost twice as likely to experience dental trauma as girls.

Head and tooth trauma are important public health problems worldwide.

DENTAL TRAUMA

Percentage of the UK population experiencing trauma to the front teeth 1993 5%

7 – 10 years old 18%

proportion increases to 40% in deprived areas

15 – 18 years old

The highest risk of tooth trauma is associated with football (soccer), handball and ice hockey.

When a tooth is knocked out completely, keeping it either in a glass of milk or in your mouth under the tongue can help maximise the chance of reattachment. See a dentist immediately!

RISK FACTORS FOR DENTAL INJURIES • large overbite (protrusion of front teeth) • traffic and bicycle accidents • contact sports

The cost of dental trauma treatment in Sweden is estimated at US$3.3 – US$4.1 per person per year.

• violence • falls • piercing of tongue and lips • physical abuse (children/elderly)

ost traumas to the jaws and teeth are associated with sports, unsafe environments (schools and playgrounds), traffic accidents or violence. The costs of treatment and follow-up care for trauma patients is significant; thus trauma is an important public health problem worldwide. Head trauma can result in tooth chipping, fracture of the tooth or supporting bone, as well as tooth loss or dislocation. In many cases the long-term survival of the tooth is at risk. Traffic accidents and violence are the most important risk factors for fractures of the jaw and facial bones, which are usually fixed by the surgical insertion of titanium plates.

Health Actions • Wear a mouth guard during contact sports. • Wear a helmet during exposed transportation and for accident-prone sports (motorcycles, skates, biking, etc.). • Always wear a seatbelt.

HEALTH CARE PROVISION

EXPENDITURE ON DENTAL CARE

Percentage of Gross Domestic Product spent on health care 2005

As percentage of total health expenditure, where known latest available 2004–07

less than 4.0% 4.0% – 5.9%

In 2004, only 44% of US citizens went to see a dentist. The average treatment took 2.1 sessions and the average cost was US$560.

C A N A D A

6% – 12%

6.0% – 7.9%

8.0%

less than 6%

8.0% – 9.9%

In 2000, more than 2 million jobs in the USA related directly or indirectly to dental services.

10% or more U S A

In 2009, total expenditure for dental care in the USA was estimated at more than US$100 billion.

no data World average: 6.3% Highest: Marshall Islands 15.4% Lowest: Equatorial Guinea 1.7%

4.5%

BAHAMAS

MEXICO

CUBA

THE GLOBAL DENTAL SUPPLIES MARKET

DOMINICAN REP.

Breakdown of expenditure 2007

BELIZE JAMAICA

HAITI ANTIGUA & BARBUDA

ST KITTS & NEVIS

endodontics 3% cements 1% impression materials 4% adhesives 1% composites 4% orthodontics 5% equipment 25% pharmaceuticals 6% other implants 13% crown/ consumables 20% bridge 18%

HONDURAS GUATEMALA ST VINCENT & THE GRENADINES EL SALVADOR NICARAGUA GRENADA COSTA RICA PANAMA

VENEZUELA

$744

COLOMBIA

DOMINICA ST LUCIA

BARBADOS TRINIDAD & TOBAGO

GUYANA SURINAME

ECUADOR

BRAZIL

PERU

5.0% BOLIVIA PARAGUAY

CHILE

Total global dental supplies market: US$16 billion Latin America 4%

URUGUAY

$270

Asia 6%

Japan 14%

ARGENTINA

$327

other 6%

USA 40%

$161 $91

$81

Malaysia

Slovakia

Europe 30% UK

Spain

Costa Rica

Turkey

Wisdom tooth removal (surgical)

I find that most men would rather have their bellies opened for five hundred dollars than have a tooth pulled for five. Martin H. Fischer, US physician and author, 1879–1962

ral diseases impact on individuals, communities, society, health systems and the economy. It is difficult to calculate the full economic impact of oral diseases and no comprehensive international statistics exist in this context. The World Health Organization (WHO) estimates that oral diseases are the fourth most expensive diseases to treat. Another study showed that if treatment were available, the costs of treating the dental decay of children alone would be greater than the total health care budget of many low- and middle-income nations. However, prevention and early treatment substantially reduce overall costs. In addition to the direct costs of treatment, there are indirect costs to

ICELAND

NORWAY

8.0% 7.0% SWEDEN

3.5% IRELAND

LATVIA

DENMARK

3.3%

CZECH SLOVAKIA REP.

8.6%

AUSTRIA

SWITZ.

PORTUGAL

HUNGARY

ITALY MONACO

ALB.

SPAIN

UKRAINE MOLDOVA

ROMANIA CROATIA 3.0% B-H SERBIA BULGARIA

S. M.

ANDORRA

BELARUS

POLAND

LUX.

FRANCE

LITHUANIA

3.6%

BELGIUM

The market for dental supplies in China will reach US$3.1 billion in 2012, with an 11% annual growth rate.

2.4%

7.0%

GERMANY

NETH.

6.5%

ESTONIA

8.5%

ECONOMICS 12

FINLAND

RUSSIA

MACEDONIA

KAZAKHSTAN

7.6%

SLOVENIA 3.0%

3.0%

MONTENEGRO

GREECE

TUNISIA

5.0%

TURKEY

MALTA

IRAQ

IRAN

ISRAEL JORDAN

ALGERIA

BAHRAIN QATAR

EGYPT

MAURITANIA

MALI

GHANA TOGO

SENEGAL GAMBIA BURKINA GUINEAFASO GUINEA BISSAU CÔTE SIERRA D’IVOIRE LEONE LIBERIA

CHAD

ERITREA

SUDAN

BENIN

NEPAL

NIGERIA CAMEROON

BANGLADESH

INDIA

MYANMAR

OMAN

LAOS

YEMEN

CONGO

MALAYSIA

I N D O N E S I A EAST TIMOR

COMOROS

BOTSWANA

SOUTH AFRICA

$112

MADAGASCAR

MOZAMBIQUE

LESOTHO

Greece

MAURITIUS

GEOGRAPHICAL DIFFERENCES

$95

Czech Rep. Costa Rica

AUSTRALIA

Average patient cost of basic dental treatments including hospital and doctors’ fees in selected countries 2007 US$ $149

$54 UK

PAPUA NEW GUINEA

MALAWI

SWAZILAND

$131

NIUE

SEYCHELLES

ZIMBABWE NAMIBIA

TONGA

SINGAPORE

TANZANIA

ZAMBIA

COOK ISLANDS

FIJI

BRUNEI

KENYA

ANGOLA

VANUATU

SRI LANKA

3.0%

RWANDA BURUNDI

TUVALU SAMOA

PHILIPPINES

VIETNAM CAMBODIA

MALDIVES

DEMOCRATIC REPUBLIC OF CONGO

KIRIBATI

SOLOMON ISLANDS

THAILAND

UGANDA

SÃO TOMÉ GABON & PRINCIPE

MARSHALL ISLANDS

BHUTAN

NAURU

ETHIOPIA

CENTRAL AFRICAN REP.

PALAU FED. STATES MICRONESIA

DJIBOUTI

EQUATORIAL GUINEA

1.8%

SOUTH KOREA

UAE

SAUDI ARABIA

NIGER

PAKISTAN

JAPAN

CHINA

AFGHANISTAN

KUWAIT

12.0%

L I B YA

NORTH KOREA

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN TAJIKISTAN

CYPRUS SYRIA LEB.

MOROCCO

MONGOLIA

0.5%

UZBEKISTAN

GEORGIA

CAPE VERDE

Dental care is both an important industry and unaffordable for most countries.

$46 Vietnam

5.8%

NEW ZEALAND

$121 $84

$61

$26 India

$39

Portugal Costa Rica Macedonia

Simple tooth extraction consider. In the USA alone, 2.4 million days of work and 1.6 million days of school were lost due to oral disease in 1996. Additionally, absenteeism from school and work can lead to limited academic achievement and reduced employment opportunities. On the other hand, dentistry and the related health care industry generate significant contributions to a country’s employment market and economy as a whole. Dental care is the most common reason for medical tourism, where patients travel to other countries for cheaper treatment. Yet, for the majority of health systems in the world, appropriate dental care and coverage for the entire population are not realistic because of low expenditure on health in general and other, more pressing, health priorities.

$23

Slovakia Philippines

White composite filling

EXPENDITURE ON DENTAL SERVICES

Total in US$ in selected countries 2005–07

$95 billion

USA

$15 billion

Germany

$10 billion

Canada

DENTAL DECAY

Percentage of 6–19-year-olds with dental decay latest available 1982–2007

$5,044

US$159 million was spent in 2004 on pain-relief gels and other medications for oral pain relief in US supermarkets and drugstores.

80% or more 60% – 79%

C A N A D A

40% – 59% fewer than 40%

ICELAND

no data World average: 70% Highest: Argentina 100% Lowest: Japan 16%

6% of Californians, or about 1.8 million people, miss work or school each year due to dental problems.

U S A

MEXICO

CUBA HAITI

GUATEMALA

THE PRICE OF NEGLECT

JAMAICA HONDURAS

ANTIGUA & BARBUDA ST VINCENT & THE GRENADINES

NICARAGUA

BARBADOS TRINIDAD & TOBAGO

COSTA RICA PANAMA

The average cost of dental care per person in California in US$ 2009

GUYANA

CAPE VERDE

SENEGAL GAMBIA

GUINEA-BISSAU SIERRA LEONE

ECUADOR

routine dental care

BRAZIL

visits to the hospital Emergency Department due to dental causes

BOLIVIA CHILE

$172

ARGENTINA URUGUAY

$41

$60

regular comprehensive without with check-up check-up hospitalisation hospitalisation

Children live for months with pain that grown-ups would find unendurable. The gradual attrition of accepted pain erodes their energy and aspiration. Jonathan Kozol, US writer and educator, 1991

ral diseases are traditionally measured with clinical or statistical indices, but measuring their significant negative impact on the quality of life is equally important. The impact of oral diseases is higher in poorer countries and for populations with lower socio-economic status, mainly due to the prohibitive costs of treatment. Oral diseases can affect self-esteem, social interactions and communication. They can also disrupt crucial functions such as chewing, swallowing, speaking and sleeping, leading to difficulties in concentration and missed days of school and work. Oral diseases have an impact on individuals, communities, businesses, health systems and society as a whole. Impact is an important criterion for determining whether a disease

IMPACT OF ORAL DISEASES 13

Up to a quarter of the UK population experiences dental pain every year. FINLAND

NORWAY

ESTONIA

SWEDEN

LATVIA

DENMARK IRELAND

LITHUANIA

POLAND BELARUS

NETH. BEL.

GERMANY

CZ. REP. SL. AUS. HUN. SL. CRO. B-H

FRANCE SWITZ.

ITALY

PORTUGAL

MONGOLIA ROM.

UZBEKISTAN

BUL.

MAC.

SPAIN

SOUTH KOREA

CYPRUS LEB. ISRAEL

TUNISIA

IRAQ JORDAN

L I B YA

JAPAN

TURKEY

GREECE

MOROCCO

Oral diseases and oral pain have great impact on individuals, populations, health systems and society at large.

Between 1997 and 2006 there has been a 66% increase in the number of children admitted into hospital for tooth extraction in the UK.

IRAN

CHINA

AFGHANISTAN

KUWAIT

NEPAL

BAHRAIN

EGYPT

SAUDI ARABIA

UAE

BHUTAN

NIGER

I NDIA

MYANMAR

BENIN

GHANA

NIGERIA

LAOS

Macau SAR

MARSHALL ISLANDS

PHILIPPINES

THAILAND

YEMEN

SUDAN CÔTE D’IVOIRE

Hong Kong SAR

BANGLADESH

OMAN

In the Philippines, 85% of 6-year-old children had signs of dental infection, such as abscess, ulceration, fistula or open pulp in 2006.

VIETNAM CAMBODIA

ETHIOPIA

SRI LANKA BRUNEI

CAMEROON

MALDIVES

UGANDA

FIJI

MALAYSIA

TONGA

KENYA

DEMOCRATIC REPUBLIC OF CONGO

BURUNDI

SEYCHELLES

TANZANIA

ZAMBIA

59% of adults in Tanzania reported oral pain during 2008.

I N D O N E S I A

PAPUA NEW GUINEA

MADAGASCAR

ZIMBABWE NAMIBIA MOZAMBIQUE

SOUTH AFRICA

LESOTHO

In South Africa in 2001, 88% of schoolchildren reported having experienced toothache in their lifetime.

MAURITIUS

In Sri Lanka in 2005, 53% of 6-year-old school children reported having experienced oral pain in their lifetime.

In Thailand, 1,900 hours of school were lost per 1,000 children in 2008 because of dental problems.

AUSTRALIA

NEW ZEALAND

condition is a public health problem or not. For some oral conditions, such as birth defects or noma, the impact for the individual affected is very high, while the overall effect on society is not; for other diseases, such as dental decay, the cumulative impact on society is substantial. Dental pain and toothache are commonly ranked among the worst pain imaginable. There is no comprehensive data on the prevalence of oral pain, but untreated dental caries is the most common reason for dental pain, particularly affecting children. Pain resulting from oral diseases leads to a complex sequence of related issues: the need to pay for treatment, the loss of productivity and the downward cycle of health problems, poverty and deprivation.

Further improvements in oral health and a reduction in oral health equalities will only be secured through the adoption of oral health promotion policies based upon the common risk factor approach. â&#x20AC;Ś Isolated, individualistically focused oral health education interventions are ineffective, wasteful of limited resources and may increase inequalities. Aubrey Sheiham and Richard Watt, 2000

Part 3 RISK FACTORS 41

Common risk factors

RISK FACTORS FOR IMPAIRED HEALTH

Common risk factors

Modified from Sheiham & Watt, 2000

Obesity smoking

bad diet Cancers

Heart disease stress alcohol Respiratory disease

lack of control

Dental caries

relates to the individual’s capacity to influence their own living and working conditions.

ORAL DISEASES

lack of exercise

Periodontal diseases

Trauma lack of hygiene

As I see it, every day you do one of two things: build health or produce disease. Adelle Davis, pioneering US nutritionist, 1907–74

injuries

hronic diseases, including oral diseases, are of long duration, generally progressing slowly and usually non-communicable. A small number of common causes (risk factors) are responsible for most chronic diseases. Major risk factors, such as tobacco use, physical inactivity and a diet high in fat, salt and sugar, contribute to a range of chronic diseases, such as obesity, diabetes, cardiovascular diseases and oral diseases. The risk factors for chronic diseases compound over time, resulting in higher levels of chronic disease as age increases. Poverty and chronic disease are linked into a vicious cycle; chronic diseases can exacerbate poverty and the poor have greater exposure to risk and less access to health services.

RISK FACTORS 14

High consumption of sugar is the number one risk factor for tooth decay and diabetes. Almost 80% of diabetes deaths occur in low- and middle-income countries.

A range of oral and other chronic diseases can be reduced, or even prevented, when the key risk factors responsible are addressed.

THE SOCIAL DETERMINANTS OF HEALTH Modified from Whitehead & Dahlgren,1991

work

water

poverty and inequality

education Globally, 1.4 billion adults are overweight and at least 400 million adults are obese.

housing

Age, sex and hereditary factors

lif e s t y

sanitation

al du

c o m m u n it y

nutrition

d an

unemployment

ti o

, c u lt u ral a n d e n vir o

i oc

o ec

ic om

health care

Tobacco use is the most important risk factor for six out of the nine leading causes of death.

Supportive policies, a healthy environment and individual behaviour contribute to reducing the major risk factors. Many risk factors are results of broader determining factors, such as lifestyle, socio-economic status, or living conditions. A dramatic increase in most chronic diseases, such as diabetes and obesity, has been observed in low- and middle-income countries. It is important to monitor and collect data about risk factors to predict future disease burdens and plan health services accordingly. The following pages look in more detail at a few major common risk factors for oral health: sugar, tobacco, and socio-economic status.

A TASTE FOR SUGAR

Annual sugar consumption kilograms per person 2007

Diet soft drinks and sugar-free gums contain sugar substitutes, which are similar in taste to sugar but have less energy and cannot be metabolised by the bacteria in the mouth. They reduce, but do not eliminate, the risk of tooth decay.

45 kg or more 30 kg – 44 kg CANADA

15 kg – 29 kg less than 15 kg

ICELAND

no data World average: 30 kg per person per year Highest: Swaziland 102 kg Lowest: Dem. Rep. Congo 1.3 kg

USA

The average American consumes 336 litres of soft drinks a year.

top sugar-cane producers MEXICO

CUBA JAMAICA BELIZE

GUATEMALA EL SALVADOR

HONDURAS

BAHAMAS

DOMINICAN REP.

HAITI CAPE VERDE

ST KITTS & NEVIS

NICARAGUA

COSTA RICA PANAMA

VENEZUELA

Grams/teaspoons of sugar per 300ml 2007 1 tsp = 4.2 g

Milk, low-fat

ECUADOR FICTION Sugar substitutes cause cancer and diarrhea. FACT The US Food and Drug Administration has approved five sugar substitutes as safe: saccharin, aspartame, sucralose, neotame, and acesulfame potassium.

3.6 tsp 15 g

GUINEA-BISSAU GUINEA SIERRA LEONE

TRINIDAD & TOBAGO

GUYANA SURINAME

COLOMBIA

SUGAR CONTENT OF POPULAR DRINKS

MAURITANIA SENEGAL GAMBIA

BARBADOS

PERU

LIBERIA

33 million tonnes BRAZIL BOLIVIA

CHILE

PARAGUAY

ARGENTINA URUGUAY

Coca-Cola

6.9 tsp 29 g

7.5 tsp 31.2 g

Tropicana Orange Juice

There are no bad foods, just bad diets. Stephan Loerke, World Federation of Advertisers, 2003

The global confectionary market is expected to reach US$107 billion by 2010.

ugars are carbohydrates and, like all carbohydrates, provide an essential source of energy in a balanced diet. Sugars primarily come from sugar cane, corn and sugar beets, but also occur in fruit, honey and many other sources. The frequency and amount of sugar consumption is directly related to increased risks of tooth decay, type 2 diabetes and obesity. Oral bacteria, such as Streptococcus mutans, metabolise sugars into lactic acid, which can cause demineralisation of tooth tissue and tooth decay. This is why the frequent consumption of snacks and beverages containing high sugar levels increases the risk of tooth decay.

SUGAR 15

FINLAND NORWAY SWEDEN

NETH.

RUSSIA

SLOVAKIA

MOLDOVA

HUNGARY

AUSTRIA SLOV.

RUSSIA

ROMANIA

B-H SERBIA CROATIA BULGARIA MONT. MACEDONIA ALBANIA

PORTUGAL

SPAIN

ITALY

KAZAKHSTAN

GREECE

MONGOLIA UZBEKISTAN

GEORGIA

TUNISIA

CYPRUS SYRIA LEB.

MALTA MOROCCO

ISRAEL

IRAQ

IRAN

JORDAN

PAKISTAN

MALI

NIGER

GHANA TOGO BENIN

BURKINA FASO

EGYPT

CHAD

SAUDI ARABIA

ERITREA

Hong Kong SAR MYANMAR

LAOS PHILIPPINES

THAILAND

VIETNAM CAMBODIA

SRI LANKA

SAMOA

BRUNEI

CAMEROON

UGANDA

GABON

DEMOCRATIC REPUBLIC OF CONGO

CONGO

BURUNDI

EXPANDING SERVING SIZES

RWANDA

ZAMBIA

I N D O N E S I A

PAPUA NEW GUINEA

COMOROS

MALAWI

MADAGASCAR

ZIMBABWE BOTSWANA

TONGA

SINGAPORE

Standard soft drink 1998–2008

ANGOLA

FIJI

MALAYSIA

SOMALIA

KENYA

TANZANIA

SOUTH AFRICA

People consuming less than 15–20 kg/year of sugar have less tooth decay.

BANGLADESH

29 million tonnes

ETHIOPIA

CENTRAL AFRICAN REP.

NAMIBIA

INDIA

YEMEN

SUDAN

NIGERIA

UAE

NEPAL

JAPAN

SOUTH KOREA

14 million tonnes CHINA

AFGHANISTAN

KUWAIT

L I B YA

ALGERIA

NORTH KOREA

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN TAJIKISTAN

TURKEY

CÔTE D’IVOIRE

High sugar consumption is a key risk factor for dental decay and many other health problems.

UKRAINE

CZECH REP.

SWITZ.

BELARUS

POLAND

GERMANY

LUX. FRANCE

Sugar rationing in the UK and Japan during WWII led to a dramatic reduction in tooth decay.

RUSSIA

LATVIA LITHUANIA

DENMARK

IRELAND

ESTONIA

MAURITIUS

MOZAMBIQUE

SWAZILAND

600 ml

LESOTHO

The average person in the Democratic Republic of Congo consumes less than one teaspoon of sugar a day, while the average person in the USA consumes more than 19.

may contain 15 teaspoons (63.6 g) of sugar

AUSTRALIA

375 ml Soft-drink consumption doubled in New Zealand between 2000 and 2006. 1998

NEW ZEALAND

2008

The food and associated industries spend a lot of money on promoting and advertising sweetened products. Carbonated beverages (also known as soft drinks, fizzy drinks, or soda pop) contain large amounts of sugar, have very little nutritional value and replace other, more nutritional fluids, such as milk. These products are heavily advertised, are cheap, and are sold in virtually every country in the world. Diet soft drinks and sugar-free gums contain sugar substitutes. They may reduce, but do not eliminate, the risk of tooth decay.

Health Actions • Limit the consumption of sugary foods and drinks, especially between meals. • Snacks and sweets labelled as “sugar-free” are usually less harmful to oral health.

ANNUAL CIGARETTE CONSUMPTION

Tobacco use is responsible for up to half of all periodontal (gum) diseases.

Per person aged 15 and over 2007

Patients who smoke have a higher failure rate for dental implants.

2,000 and above 1,500 – 1,999

C A N A D A

1,000 – 1,499 500 – 999 IRELAND

fewer than 500 no data

357

Top 5 cigarette-consuming countries

U S A

number given in billions

Tobacco kills more people in the USA annually than AIDS, alcohol, cocaine, heroin, homicides, suicides, car accidents, and fires combined.

PORTUGAL

MOROCCO

MEXICO

Oral diseases related to tobacco are used as pictorial warnings.

CUBA DOMINICAN REP.

JAMAICA GUATEMALA EL SALVADOR

HONDURAS

SENEGAL

NICARAGUA

TRINIDAD & TOBAGO

COSTA RICA PANAMA

6,769

VENEZUELA

Wound healing time after tooth extraction for smokers is double that for non-smokers.

COLOMBIA

6,319 projected figure

5,328

GLOBAL CIGARETTE CONSUMPTION

4,485

1940–2020 billions of sticks

projected figure

ECUADOR

5,711

PERU

BRAZIL BOLIVIA

3,262 CHILE

2,150

ARGENTINA URUGUAY

1,686

Every 6.5 seconds a tobacco user dies from a tobacco related disease somewhere in the world.

1,000

1940

1950

1960

1970

1980

1990

When I was young, I kissed my first woman and smoked my first cigarette on the same day. Believe me, never since have I wasted any more time on tobacco. Arturo Toscanini, Italian conductor, 1867–1957

PARAGUAY

2000

2010

2020

sing tobacco has a great impact on oral health and is one of the key risk factors for oral disease. Among the most significant effects of tobacco use are oral cancers and pre-cancers, increased severity and extent of periodontal diseases, and poor wound healing. Tobacco is dangerous in all its forms – manufactured cigarettes, roll-your-own, cigars, pipes, snuff, chewing tobacco and paan. There are currently an estimated 1.4 billion smokers in the world and the number of smokers continues to increase. The World Health Organization (WHO) estimates that by 2030 there could be about 1.6 billion smokers. Tobacco use killed 100 million people worldwide in the 20th century and the WHO predicts that it could kill 1 billion more in the 21st century unless

CÔTE D’IVOIRE

TOBACCO 16

ESTONIA

SWEDEN DENMARK

BEL.

POLAND BELARUS

GERMANY

FRANCE SWITZ.

CZ. REP. SL. AUS. HUN. SL. CRO. B-H ALB.

SPAIN

ITALY

KAZAKHSTAN

UKRAINE MOLDOVA ROM. BUL.

TURKEY

GREECE

ISRAEL

IRAQ

JORDAN

2,163

JAPAN

SOUTH KOREA

259

CHINA

IRAN KUWAIT

PAKISTAN NEPAL

L I B YA

EGYPT

SAUDI ARABIA

NIGERIA

ETHIOPIA

CAMEROON KENYA

DEMOCRATIC REPUBLIC OF CONGO

UAE

INDIA

BANGLADESH

Hong Kong SAR

LAOS

MYANMAR

PHILIPPINES

THAILAND

YEMEN

SUDAN GHANA TOGO

NORTH KOREA

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN

CYPRUS SYRIA LEB.

TUNISIA

UZBEKISTAN

GEORGIA

MAC.

MALTA

A LGERIA

RUSSIA

LATVIA LITHUANIA

RUSSIA

UK NETH.

331

FINLAND

NORWAY

Tobacco use in all forms is dangerous for health and oral health. Dentists and their teams can help patients to quit.

Although forbidden by law, toothpaste containing tobacco is still produced and widely used in India.

VIETNAM CAMBODIA

SRI LANKA MALAYSIA

SINGAPORE

239 I N D O N E S I A

TANZANIA ANGOLA ZAMBIA

MADAGASCAR

ZIMBABWE MOZAMBIQUE

SOUTH AFRICA

EFFECTS OF TOBACCO ON ORAL HEALTH

MAURITIUS

• oral cancer • smoker’s palate • periodontal diseases • premature tooth loss • gingivitis • staining • halitosis (bad breath) • loss of taste and smell

AUSTRALIA

NEW ZEALAND

governments act now to dramatically reduce it. Tobacco use is the second biggest killer in the world, causing 5.4 million deaths a year. Cigarettes kill half of all lifetime users, half of whom die in middle age (35–69 years), losing an average of 20 to 25 years of life. Oral health professionals play an important role in helping their patients stop smoking. The FDI World Dental Federation and the WHO promote an active role for oral health professionals and their associations in tobacco control. Dentists and their team are as effective as other health professionals at cessation counselling. In order to be successful role models, health professionals need to quit smoking and make all health facilities smoke free.

Health Actions • Reducing or quitting tobacco use will improve your oral health. If you cannot do this, remind your dentist to check for oral cancer symptoms. • Advocate for smoke-free environments.

COUNTRY INCOME AND DENTAL DECAY

71% 67%

Many low- and lower-middleincome countries are moving into the “danger zone” – changes in diet associated with higher income, but no preventive efforts to address the impact on dental decay.

Comparison of data on 5–6 year olds by country income group latest available 1996–2006 low-income countries 45%

4.5

middle-income countries high-income countries 3.3

2.3

caries prevalence

$20,000

number of decayed, missing and filled primary teeth

COUNTRY INCOME AND DENTAL CARE Relationship between GDP per capita and care index for people aged 33–44 years 1990s

USA Norway

$15,000 US$ GDP

Italy

Japan France

Singapore

$10,000

Denmark New Zealand

Spain Turkey

Cyprus

The Care Index shows filled teeth as a percentage of Decayed, Missing, Filled Teeth (DMFT).

Brazil

$5,000

Hungary Ghana

0 0%

10%

20%

If the major determinants of health are social, so must be the remedies. Michael Marmot, Epidemiology & Public Health Department, University College London, 2005

China

Peru 30%

40% Care Index

50%

60%

70%

80%

s the WHO Commission on Social Determinants on Health (2008) expressed so clearly: “In countries at all levels of income, health and illness follow a social gradient: the lower the socio-economic position, the worse the health.” Such social gradients are present in oral health and disease. They are seen in the unequal distribution of gum disease, tooth decay and oral cancer across countries of different incomes, and also occur within countries, with those occupying the lowest socio-economic positions having the highest levels of oral diseases. Many of the factors determining oral health are found outside the mouth, including income, education, housing and sanitation, gender, ethnic origin, availability and access to health services.

SOCIO-ECONOMIC STATUS 17 Socio-economic status is a key risk factor for many oral diseases, and significantly determines both general and oral health.

RESPONSIBILITY FOR ORAL HEALTH

Relationship of individual and social factors to oral health

population health

Population

society

SOCIO-ECONOMIC FACTORS

Strength of link between socio-economic status and different oral diseases

community strong individual

IMPACT OF POVERTY Compared with their compatriots of high socio-economic status, those on a low income and of low educational attainment, including immigrants and ethnic minorities, experience: •

fewer dental visits

•

fewer fillings

•

more missing teeth

•

higher tobacco consumption

•

higher rates of oral cancer

•

higher rates of caries and untreated decay

•

higher rates of periodontal disease

Dental decay rates are highest in middle-income countries experiencing economic transition. People are able to increase their income and their ability to purchase sweet foods, but may not be exposed to populationwide preventive measures such as fluoridation, or have access to affordable dental care. Simple, proven and cheap population interventions, such as fluoridation, make systematic disparities in oral health avoidable, and their continuation unfair. The WHO Commission on Social Determinants on Health concluded powerfully that “reducing health inequities is … an ethical imperative. Social injustice is killing people on a grand scale.”

weak

getting oral cancer

Intervention

dying of oral cancer

jobs, housing, education

tooth decay

policy advocacy

gum disease

prevention promotion

Link to socio-economic status

individual illness disease care

Oral diseases

Maori women are five times more likely than New Zealand Caucasian women to be toothless.

The gaps in health outcomes, seen within and between countries, are greater now than at any time in recent history. Margaret Chan, WHO Director-General, 2009

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. Max Planck, German physicist, 1920

Part 4 SOLUTIONS – TAKING ACTION 51

IMPROVING AND PROTECTING YOUR ORAL HEALTH Dental decay • • • • • •

Brush your teeth twice a day with a fluoride toothpaste (best after breakfast and before going to bed) Limit consumption of sugary foods and drinks, especially between meals. Avoid unhealthy snacks between meals. Chew sugar-free gum after meals and snacks. If available, buy and use fluoridated salt. If available, drink fluoridated water.

Periodontal disease • • • •

Keep your teeth clean – brush twice a day with fluoride toothpaste. Stop or reduce smoking. Get a medical check-up to ensure that your general health is good. Ask an oral health professional about the correct way to brush your teeth.

Oral cancer • •

Reduce tobacco and alcohol use to keep your oral cancer risk low. If you have pain, sores, white or dark patches or unusual bleeding in your mouth that does not go away within two weeks, see your dentist or physician.

Trauma • •

Wear a mouth guard during contact sports to protect your teeth. Wear a helmet during exposed transportation and for contact and accident-prone sports (e.g. hockey, motorcycling, skating, biking).

Advice and support • • •

• •

You don’t have to brush all your teeth – just the ones you want to keep. Anonymous

Visit your dentist regularly – together you can determine the intervals for recall visits. Ask your dentist about the best way for you to benefit from fluoride and prevent tooth decay. Know your HIV status so that your dentist and physician can help in monitoring disease progression. Ask your dentist or physician for support if you need help quitting tobacco. Support and engage in community activities to promote oral health.

ral diseases are largely preventable. Personal behaviour, lifestyle and oral care habits are important factors for retaining a healthy mouth throughout a lifetime. Behaviour patterns are determined early in life, thus most health education efforts focus on children. Parents and peers are crucial role models in this context. There are a few key preventive behaviours that can secure good oral health: brushing twice daily with a fluoride toothpaste; a varied and balanced nutrition low in sugary foods and soft drinks; not smoking or chewing tobacco; consuming alcohol within recommended safe limits; wearing protective mouth guards if participating in contact sports; and visiting an oral health professional for check-ups and preventive advice.

BEHAVIOUR AND CHOICES 18 In many parts of the world miswak (chewing sticks) are used to clean teeth. They are mainly obtained from the Arak (Salvadora persica) or Neem tree (Azadiracta indica). They have antimicrobial properties and can be as effective as using a toothbrush.

Oral diseases are preventable by appropriate behaviour, which is reinforced and encouraged by public health policies and health promotion.

FAQS ABOUT ORAL HEALTH

Q A Q A Q A Q A Q A

How often should I brush my teeth? Evidence shows that brushing twice daily with a fluoride toothpaste is sufficient for good oral health. If you wear a denture, clean it regularly.

In 2003, the toothbrush was selected as the number one invention Americans could not live without.

Should I use dental floss? There is moderate evidence to recommend flossing to prevent dental caries and little or no evidence to recommend flossing to prevent gum disease.

Should I use a mouth rinse? Only a small percentage of the bacteria living in the mouth cause dental decay or gum disease, the rest are harmless. Antibacterial rinses should not be used on a daily basis unless prescribed. Alcohol-free rinses containing fluoride are more likely to be beneficial.

Should I use a manual or electrical toothbrush? There is evidence showing that a rotation-action electrical toothbrush removes more plaque than a manual toothbrush. Additionally, some electrical brushes have a timer, which can help encourage tooth brushing for the recommended time. But it is also possible to keep the teeth clean with a manual toothbrush.

What kind of toothpaste should I use? Only use toothpaste that contains fluoride. Brushing your teeth with a non-fluoride toothpaste does not protect your teeth from dental decay.

However, knowledge about even simple personal oral care measures should not be taken for granted. Dental teams and health professionals in general have the professional responsibility to help their patients acquire the knowledge and skills to maintain good oral and general health. All recommendations on oral hygiene must be based on the best possible evidence and take the individual situation into account. In the long term, positive oral health behaviour is only sustained if it is supported by additional public health actions that tackle the broader social and environmental causes of poor oral health.

FLUORIDE IN WATER

Percentage of the population with access to appropriate adjusted or natural levels of fluoride in water 2004

The US Centers for Disease Control and Prevention have selected water fluoridation as one of the 10 great public health achievements of the 20th century.

76% – 100%

C A NADA

51% – 75% 26% – 50%

The Center for Global Development has chosen salt fluoridation in Jamaica as one of the 17 most relevant public health initiatives taken worldwide in recent years.

6% – 25% less than 5%

USA

no data countries with some milk fluoridation, percentage of children aged 0–14 years reached countries where fluoridated salt is available and market share if known

79%

60%

MEXICO

GLOBAL FLUORIDE USE

GUATEMALA

Number of people worldwide using different sources of fluoride 2001

CUBA

100%

DOMINICAN REP.

HAITI

COSTA RICA PANAMA

Fluoridated milk less than 1 million

SENEGAL

VENEZUELA

ECUADOR

Professionally applied topical fluoride 30 million

BRAZIL

PERU

40%

Water with naturally appropriate levels of fluoride 50 million 100 million Salt fluoridation 160 million

GUYANA

COLOMBIA

Fluoride drops/tablets 15 million

Fluoride mouthrinses

PUERTO RICO

JAMAICA

Universal access to fluoride for dental health is a part of the basic human right to health, as confirmed by WHO, FDI and IADR.

BOLIVIA CHILE

PARAGUAY

ARGENTINA

URUGUAY 90%

Water fluoridation (adjusted) 368 million Fluoride toothpaste 1,500 million

Fluoridation is the single most effective public health measure to prevent tooth decay and improve oral health over a lifetime, for both children and adults. David Satcher, US Surgeon General, 2001

or over 60 years, fluoride has been crucial in strategies to prevent dental caries. Fluorides are compounds containing the element fluorine, the 13th most abundant element in the Earth’s crust. Fluorine occurs naturally in rock, soil, water, plants and animals. In the early 1940s, the relationship between fluoride levels in drinking water and dental caries was established. Early programmes to artificially adjust the level of fluoride to optimum levels in public water supplies (water fluoridation) resulted in a reduction in decay of around 50 per cent. Many methods of fluoride delivery are available. In addition to community measures such as water, salt and milk fluoridation, there are self-applied measures including fluoride toothpaste and rinses, as well as professionally

FLUORIDE 19

FINLAND SWEDEN

<1%

DENMARK

Universal access to fluoride for dental health is a part of the basic human right to health.

IRELAND

35% POLAND 69% CZECH

GERMANY

BELGIUM

REP.

SLOVAKIA

<1%

RUSSIA

FRANCE

SERBIA

SPAIN

BULGARIA

AUSTRIA

3% 88%

SWITZERLAND

CYPRUS

MALTA

Fluoridated salt was first used for caries prevention on a community level in the Canton of Zurich, Switzerland, in 1955.

SOUTH KOREA

ISRAEL

LIB YA

Hong Kong SAR

In some parts of India (and other countries) natural fluoride levels in water are too high, and can cause health problems.

NIGERIA

For every US$1 spent on salt fluoridation, around US$250 are saved in treatment costs.

KIRIBATI

VIETNAM

THAILAND SRI LANKA

FIJI

BRUNEI

MALAYSIA GABON

SINGAPORE

DEMOCRATIC REPUBLIC OF CONGO

PAPUA NEW GUINEA

TANZANIA

ZAMBIA ZIMBABWE

FICTION Fluoride is a poison and causes damage to teeth and health. FACT Over 60 years of scientific research has confirmed the safety and efficacy of fluoride to prevent caries at the recommended dosage.

AUSTRALIA

In 1945, the first community water fluoridation programme to prevent caries was started in Grand Rapids, Michigan, USA.

applied or prescribed measures such as varnish, gel and tablets. Fluorides prevent caries topically by inhibiting bacterial metabolism (acid production) in dental plaque, inhibiting demineralisation of teeth, enhancing remineralisation (repair) and making the teeth more resistant to future acid challenge. Exposure to higher than recommended levels of fluoride during tooth development (mainly between birth and four years of age) might cause dental fluorosis. This condition is often not noticeable; only the rare and severe forms show brown spots and discolouration of teeth. Older children and adults are not at risk. If applied at recommended levels, fluorides are a safe and effective way of reducing the global burden of dental decay.

NEW ZEALAND

Health Actions • Ask your dentist about the best way for you to benefit from fluoride to prevent caries. • Only use toothpaste that contains fluoride and brush your teeth twice a day. • When available, use fluoridated salt.

30.42

Zambia Tanzania Ghana Kenya Senegal Côte d'Ivoire Botswana Cambodia Bulgaria Peru Nepal China Brazil Azerbaijan Bangladesh Laos Argentina Philippines India Vietnam Uruguay Estonia Malaysia Thailand Costa Rica Indonesia Italy South Korea Slovenia France Netherlands Turkey UK Australia Canada Denmark Norway Germany USA Japan

14.30 12.22 8.62 4.69 4.35 4.04 3.86 3.43 3.25 3.25 3.20 2.90 2.72 2.54 2.14 1.99 1.76 1.44 1.34 1.34 1.20 1.13 0.76 0.55 0.50 0.36 0.32 0.32 0.32 0.31 0.24 0.22 0.19 0.17 0.16 0.11 0.09 5

Money in the bank is like toothpaste in a tube. Easy to take out, hard to put back. Earl Wilson, US baseball player, 1934–2005

Days of household expenditure needed to buy a year’s supply of fluoride toothpaste for the poorest 10 per cent of the population 2006

6.73

FLUORIDE TOOTHPASTE: HOW AFFORDABLE IS IT?

9.91

Brushing twice a day with a fluoride toothpaste results in greater reduction in decay than brushing once a day or less. Rinsing with large amounts of water after brushing can reduce the anti-caries effect of fluoride toothpaste.

WHAT IS IN YOUR TOOTHPASTE TUBE? Typical composition of toothpaste

40-70% 10-50% 0-50% 0.5-10% 0-14% 0.5-2.5% 0.8-1.5% 0.1-1.5% n sa nd triclo

ants Humect es Abrasiv Water /salts Buffers rs e Thicken ts an Surfact & sweeteners de a Flavours ents e.g. fluori g Active a

N u m b e r 10

o f 15

d a y s 20

ater and salt fluoridation are not available to the majority of the world’s population, therefore fluoride toothpaste remains the most significant method of fluoride dissemination globally. Fluoride toothpaste is the most rigorously evaluated means of fluoride use, with over 100 clinical trials confirming its efficacy in preventing tooth decay. There are huge differences in the affordability and quality of fluoride toothpaste available worldwide. Toothpaste came into general use in the 19th century and fluoride was first added to toothpaste in 1914. Joseph Muhler and his team at Indiana University developed the first effective fluoride toothpaste to prevent dental caries, which led to the first commercially available fluoride

FLUORIDE TOOTHPASTE 20 In 1960, Crest® became the first brand of toothpaste to receive an endorsement from the American Dental Association for being effective in preventing tooth decay. In 2009, 51 fluoride toothpaste brands marketed in the USA bore the ADA seal.

Combined use of fluoride toothpaste and fluoridated water is more effective in preventing caries than either used alone. There is no harm or risk of overdose if both fluoride sources are used.

The widespread use of fluoride toothpaste has been recognised as the single most important reason for the decline of dental caries.

$8.55

WORLD TOOTHPASTE MARKET

$6.72

Average annual expenditure per person by region 2006

$4.03

1 US$

Eastern Europe North America

Western Europe $1.03

$0.74 $3.68

Asia–Pacific

Middle East & Africa

$6.14

Latin America Australasia

Children under the age of six should only use a pea-sized amount of fluoride toothpaste and be supervised to minimise the amount swallowed.

In the Netherlands an average 300 g of toothpaste are used per person per year. In Myanmar 35 g are used per person per year.

In India and Nepal tax accounts for 25% of the retail price of toothpaste; in Burkina Faso this is up to 50%.

toothpaste, sold as Crest®, in 1955. By the 1990s, more than 90 per cent of the toothpaste sold in the USA, Canada, and other high-income countries contained fluoride. Fluoride toothpaste is available in a number of formulations both as a paste and gel. Sodium fluoride (NaF) and sodium monofluorophosphate (Na2PO3F) are the most common forms of fluoride used in toothpaste. Stannous and amine fluoride formulations are also marketed. Most toothpastes contain between 1,000 and 1,450 ppm (parts per million) of fluoride, although low-fluoride formulations for children exist.

Health Actions • Brush your teeth twice a day with a toothpaste containing fluoride (best after breakfast and before going to bed). • Spit, but do not rinse after brushing to increase the anti-caries effect.

DEBATE Some countries have banned amalgam as a filling material due to concerns about patient safety and environmental concerns relating to the mercury component.

Major international scientific and health bodies, including the World Health Organization, confirm that dental amalgam is a safe, reliable and effective restorative material.

In the USA, it is estimated that 30–40 million people avoid dental treatment every year due to anxiety and fear.

Crown: Also known as a cap, involves reducing a tooth so that a covering made of metal, porcelain fused to metal, or ceramics, made by dental technicians, can be permanently fixed to restore tooth function.

In 2007, about 43,000 UK patients travelled abroad for dental treatment, each spending an average of US$6,000.

Filling: Involves removing caries and placing a restoration (consisting of an amalgam, ionomer or composite resin) into a prepared cavity in a tooth.

Extraction and surgery: Tooth removal, draining of abscesses, and other surgical procedures.

Preventive treatment: Includes preventive advice and action such as tobacco cessation, dietary advice, fissure sealants etc.

More than 80% of the world’s population live on less than US$2 a day – a simple tooth extraction can cost between US$2 and more than US$100.

ental treatment, using a broad range of available restorative, corrective and cosmetic procedures, is traditionally a core activity of dentists. Interventions include check-ups, x-rays, tooth cleaning, tooth extraction, different types of fillings, veneers, crowns, bridges, root canal treatment, partial or full dentures, implants, complex rehabilitation of function and aesthetics, prevention and treatment of oral infections. Orthodontics (braces, retainers, etc.) and cosmetic dentistry are also options for patients able to afford the costs. Dental care is provided in a variety of settings and with different standards, ranging from street corners to modern dental surgeries. Despite advances in pain-free treatment, many patients still associate oral care with

TREATMENT 21 Globally, dentists give approximately 8 million anaesthetic injections every day.

Modern dental treatment can restore almost all functions and aesthetics of a healthy dentition.

If suffering brought wisdom, the dentistâ&#x20AC;&#x2122;s office would be full of luminous ideas. Mason Cooley, US aphorist, 1927â&#x20AC;&#x201C;2002

Bridge: Is used to replace one or more missing teeth and is anchored to the adjacent teeth.

Dental implant: A titanium post is implanted in the jaw bone to attach a crown or anchor a denture.

The US market for dental implants is estimated to be US$1 billion in 2011.

Gold is the most expensive filling material and has been used in dental fillings for thousands of years.

Dentures: Removable replacement of some or all the teeth; they are usually made of resin or a combination of resin and metal.

Orthodontic treatment: The correction of bite anomalies through braces and removable appliances.

fear and avoid regular check-ups. The dogma of two check-ups a year has been abandoned for a more flexible schedule based on individual need. Dental care is the most frequent reason for seeking health care abroad. Dental tourism is a growing trend, which involves people travelling to other countries for private dental care at a fraction of the cost of care in their home countries. There are huge inequalities in dental care throughout the world. Treatment is limited due to available resources, as well as affordability and accessibility for patients. Quality restorative oral care is only realistic for affluent, urban population groups, while rural, poor and deprived population groups lack access to even basic emergency care.

Left: Oral Urgent Treatment in Cambodia. Below: Removing caries with a hand instrument prior to ART restoration.

The WHO Oral Health Programme recommends that: “Health authorities should strengthen the implementation of oral disease prevention and health promotion programmes rather than traditional curative care. Community-oriented essential care and affordable fluoride toothpaste should be encouraged.”

BASIC PACKAGE OF ORAL CARE WHAT IS OUT? Oral Urgent Treatment (OUT) is an on-demand service providing basic emergency oral care. The three fundamental elements of OUT are: • relief of oral pain • first aid for oral infections and dento-alveolar trauma • referral of complicated cases. OUT can be provided by trained non-dentist personnel.

For nearly 20 years, Cambodia has successfully provided essential dental treatment in most rural areas by training community nurses. Dentists help with training, and supervise and manage the programme.

WHAT IS AFT? Use of Affordable Fluoride Toothpaste (AFT) is one of the most important preventive measures in managing dental caries. However, fluoridated toothpaste is often too expensive for disadvantaged groups in low- and middle-income countries to purchase. AFT programmes are designed to allow people to clean their teeth twice daily with affordable fluoridated toothpaste.

WHAT IS ART? Atraumatic Restorative Treatment (ART) is a caries management approach, consisting of a preventive (fissure sealant) and a restorative component (filling). ART can be performed inside and outside a dental clinic, as it uses only hand instruments and does not rely on electricity and running water. It causes minimal pain, minimises the need for local anaesthesia, and helps with cross-infection control.

No one should suffer from oral diseases or conditions that can be effectively treated or prevented. Richard Carmona, US Surgeon General, 2002

In Tanzania, ART restorations accounted for between 8% and 20% of the total number of dental procedures carried out in 13 public dental clinics during a 31-month period following introduction of the approach.

ppropriate, accessible and affordable oral health care remains a remote aspiration for the majority of the world’s population. Oral health care using a technology-focused curative approach is unrealistic for most low-income countries. The Basic Package of Oral Care (BPOC), developed by the WHO Collaborating Centre for Oral Health Care and Future Scenarios at the University of Nijmegen, Netherlands, is designed to better match the realities of low-income countries. The BPOC is a milestone, providing a conceptual framework for integration of oral health into Primary Health Care. This WHO-endorsed concept is based on modular components that can be adapted to the resources and needs of recipient communities.

ORAL HEALTH & PRIMARY HEALTH CARE 22

THE PRIMARY HEALTH CARE PYRAMID

low

Basic oral care and prevention are possible even in low-resource settings, using cost-effective and evidence-based interventions.

high Many village health care centres in Africa report that oral pain is among the five most frequent health complaints.

Advanced oral care by dentist

Basic oral-care services (by non-dentist personnel) – first level in formal health-care system

For every US$1 spent on an advocacy project to increase the availability and consumption of fluoride toothpaste in Nepal, there is a potential saving in the direct cost of treating caries of US$87–US$356.

Costs

Frequency of need

Specialist oral care by dentists and specialists

Informal community care and traditional medicine (self-help groups, community health programmes involving non-health professionals)

Self-care and prevention high

low

The “Fit for School” programme in the Philippines provides for teacher-supervised daily tooth-brushing and hand-washing, and twice-yearly de-worming. Cost for material is US$0.50 a child per year. It reduces caries by 40% and reduces the progression of caries into the pulp by 60%.

Quantity of care needed

A Primary Health Care system that provides universal coverage is people-centred, has demand-led policies and programmes and integrates health into all policies (labour, environment, education, etc.). It is more likely to benefit a greater proportion of the population than traditionally designed health care services. In settings with low resources, essential health packages pool high-impact interventions in a scalable, affordable and synergistic way. Focus should be on preventive actions, priorities allocated according to disease burden, and basic emergency care and pain relief. It is possible to target interventions to specific population groups. The elderly are likely to benefit most from treatment, while children will benefit most from prevention.

UN MILLENNIUM DEVELOPMENT GOALS The MDGs were agreed by all member states of the United Nations in 2000 in order to address the growing gaps in development between nations by 2015. The goals have a significant impact on the international health agenda, and oral health can be linked to all goals.

GOVERNMENT AND ORAL HEALTH

Aiming for integrated action country with Chief Dental Officer (where known)

Eradicate extreme poverty and hunger • Toothache, dental infection and toothlessness lead to mal- and under-nutrition. • Poor people are significantly affected by expenditure on dental care. • Dental problems lead to days missed from work and subsequent loss of income.

1986: Ottawa Charter on Health Promotion.

CANADA

U S A

Achieve universal primary education • Dental problems can result in days missed at school. • Toothache has an impact on a child's concentration, sleep, and school performance.

BERMUDA

Promote gender equality and empower women • Mothers need to know about basic oral hygiene and healthy diet for their children. • As women live longer there is a need to embrace good oral health throughout life.

MEXICO

BAHAMAS

CUBA CAYMAN IS.

BELIZE JAMAICA

DOMINICAN REP. BR. VIRGIN IS. ANGUILLA ANTIGUA & BARBUDA DOMINICA ST LUCIA

ST KITTS & NEVIS HONDURAS MONTSERRAT GUATEMALA ST VINCENT & THE GRENADINES EL SALVADOR NICARAGUA GRENADA

Reduce child mortality • Dental infection, noma and harmful traditional practices can lead to death.

COSTA RICA PANAMA

VENEZUELA COLOMBIA

BARBADOS TRINIDAD & TOBAGO

GUYANA SURINAME

ECUADOR

Improve maternal health • Poor maternal oral health may impact on delivery and birth weight as well as on child oral health. • Poor maternal oral health negatively impacts on child oral health. Combat HIV/AIDS, malaria and other diseases • There is a link between HIV/AIDS and oral health, and oral problems can be an early indicator of infection. • Dental decay is the most frequent childhood disease. • Proper cross-infection control is necessary to avoid transmission of diseases during dental treatment. Ensure environmental sustainability • In oral health care this involves using appropriate technology, effective infection control and safe disposal of medical waste. Develop a global partnership for development • This involves partnerships promoting oral health among key stakeholders. • Access to essential medicines, basic oral care and prevention through fluoride are all important.

Medical breakthroughs mean little if they fail to reach those in greatest need. Tadataka Yamada, President, Global Health Program, Bill & Melinda Gates Foundation, 2008

PERU

BRAZIL

BOLIVIA CHILE

PARAGUAY

ARGENTINA URUGUAY

Global Goals for Oral Health In 1981, the WHO and FDI jointly agreed the Global Goals for Oral Health by the Year 2000. The target was a DMFT value of less than 3 for 12-year-old children. Although not all countries reached the goals, they catalysed action for oral health. New goals for 2020 were agreed in 2003.

ecause oral health and general health are related, oral care and prevention of oral disease must be an integral part of any health system. Oral health is a human right and requires appropriate provision for everyone. This goal is yet to be achieved and will remain a challenge for decades to come. Through the Global Goals for Oral Health by the Year 2000 many countries have proved that health targets can be reached, if priorities and political support follow population needs. The Millennium Development Goals (MDGs), as well as many other international declarations, provide the platform for increased advocacy for improved oral health worldwide. International stakeholders, NGOs and the oral health care industry play an essential role in this context.

ADVOCACY AND INTEGRATION 23 2003: Ferney-Voltaire Declaration on Global Oral Health. NORWAY

ICELAND

1982: Berlin Declaration on oral health in deprived communities.

FINLAND

SWEDEN UK IRELAND

ESTONIA LATVIA LITHUANIA

DEN. NETH.

RUSSIA

BELARUS POLAND BELGIUM CZ. SLOVAKIA REP. LIECHT. LUX. AUS. HUN. ROMANIA SWITZERLAND SLO. B-H BULGARIA ALBANIA SPAIN GERMANY

PORTUGAL

ALGERIA

MAURITANIA

GUINEA SIERRA LEONE LIBERIA

MALI BURKINA FASO

CÔTE D’IVOIRE

GHANA TOGO BENIN

SENEGAL GAMBIA

K A Z H A K S TA N

2005: Crete Declaration on Oral Cancer Prevention.

GREECE MALTA

NIGER

International policies and the UN Millennium Development Goals support the integration of appropriate oral health services in health systems worldwide. 1978: Alma-Ata conference on Primary Health Care. SOUTH KOREA

CHINA

ISRAEL

2003: WHO Framework Convention on Tobacco Control.

KUWAIT

PAKISTAN

BAHRAIN

2007: Beijing Declaration on promoting oral health by using fluoride in China and South-East Asia.

Hong Kong SAR

INDIA OMAN

VANUATU

FIJI

THAILAND

ERITREA

CAMBODIA NIGERIA

PALAU

CAMEROON

UGANDA

DEMOCRATIC REPUBLIC OF CONGO

GABON

2004: Phuket Declaration on Oral Health in HIV/AIDS.

KENYA

BURUNDI

BRUNEI

MALAYSIA

SINGAPORE

I N D O N E S I A

TANZANIA COMOROS

ANGOLA

2004: Bangkok Charter on Health Promotion in a Globalised World.

ZAMBIA ZIMBABWE

NAMIBIA

BOTSWANA

MADAGASCAR

MOZAMBIQUE

MAURITIUS

2004: Nairobi Declaration on Oral Health in Africa.

AUSTRALIA

SWAZILAND

SOUTH AFRICA

LESOTHO

What is a Chief Dental Officer? Many governments have a dedicated person for oral health matters, often called a Chief Dental Officer (CDO). As the principal dental advocate they are crucial in ensuring that oral health is integrated into the government's agenda, and that oral health is part of national health planning and health budgeting. However, not all countries have a CDO, or the position is sidelined by lack of involvement and budgets.

World Oral Health Day World Oral Health Day was designated as 12 September by the FDI in 2007, in commemoration of the birthday of the FDI’s founder, Charles Godon, and in recognition of the Alma-Ata conference on Primary Health Care, which took place on that date in 1978. Every year, the day is an occasion to advocate for oral health worldwide.

During a Global Oral Health Workshop, convened by the FDI in 2003, the Ferney-Voltaire Declaration was adopted. It urges all concerned with health to work together in a network of formal and informal partnerships to reduce inequalities in health and to increase access to affordable oral health care by developing policies that focus on: “Improving living and working conditions, enabling people to adopt healthier lifestyles, encouraging communities to participate in every stage of the policy planning process, enabling all people to access an appropriate, locally determined, programme of basic oral health care that includes: relief of pain, promotion of oral health and the management of oral diseases and conditions.”

NEW ZEALAND

Accrediting [dental] bodies should consider requiring competency in oral health advocacy as a measured standard. Lawrence Garetto & Karen Yoder, Indiana University, USA, 2006

Oral health practice is broader than, but includes, the professional practice of dentistry. The specific practice of dentistry is a large and critical facet in this regard; but dentistry cannot be successful alone as it is not sufficient to resolve the challenges at hand. In many regards, it appears that the practice of dentistry may contribute as much to the problem as it has potential to participate in the solution. Caswell A. Evans, College of Dentistry, University of Illinois at Chicago, 2006

Part 5 ORAL HEALTH WORKFORCE 65

Dental Assistant Dental assistants support the dentist in the surgery and help with administration; they normally work under the supervision of a dentist.

Dental Hygienist Dental hygienists focus on oral hygiene and education, application of preventive agents to teeth and gums, and procedures aiming at preventing tooth decay and periodontal diseases. In some countries they practise independently without the supervision of a dentist.

Training: 1–3 years Training: 1–3 years

Dentist Dentists lead the oral health team and are responsible for diagnosis, giving advice, provision of oral health care and writing prescriptions.

Training: 4–6 years (+ postgraduate if specialised)

80 per cent of all oral health care is concentrated in 20 per cent of the population. International Federation of Dental Education Associations (IFDEA)

team approach in dentistry, as in other health professions, has become more and more common in many countries. The dental team may include up to five different types of oral health professionals and is usually led and supervised by a dentist. Dental assistants (also called dental nurses), dental hygienists, dental laboratory technicians and dental therapists perform a range of complementary tasks. National regulations determine the exact roles and duties of the five allied oral health professions, and ensure their proper training. Depending on community needs, available resources and local legislation, these roles vary from country to country, and not all professions exist in all countries. There are no comprehensive international statistics covering these

THE DENTAL TEAM 24 Dental Therapist Dental therapists provide basic dental treatment such as extractions and simple fillings, as well as undertaking the tasks of hygienists. In some countries they practise independently without the supervision of a dentist.

Dental teams function in a variety of settings, ranging from high-tech clinics to simple community or field settings.

DEBATE Delegating basic tasks to lower-trained and non-dental personnel can increase access to care.

Only oral health professionals can provide quality oral health care.

Training: 1–4 years

New Zealand has an extensive system of School Dental Therapists. Treatment costs for children up to the age of 12 are covered by the state.

Dentistry is defined as the “evaluation, diagnosis, prevention and/or treatment of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body.”

Dental (Laboratory) Technician Dental technicians are responsible for manufacturing crowns, bridges, dentures, and other dental prosthetics following a prescription from a dentist. In some countries they are allowed to manufacture and fit dentures independently, without involving a dentist (then called a “denturist”).

Training: 1–3 years (+ postgraduate if specialised)

professions, but it can be estimated that their total worldwide number is at least twice the number of dentists, bringing the total number of “dental workers” to about 3 million worldwide. Illegal or “quack” providers carry out routine dental care in many countries, sometimes outnumbering registered dentists. These illegal practitioners typically lack proper training, tools, cross-infection controls or anaesthetics, resulting in low-quality, ineffective and often dangerous, counterproductive care. However, for many they are the only available or affordable providers of oral care and pain relief. In the context of task shifting, new, more flexible, workforce models are being developed to better address the needs of resource-poor or remote communities.

The dental team aims to prevent oral disease and ensure the best possible quality of oral health care.

GLOBAL DENSITY OF DENTISTS Population per dentist 2007

fewer than 3,000 3,000 – 19,999 20,000 – 49,999

ICELAND

CANADA

50,000 – 199,999 200,000 or more

IRELAND

no data World country average: 5,875 people per dentist Highest density: Croatia 568 people per dentist Lowest density: Ethiopia 1,278,446 people per dentist

More than 3,000 Cuban dentists are serving in 68 countries worldwide.

USA

PORTUGAL

MOROCCO BAHAMAS

MEXICO

CUBA DOMINICAN

JAMAICA HAITI REP. BELIZE

2:1

COSTA RICA PANAMA

ALGERIA

COLOMBIA

1:1 GUINEA-BISSAU

5:1

MAURITANIA

MALI

2:1 NIGER

GAMBIA GUINEA SIERRA LEONE

CÔTE D’IVOIRE

GHANA TOGO BENIN

2:1

VENEZUELA

CHAD

20:1

GABON EQUATORIAL GUINEA CONGO

ERITREA

SUDAN

10:1

15:1

PERU

1:1

4:1

UGANDA RWANDA

Rural:urban distribution of dentists in Africa 2002–04

TANZANIA

1:1

6:1

CHILE

BURUNDI COMOROS

ZAMBIA

PARAGUAY

CÔTE

There are more dentists from Benin in France than in Benin.

14%

ARGENTINA URUGUAY

4:1

MAURITIUS

1:1 SWAZILAND

86%

no data ratio of urban dentists to rural dentists

The dentist is a little like a sentinel at the door of the human citadel; often it is he who sounds the first alarm that the whole organism is in danger. Charles Godon, founder of FDI, 1900

USA 134,245

GUINEA

D’IVOIRE SIERRA LEONE LIBERIA

BOLIVIA

no rural dentists some rural dentists

GUINEA-BISSAU

15:1

DEMOCRATIC REPUBLIC OF CONGO

RURAL NEGLECT

MAURITANIA

SENEGAL GAMBIA

GUYANA SURINAME

BRAZIL

ETHIOPIA CENTRAL AFRICAN REP.

BARBADOS TRINIDAD & TOBAGO

ECUADOR

DJIBOUTI

CAMEROON

<1:1

2:1

CAPE VERDE

ANTIGUA & BARBUDA DOMINICA ST LUCIA

ST KITTS & NEVIS

HONDURAS GUATEMALA ST VINCENT & THE GRENADINES EL SALVADOR NICARAGUA GRENADA

entists are health care professionals who focus on the diagnosis and treatment of diseases that affect the mouth and teeth. Dentists and dental teams are usually an integral part of health services, providing education, prevention, supervision and management. Dentists work in a variety of settings including academia, hospitals, private practices, community clinics, research institutes, private companies and the public health sector. Dental councils or equivalent institutions register and license dentists, provide ethical guidance and quality control. The dentist-topopulation ratio is a rough indicator of service availability, and a higher number of dentists does not necessarily result in the improvement of all aspects of oral health.

“The primary duty of the dentist is to safeguard the oral health of patients.” International principles of ethics for the dental profession, FDI 1997 FINLAND

NORWAY

SWEDEN

ESTONIA

RUSSIA

LITHUANIA

DENMARK NETH.

GERMANY

BEL. LUX.

SWITZ.

FRANCE

LATVIA

MONT. ALB.

ITALY

SPAIN

MAC.

RUSSIA

TURKEY

GREECE

TUNISIA

K A Z A K H S TA N

MONGOLIA UZBEKISTAN

GEORGIA

IRAQ

KUWAIT BAHRAIN QATAR

EGYPT

MALI

NIGER

CHAD

ERITREA

SUDAN

GHANA TOGO BENIN

BURKINA FASO

CHINA

PAKISTAN

NEPAL

UAE

BHUTAN

Hong Kong SAR

BANGLADESH

INDIA

SAUDI ARABIA

JAPAN

SOUTH KOREA

AFGHANISTAN

IRAN

JORDAN

LIBYA

NORTH KOREA

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN TAJIKISTAN

CYPRUS SYRIA LEB. ISRAEL

MALTA

ALGERIA

There are more than a million dentists worldwide – but unequally distributed, leaving many of the world’s poorer countries with a shortage of qualified dentists.

POLAND BELARUS

UKRAINE CZ. REP. SL. MOLDOVA AUS. HUN. ROM. SL. CRO. B-H SERB. BUL.

ANDORRA

DENTISTS 25

There is a critical global shortage of dentists trained in public health. They are required to manage health systems, design and implement preventive population-wide health promotion programmes and to plan effective services.

MYANMAR

OMAN

MARSHALL ISLANDS FED. STATES MICRONESIA

Macau SAR

LAOS

KIRIBATI

NAURU

PHILIPPINES

THAILAND

YEMEN

VIETNAM CAMBODIA

DJIBOUTI

TUVALU SAMOA

NIGERIA CAMEROON

ETHIOPIA

CENTRAL AFRICAN REP.

EQUAT. GUINEA

UGANDA

SAO TOME GABON & PRINCIPE

RWANDA BURUNDI SEYCHELLES

TANZANIA

ZAMBIA

BOTSWANA

TONGA

I N D O N E S I A

In India, the dentist:population ratio in rural areas is 1:300,000 and 1:27,000 in urban areas.

PAPUA NEW GUINEA

SOLOMON ISLANDS

MAURITIUS

MOZAMBIQUE SWAZILAND

SOUTH AFRICA

BRUNEI

MALAYSIA

MADAGASCAR

ZIMBABWE NAMIBIA

FIJI

SINGAPORE

COMOROS

ANGOLA

PALAU

SRI LANKA

There are only 16 dentists in Eritrea, and 15 of them work in the capital.

SOMALIA

KENYA

DEMOCRATIC REPUBLIC OF CONGO

CONGO

MALDIVES

GENDER RATIOS 2000 or later 000

LESOTHO

AUSTRALIA

number of dentists surveyed male dentists female dentists

39%

38% 62% Germany 65,928

NEW ZEALAND

61%

Thailand 6,966

46% 42% 58%

Pakistan 6,452

54% 69%

Morocco 3,091

31%

Madagascar 410

There is a significant shortage of dentists around the world, particularly in low-income countries. Practitioners tend to cluster in affluent urban areas, leaving rural areas or less affluent populations with a serious lack of access to quality care. Illegal practitioners, many of whom lack formal training and appropriate equipment, often fill the gap. Unfortunately, although such illegal services can be harmful to patients they may provide the only available or affordable relief. Adding to the shortage of dentists is a growing “brain drain”, with oral health professionals migrating away from their country of origin.

MIGRATION OF DENTISTS Major flows 1999–2000

22% of dentists practising in the UK are foreign born.

15% of dentists practising in France are foreign born.

15% of dentists practising in the USA are foreign born.

“Planned international recruitment of oral health professionals can only be a partial solution to domestic shortages. It is essential that international recruitment be done without detriment to health services of countries.” FDI Policy Statement

Two-thirds of dental graduates from the Philippines migrate to the USA. Most of them do not work as dentists but as other health professionals.

China

1:86

Côte d’Ivoire

1:20

Botswana

1:12

USA Germany Brazil

1:5.5 1:4.4

Selected countries 2008–09 dentist

1:0.9

Syria has invested significantly in scaling up the dental workforce: dentist numbers increased from 1,975 dentists (1981) to 14,610 (2002). However, the percentage of untreated caries and the number of Decayed, Missing, or Filled Teeth (DMFT), remained more or less unchanged.

DENTIST TO PHYSICIAN RATIOS

Brazil is the only country with almost equal numbers of dentists and physicians.

physician

he global oral health workforce is affected by many factors: emerging dental education institutions; demographic developments; evolving science; economic pressures in the private sector; changing public health priorities. In many high-income countries a large proportion of dentists will leave active work and retire in the coming decade without being replaced by new graduates, resulting in a decrease of active dentists. On the other hand, dentist numbers are steadily increasing in many middle-income countries. The overall shortage and unequal distribution of dentists is complicated by a growing trend of “brain drain”, as oral health professionals migrate from their country of origin to work in a different country, often attracted

WORKFORCE CHALLENGES 26 UNEQUAL DISTRIBUTIONS

The global oral health workforce is in constant change. Innovative solutions are required.

Total number of working dentists per region based on highest number reported 2002â&#x20AC;&#x201C;09 represents 1,000 dentists

Total dentists: 1,128,628

North America 147,930

Central America and Caribbean 22,170

South America 289,276 (including Brazil 223,000)

Europe 342,278

North Africa 2,492

Middle East 64,066

Sub-Saharan Africa 11,002

Russia and Central Asia 44,904

East Asia 111,557

South Asia 47,287

South-East Asia 34,292

Oceania 11,374

by higher salaries and better work environments. Detailed and current data about dentist migration are scarce. Governments and professional organisations try to address the problems related to international migration with ethical codes, calling for equal working conditions for all health professionals and discouraging active recruitment. The relations among members of the dental team in many countries are not well defined, making matters of independent practice, supervision, and delegation a constant topic of debate. In some countries innovative models of task-shifting from highly trained dentists to other oral health professionals with less extensive training are implemented to improve access to care and lower costs, particularly in rural or remote areas.

The World Health Assembly urges member states ...to scale up capacity to produce oral health personnelâ&#x20AC;Ś providing for equitable distribution of these auxiliaries to the primary-care level, and ensuring proper service back-up by dentists through appropriate referral systems. From a resolution adopted by all 194 member states of the WHO, 2007

It is not the knowing that is difficult, but the doing. Chinese Proverb

Part 6 ACTORS AND ORGANISATIONS 73

DENTAL SCHOOLS

Number of dental schools 2006 or latest available data more than 60 10 – 60 2–9 1

The average cost to a US university per four-year training of a dental student is $71,139 (2000). The average cost per inmate for a four-year prison term in California is $142,000 (2004).

CANADA

The Baltimore College of Dental Surgery in the USA opened in 1840 and was the world’s first dental school.

Average dentalstudent debt on completion of study in USA in 2002: $107,000.

no data IFDEA world congresses Countries with the most dental schools: India 206; Brazil 191; China 93

In Brazil approximately 10,000 dentists graduated in 2008. In all 46 WHO/AFRO member states, only 168 graduated in 2002.

USA

“There is a wide variety of dental educational systems throughout the world. These systems... should all result in the graduate being competent to perform nationally or internationally agreed basic clinical competence covering patient examination assessment and diagnosis, communication and patient education, ethics and jurisprudence, treatment, medical emergencies and practice management.” FDI Policy Statement “Basic Dental Training”, 2003

Washington DC 2011

MEXICO

CUBA HAITI

GUATEMALA EL SALVADOR

DOMINICAN REP.

JAMAICA HONDURAS NICARAGUA

TRINIDAD & TOBAGO

COSTA RICA PANAMA

VENEZUELA COLOMBIA

GUYANA SURINAME

ECUADOR

PERU

BRAZIL

BOLIVIA

The Journal of Dental Education, launched in 1936, is a monthly journal published by the American Dental Education Association. The European Journal of Dental Education, launched in 1997, is published quarterly by the Association for Dental Education in Europe. Both journals are available free to low-income countries through WHO HINARI.

It is extrapolated that the vast bulk of oral treatment must be carried out by personnel without formal training in dentistry because over 90 per cent [of people] do not have access to routine dental care. Diarmuid Shanley, former Dean, Trinity College Dental School, Ireland, 2008

CHILE

PARAGUAY

ARGENTINA URUGUAY

Many countries require dentists to engage in continuing professional education to maintain their licence.

entistry emerged as a profession, with its own system of education, at the end of the 19th century. Since then, dental education has been largely separate from medical teaching. Dental degrees require four to six years of university study and are expensive, for the country, the institution and the student. Generally, dental school entry requirements and training are comparable to those of medical schools. Dental education covers theoretical and practical training, including anatomy, physiology, biochemistry, pathology, behavioural sciences and dental materials science, as well as clinical skills. However, dental training is often disproportionately focused on restorative care, neglecting oral health

DENTAL EDUCATION 27 Dental education should ensure that oral health professionals are equipped with the necessary skills to meet the needs of their patients and populations.

Prague 2001 ICELAND

Dublin 2007

FINLAND

NORWAY

SWEDEN

LATVIA LITHUANIA

IRELAND

POLAND BELARUS

NETH. BEL.

RUSSIA

ESTONIA

DENMARK

GERMANY

FRANCE

SWITZ.

CZ. UKRAINE REP. SL. AUS. HUN. ROM. SL. CRO. SERB. BUL. MONT. MAC.

SPAIN

TURKEY

ITALY

PORTUGAL

TUNISIA

GREECE

LEB. ISRAEL

MALTA

MOROCCO

KAZAKHSTAN

MONGOLIA UZBEKISTAN

GEORGIA

IRAQ

L I B YA

CHINA

IRAN KUWAIT

PAKISTAN

BAHRAIN

EGYPT

NEPAL

UAE

SAUDI ARABIA

INDIA

Hong Kong SAR

BANGLADESH MYANMAR

LAOS PHILIPPINES

THAILAND

SENEGAL

VIETNAM CAMBODIA

GHANA

SUDAN

CÔTE D’IVOIRE

NIGERIA

SRI LANKA

ETHIOPIA

FIJI

206

TONGA

MALAYSIA

UGANDA KENYA

DEMOCRATIC REPUBLIC OF CONGO

JAPAN

SOUTH KOREA

SYRIA

JORDAN

ALGERI A

NORTH KOREA

KYRGYZSTAN

ARMENIA AZERBAIJAN TURKMENISTAN TAJIKISTAN

Singapore 2004

SINGAPORE

I N D O N E S I A

TANZANIA

GOING PRIVATE

Number of dental colleges in India 1950–2005

134 ZIMBABWE

MADAGASCAR

private colleges public colleges

SOUTH AFRICA

In 2006, a total of 11,582 new dentists graduated from 29 European countries. 3 1950

Cost of training a dental student: • New Zealand US$115,512 • Sri Lanka US$14,755

14 13

1960

1970

22 17 1980

24 1990

AUSTRALIA

2000

2005

promotion, disease prevention and public health. In recent years, privatisation of dental education has become a significant trend in some regions and a lucrative business, raising questions of accreditation, quality control and geographical distribution. There is also a shift away from public service towards cosmetic dentistry and advanced forms of restorative care. The International Federation of Dental Educators and Associations (IFDEA), established in 1992, provides a network for more than 1,200 dental schools worldwide. IFDEA promotes high-quality dental education and greater understanding of global health priorities.

NEW ZEALAND

Mannequin used by oral health professionals.

A WORLD OF RESEARCH

It has been estimated that just 10% of funding for health research is directed to issues that affect 90% of the world’s poorest population. Oral health research follows the same pattern.

Number of members of International Association for Dental Research (IADR) by region 2009

Medline, a global database for bio-medical scientific papers, currently lists 869 journals in dentistry and more than 350,000 related papers.

IADR headquarters planned IADR General Sessions, with date

Government agencies, international organisations, universities and industry commission and conduct most oral health research.

2013 Seattle, Washington

IADR has more than 11,000 individual members in 95 countries.

LARGEST SUPPORTERS OF ORAL HEALTH RESEARCH Based on publications in Journal of Dental Research 2004–08

North American Region 4,464 members

IADR Global Headquarters, Alexandria, Virginia

2011 San Diego, California

The National Institute of Dental and Craniofacial Research (NIDCR) in the USA is the largest funding agency for dental research worldwide.

DENTAL RESEARCH

The scope of dental research includes:

• genetics

Latin American Region 1,056 members

• microbiology Australia

• immunology and virology

Brazil

• biomaterials

Canada

• tissue engineering and nanotechnology

China

• clinical trials

Finland

• diagnostics

Germany

• prevention

Japan Netherlands

• population sciences and public health

• health services

USA

• health policy

Research in its highest expression is open-minded inquiry for truth, to be found and revealed unreservedly for the information, instruction, advantage, and welfare of all. William J. Gies, founder of IADR, 1919

• community-based participatory research

• socio-dental sciences

2012 Rio de Janeiro

cience and research are the foundation of health programmes, policies and practices. Through basic clinical and public health research, scientists uncover the causes of diseases, develop improved diagnostic and treatment methods, provide evidence to support quality care and promote overall health. Increasingly, researchers worldwide are collaborating across disciplines, across institutions and across countries. There have been great advances in dental research, including breakthrough findings in birth defects, salivary diagnostics, oral cancer and HIV/AIDS. The USA, UK, Japan and Scandinavia are the most productive countries in terms of dental research as measured in total numbers of papers, papers per researcher and the impact of the research. The focus of

DENTAL RESEARCH 28 Research is the cornerstone of sound and effective policy and practice â&#x20AC;&#x201C; from the personal to the political.

The USA, UK and Japan together account for more than 60% of all published dental research.

European Region 2,284 members

2010 Barcelona

Asia/Pacific Region 3,012 members William J. Gies, founder of IADR.

Africa/Middle East Region 515 members In 2001, a dentist wishing to stay up-to-date on paediatric dentistry would have to read approximately 24 articles each week from more than 75 different journals.

2014 Cape Town

The IADRâ&#x20AC;&#x2122;s Journal of Dental Research has the highest Impact Factor of all dental journals publishing original research in the category: Dentistry, Oral Surgery and Medicine.

dental research, however, has been on the needs of high-income countries. As with most health research, low-income countries are under-represented in terms of research facilities. The International Association for Dental Research (IADR) is a nonprofit organisation located in Alexandria, Virginia, USA. Established in 1920, its mission is: to advance research and increase knowledge for the improvement of oral health worldwide; to support and represent the oral health research community; and to facilitate the communication and application of research findings. IADR emphasises transforming science and knowledge into practice, creating tangible benefits, particularly in low-income countries.

Are we focusing enough ... attention on fundamental, cross-cutting, and far-reaching ... approaches to the control of oral disease globally? Or are we ... dealing with them in compartments ... without attacking the underlying, fundamental issues? Deborah Greenspan, past president of IADR, 2007

WORLDWIDE DENTISTRY

FDI World Dental Federation is the second oldest international professional organisation, after the International Council of Nurses (1899). It was founded in Paris in 1900 as the Fédération Dentaire Internationale (FDI) by Charles Godon.

Countries with a member organisation of the FDI 2008

country with FDI member organisation country without FDI member organisations projects of World Dental Development Fund

C A N A D A

countries with LLL projects headquarters of FDI, Geneva, Switzerland

The first FDI Congress was held in Paris, France in 1900 with eight countries represented.

U S A

Live.Learn.Laugh. (LLL) The FDI currently manages 40 oral health promotion projects in 36 countries around the globe through the Live.Learn.Laugh. programme, a public-private partnership with Unilever Oral Care.

MOROCCO

MEXICO

BAHAMAS

CUBA DOMINICAN REP.

HONDURAS HAITI NICARAGUA EL SALVADOR COSTA RICA PANAMA

21ST-CENTURY FDI CONGRESSES Geneva

SWITZERLAND

2011

Mexico City

MEXICO

2010

Salvador da Bahia

BRAZIL

2009

Singapore

SINGAPORE

2008

Stockholm

SWEDEN

2007

Dubai

UNITED ARAB EMIRATES

2006

Shenzhen

CHINA

2005

Montreal

CANADA

2004

New Delhi

INDIA

2003

Sydney

AUSTRALIA

2002

Vienna

AUSTRIA

2001

Kuala Lumpur

MALAYSIA

2000

Paris

FRANCE

The FDI will have to find an equilibrium between the promotion of oral health and the protection of the profession. Ruperto Gonzales-Giralda, former FDI President, 1989

SENEGAL

VENEZUELA

MALI

GUINEA-BISSAU GUYANA

SIERRA LEONE

COLOMBIA

2012

ICELAND

CÔTE D’IVOIRE

ECUADOR

BRAZIL

PERU

BOLIVIA PARAGUAY CHILE

ARGENTINA URUGUAY

The FDI holds a continuing education course every two weeks on average.

The FDI two-digit notation system was developed in 1971 to identify teeth with a number and is the ISO-recognised international standard for tooth notation.

he FDI is a federation of national dental associations whose vision is leading the world to optimal oral health by representing the dental profession, promoting public health, providing continuing education, advocating for oral health, and stimulating and facilitating the exchange of information across all borders. The organisation was founded in Paris in 1900 as the Fédération Dentaire Internationale (FDI) by Dr Charles Godon. The FDI is governed by a General Assembly that is made up of delegates from more than 190 member associations from over 130 countries. More than 1 million dentists worldwide are represented through the organisation, thus making it the most powerful voice for oral health. There are five regional organisations,

FDI WORLD DENTAL FEDERATION 29 FINLAND NORWAY SWEDEN

LATVIA LITHUANIA

DENMARK

IRELAND

RUSSIA

BELARUS

NETH. GERMANY BELGIUM

FDI is a federation of over 190 dental associations whose vision is to lead the world to optimal oral health.

ESTONIA

LUX. SWITZ.

FRANCE PORTUGAL

CZECH REP.

POLAND

UKRAINE

SLOVAKIA

RUSSIA

MOLDOVA

AUSTRIA HUN. SLOV. ROMANIA CRO. B-H SERBIA BULGARIA

ANDORRA

ALB.

MACEDONIA

ITALY

KAZAKHSTAN

SPAIN GREECE

UZBEKISTAN

GEORGIA

MONGOLIA

JAPAN KYRGYZSTAN

ARMENIA AZERBAIJAN

TURKEY TUNISIA

CYPRUS SYRIA LEB. ISRAEL

MALTA

IRAQ

SOUTH KOREA

CHINA

IRAN

WDDF Through the World Dental Development Fund, founded in 1998, the FDI has successfully implemented 13 demonstration projects in the areas of infrastructure, education and policy development.

JORDAN PAKISTAN BAHRAIN

Hong Kong SAR

UAE

EGYPT

SAUDI ARABIA

NIGER

BANGLADESH

THAILAND

VIETNAM CAMBODIA

ETHIOPIA

NIGERIA

Macau SAR

MYANMAR

INDIA

SUDAN

B. F. GHANA TOGO BENIN

NEPAL

PHILIPPINES

SRI LANKA

SAMOA FIJI

CAMEROON

DEM. REP. OF CONGO

GABON

UGANDA

SOMALIA

KENYA

MALAYSIA

International Dental Journal (IDJ) www.idjonline.org

RWANDA

BURUNDI

SINGAPORE

TANZANIA

TONGA

I N D O N E S I A EAST TIMOR

ANGOLA ZAMBIA ZIMBABWE NAMIBIA

BOTSWANA

MAURITIUS

Developing Dentistry www.fdiworldental.org/ resources/dd.html

AUSTRALIA

SOUTH AFRICA

The 2008 Annual World Dental Congress attracted more than 15,000 participants from 124 countries.

FDI Worldental Communiqué www.fdiworldental.org/ federation/communique. html

representing Africa, Asia Pacific, Europe, Latin America and North America. The FDI is a non-governmental organisation in official relations with the United Nations and the World Health Organization. Based in Geneva, Switzerland, it is a registered not-for-profit organisation because of its work in science, education, advocacy, policy and public health. The FDI’s Annual World Dental Congress brings together oral health professionals from around the world to share best practices and to issue policy statements. The FDI is also well known for its system of two-digit notation, the international standard for labelling teeth.

NEW ZEALAND

FDI Council received by former French President Chirac, 2000.

THE WORLD HEALTH ORGANIZATION

The FDI World Dental Federation and the International Association for Dental Research (IADR) are the only two oral health NGOs in official relations with the WHO, although other dental NGOs also work actively with the WHO.

Americas Europe Eastern Mediterranean Africa South-East Asia Western Pacific

head office

regional office USA

WHO Collaborating Centre on Oral Health, one or more

AMERICAS Washington, DC, USA

The budget of WHO for 2006–07: US$3.3 billion. World expenditure on pet food (2008): US$56 billion.

WHO GLOBAL ORAL HEALTH PROGRAMME: PRIORITY ACTION AREAS • Risks to oral health: diet, nutrition, tobacco • Fluoride promotion • Important target groups: children, elderly, deprived populations • HIV/AIDS and oral health • Oral health systems • Information systems • Oral health research and evidence for public health

The WHO has 193 member states and two associate members, who meet annually at the World Health Assembly in Geneva, Switzerland, to set policy for the Organization, approve the budget and, every five years, to appoint the Director-General.

Oral diseases are a neglected area of international health. We have the tools and best practices to address them but we need to ensure that they are applied and implemented. Margaret Chan, Director-General WHO, 2007

Margaret Chan, Director-General WHO.

he World Health Organization (WHO) is the authority on international health within the United Nations system. The WHO is responsible for providing leadership in global health, coordinating health research agendas, setting standards, highlighting evidence-based policy options and providing technical support, as well as monitoring health trends. Improving oral health is the key objective of the WHO Global Oral Health Programme, one of the technical programmes within the Department of Chronic Diseases and Health Promotion. The emphasis is on developing global policies in oral health promotion and integrated chronic disease prevention. The programme assists countries in addressing modifiable risk factors related to diet, nutrition, hygiene, safe water and sanitation, use of

WORLD HEALTH ORGANIZATION 30 Sweden

Denmark UK

EUROPE Copenhagen, Denmark

Russian Federation

Germany

France Ireland

Of the more than 8,000 WHO employees globally, only three professional-level staff work exclusively on oral health.

The WHO is the UN agency in charge of international health. Its Global Oral Health Programme provides policy guidance and technical assistance to member states.

Romania

Japan

Italy China Iran

Bulgaria

EASTERN MEDITERRANEAN Cairo, Egypt

Geneva, Switzerland

AFRICA Brazzaville, Congo

WESTERN PACIFIC Manila, Philippines SOUTH-EAST ASIA New Delhi, India

Thailand

Tanzania

South Africa

The World Health Report 2003 highlights the key problems in international oral health and details the WHO policies and strategies to tackle them. It is available online at: www.who.int/oral_health

tobacco and excessive alcohol consumption. Work is focused on children, young people, older people, disadvantaged and poor people, and those affected by HIV/AIDS. The 2007 World Health Assembly adopted Oral Health: Action Plan for Promotion and Integrated Disease Prevention, a significant milestone for global oral health. WHO policies, such as global strategies on diet and nutrition, tobacco, and Primary Health Care, need to be integrated with national oral health planning. Other elements of the action plan include workforce planning, promoting fluoride, strengthening data collection for effective national planning, as well as translation of evidence into action and public health practice.

New Zealand

Oral health means more than good teeth; it is integral to general health and essential for well-being. Poul Erik Petersen, Chief, Global Oral Health Programme, WHO HQ, 2003

You are today where your thoughts have brought you; you will be tomorrow where your thoughts take you. James Allen, New Zealand Statesman, 1855â&#x20AC;&#x201C;1942

Part 7 PAST, PRESENT AND FUTURE 83

7000 BCE Pakistan Stone-age cultures in Baluchistan (“Indus Culture”) use bow drills with flint burs to remove decayed tooth substance. 5000 BCE Iraq A Sumerian text describes “tooth worms” as the cause of dental decay.

700 BCE Myanmar Teeth found in the Halin area show gold foil fillings probably made for cultural or ceremonial reasons.

2750 BCE Egypt First report of a dental surgical operation, in which an abscessed tooth is drained. 2750 BCE Egypt A specialised physician – “one who deals with teeth” – emerges. 2700 BCE China Acupuncture is used to treat toothache. 2660 BCE Egypt An inscription on the tomb of Hesy-Re describes him as “the greatest of those who deal with teeth, and of physicians”. This is one of the earliest known references to a person identified as a dental practitioner.

1750 BCE Mesopotamia Law 200 of the famous code of Hammurapi states that “if someone knocks out the tooth of an equal, his own tooth is knocked out”. 1700–1550 BCE Egypt The Ebers Papyrus, a 21-metre long text, describes extensively the knowledge and treatment of dental diseases of the time.

900–300 BCE South America The Mayans implant semi-precious stones such as jade in teeth for cosmetic and cultural reasons. Front teeth are filed into different shapes to resemble sharp animal teeth.

659 BCE China Su Kung mentions amalgam for filling a decayed tooth in his Materia Medica. 600–500 BCE Italy The Etruscans produce bridge-like structures to replace missing teeth.

500 BCE China/India Recipes are described for a paste to clean teeth. 460–370 BCE Greece The scientist and philosopher Hippocrates describes disposition, saliva and nutrition as the causing factors for caries. This contradicts the prevailing theory of tooth worms causing the disease. 450 BCE India The process of crystallising sugar-cane juice is invented. 450 BCE Italy The laws of the 12 tables, an important collection of Roman law, ban placing gold in the tombs of deceased except the gold in their teeth. 384–322 BCE Greece The scientist and philosopher Aristotle writes about dentistry, including the eruption pattern of teeth, treating decayed teeth and gum disease, extracting teeth with forceps, and using wires to stabilise loose teeth and fractured jaws. However, he wrongly believes that male humans, sheep, goats and pigs have more teeth than females. 50–25 BCE Italy The Roman medical writer Aulus Cornelius Celsus summarises contemporary knowledge of medicine and writes about oral hygiene, stabilisation of loose teeth, treatment for toothache and tooth replacement. He also describes

HISTORY 31 DENTISTRY 7000 BCE – AD 1699 a method to adjust a dislocated mandible (“lockjaw”) that is still practised today. 600 BCE – AD 400 Italy/Europe The Romans become experts in restorative dentistry and even use gold crowns and fixed bridgework. Full and partial dentures are not uncommon. They use bones, eggshells, and oyster shells mixed with honey to cleanse the teeth. Aristocrats employ special slaves to clean their teeth. 174 Italy The personal physician of Emperor Marcus Aurelius, Galen, collects all knowledge and his own research about medicine, including oral diseases. He states that “Soon there will be more doctors than parts of the body and each disease will have its own doctor.”

650 India The Indian author Vagbhata describes 75 oral diseases. 500–1000 Europe During the Middle Ages medicine, surgery, and dentistry are generally practised by monks, the most educated people of the period. While knowledge from Roman and Greek times has been lost, new folk medicine emerges with many doubtful practices, such as blood letting. 963–1013 Spain Abù I-Qàsim, an Arab surgeon from Spain, illustrates a number of dental extraction devices in his essays on medicine and surgery. 980–1037 Iran/Uzbekistan The physician and philosopher Ibn Sinà, also known as Avicenna, describes medical knowledge of the time and covers dental diseases and treatment as well. His writings influence European medial thinking throughout the Middle Ages.

1258 France A Guild of Barbers is established. Barbers eventually evolve into two groups: surgeons, who are educated and trained to perform complex surgical operations, and lay barbers, or barber-surgeons, who perform more routine hygiene services, including shaving, bleeding and tooth extraction. 1280 China Medicine is divided into 13 specialisms, among them dentistry. 1400s France A series of royal decrees prohibits lay barbers from practising all surgical procedures except bleeding, cupping, leeching, and extracting teeth. 1498 China First description of a toothbrush with bristles. 1500 The Caribbean Sugar-cane plantations are established in the new colonies, particularly in the Canaries and the West Indies. 1530 Germany The first book devoted entirely to dentistry, The Little Medicinal Book for All Kinds of Diseases and Infirmities of the Teeth, is published. It covers practical topics such as oral hygiene, tooth extraction, drilling teeth, and placement of gold fillings. It is a standard textbook for more than 200 years. The last edition of the book is published in 1756. 1533–1603 England Queen Elizabeth I fills the gaps in her dentition with cloth to improve her appearance in public. 1575 France Ambrose Paré, known as the Father of Surgery, publishes his Complete Works, which includes practical information about surgery, such as tooth extraction, the treatment of tooth decay and jaw fractures. He also performs the first cleft-lip surgery. 1687 France King Louis XIV (1638–1715) undergoes an extraction of an upper molar that results in a jaw fracture and perforation of the maxillary sinus. The subsequent infection and further treatments leave the king without upper teeth for the rest of his life. 1690 USA Sugar-cane cultivation begins in the USA.

1728 France The dentist Pierre Fauchard, credited as the Father of Modern Dentistry, describes in his book Le Chirurgien Dentiste, ou traité des dents a comprehensive system for the practice of dentistry, including basic oral anatomy and function, operative and restorative techniques, and denture construction. He also opposes the contemporary belief in tooth worms as the cause of caries. His work is translated into English only in 1946.

and patriot of the independence wars, verifies the death of his friend by identifying the bridge he constructed for him.

1746 France Claude Mouton describes a gold crown and post to be retained in the root canal.

1815 USA Levi Spear Parmly, a New Orleans dentist, is credited as the inventor of modern dental floss (a piece of silk thread); although threads used as floss have subsequently been found in prehistoric sites.

1756 Germany Philipp Pfaff, the dentist of the Prussian King Frederick II, introduces the use of wax and plaster of Paris to take an impression. This greatly improves the fitting of dentures. Like Pierre Fauchard, he establishes standards for dental care and pushes dental practice to new levels. 1771 UK John Hunter’s Natural History of the Human Teeth is published, together with A Practical Treatise on the Diseases of the Teeth.

1776 UK Joseph Priestley synthesises nitrous oxide, later known as laughing gas. By the 1840s its narcotic and painnumbing properties are used by dentists and surgeons in particular.

1776 USA In one of the first known cases of post-mortem dental forensics, John Revere, a dentist

1790 USA One of George Washington’s dentists, John Greenwood, constructs the first known dental foot engine. He adapts his mother’s foot treadle spinning wheel to rotate a drill. 1790 USA Josiah Flagg, a dentist, constructs the first chair made specifically for dental patients. 1791 France Nicolas Dubois de Chemant receives the first patent for porcelain teeth. 1795 USA Increased cancers of the lip are reported in pipe smokers by Samuel Thomas von Soemmering. 1800s China Women of higher classes paint their teeth black as a sign of marital fidelity.

1815 UK Teeth from the 50,000 soldiers killed in the battle of Waterloo are taken out and used to fabricate dentures, known as “Waterloo teeth”. Even though the use of porcelain teeth and new materials become more widespread, extracted human teeth are used until the 1860s to make dentures. 1832 USA James Snell invents the first reclining dental chair. 1839 USA The American Journal of Dental Science, the world’s first dental journal, is first published. 1839 USA Based on an earlier German discovery, Charles Goodyear develops vulcanised rubber, a material that allows for cheap and well-fitting dentures. 1839 The world’s first dental school, the Baltimore College of Dental Surgery, opens. Dental schools are opened in Berlin (Germany) in 1855, in London (UK) in 1858, in Paris (France) in 1880 by Charles Godon, the founder of the FDI, in Geneva (Switzerland) in

HISTORY 32 DENTISTRY 1700–1899 1881, in Stockholm (Sweden) in 1888 and in Vienna (Austria) in 1890. 1840 USA The American Society of Dental Surgeons, the world’s first dental society, is founded. 1841 UK John Tomes (1815–95) publishes the principles of anatomic forceps design for tooth extraction. Surgical instruments based on his concepts are still used today. 1846 France/USA The collapsible tube, made out of lead or tin, is invented in both countries. It is only in 1896 that toothpaste starts to be sold in collapsible tubes in the USA and Germany. 1858 UK The London School of Dental Surgery is opened, the first in the UK. 1866 USA Lucy Beaman Hobbs graduates from the Ohio College of Dental Surgery, becoming the first woman in the world to earn a dental degree.

1890 Germany The US scientist Willoughby Dayton Miller, living in Berlin, establishes the microbial basis of dental decay in his book Micro-Organisms of the Human Mouth. This is the beginning of a new era of increased attention to oral hygiene and restorative dentistry. 1895 UK The first British female dentist, Lilian Lindsay, qualifies in Edinburgh. 1896 Germany/USA Wilhelm Roentgen, a physicist, discovers the x-ray. The first x-rays of teeth and jaws are taken in Germany only three months later. In the USA, C. Edmond Kells takes the first dental x-rays eight months later. He develops recurring cancer on his fingers and arm due to the constant exposure to radiation. After enduring 42 operations, resulting in arm and shoulder amputation, he commits suicide in 1928. 1898 USA Johnson & Johnson is the first company to patent dental floss. 1899 USA Edward Angle classifies the various forms of malocclusion. His classification system is still used to describe how crooked teeth are. This is the beginning of orthodontics as a dental specialty.

1872 USA The first pedal-powered dental engine, manufactured by James B. Morrison, is sold at a dental meeting in Binghamton, New York. Morrison’s inexpensive, mechanised tool supplies dental burs with enough speed to cut enamel and dentine smoothly and quickly, revolutionising the practice of dentistry. 1873 USA Colgate mass-produces toothpaste in jars. 1874 UK The British government, under prime minister Gladstone, abolishes taxation on sugar, thus making it affordable by the general population. 1875 USA The first electric dental drill is patented by George Green. 1884 Austria The first local anaesthetic used in dentistry, cocaine, is introduced by the ophthalmologist Carl Koller.

1900 France The Fédération Dentaire Internationale (FDI) is formed in Paris by the French dentist Charles Godon. 1901 The FDI Commission on Public Dental Hygiene is established. 1903 USA Charles Land devises the porcelain jacket crown. 1905 Germany Alfred Einhorn, a chemist, formulates the local anaesthetic procain, later marketed under the trade name Novocain. 1905 USA Irene Newman becomes the first dental hygienist and engages in oral health promotion for children.

1908 USA G.V. Black publishes his monumental two-volume treatise Operative Dentistry, which remains the essential clinical dental text for 50 years. Black later develops techniques for filling teeth, standardises operative procedures and instruments, develops an improved amalgam, and pioneers the use of visual aids for teaching dentistry. 1910 USA The first formal training programme for dental nurses is established. The programme is discontinued in 1914, mainly due to opposition by dentists. 1919 USA/Germany The company Ritter presents a dental unit, combining drill, pressurised water, air, cauterisation and light. Other companies follow, and standards for dental surgery equipment are established.

1920s France The cord-driven Doriot arm, developed by the Parisian dentist Constant Doriot, becomes the standard to transfer the power of the electrical engine to the drill and bur. 1926 USA William J. Gies publishes a report on the state of dental education in the USA, criticising poor standards and calling for an academic, university-affiliated dental education. 1926 During the FDI Congress in Philadelphia a resolution is adopted recommending all governments to establish the position of a Chief Dental Officer.

1937 USA Alvin Strock inserts the first Vitallium dental screw implant. 1938 USA The nylon toothbrush, the first made with synthetic bristles, appears on the market. The bristles are still very hard and uncomfortable; it is only in the 1950s that improvements in nylon quality allow for softer bristles and a widespread replacement of animal hair in toothbrushes. 1938 USA The DMFT index is first used for a large population study on caries in the USA by Klein, Palmer and Knutson. 1940s USA Trendley Dean determines the ideal level of fluoride in drinking water to substantially reduce decay without mottling. 1945 USA The water fluoridation era begins when the cities of Newburgh, New York, and Grand Rapids, Michigan, add sodium fluoride to their public water systems. 1949 Switzerland Oskar Hagger, a chemist, develops the first system of bonding acrylic resin to dentin. 1949 New Zealand John Patrick Walsh patents a dental drill driven by compressed air, thus reaching very high speed. 1951 The FDI passes its first resolution supporting fluoride for caries control. 1951 Swizerland The World Health Organization’s World Health Assembly decides to incorporate a dental programme in WHO activities. 1954 Switzerland The first electrical toothbrush is manufactured. In the early 1960s, cordless models are developed. 1955 USA The first fluoride toothpaste is introduced. 1957 At the FDI’s International Dental Congress in Rome, the American John Borden introduces a high-speed air-driven handpiece. The Airotor (marketed by the company Dentsply) obtains speeds up to 300,000 rotations per minute and is a great commercial success, launching a new era of high-speed dentistry. 1958 USA A fully reclining dental chair is introduced. 1960s Sit-down, four-handed dentistry (dentist and assistant), with the patient lying almost flat, becomes popular. This technique improves productivity and shortens treatment time. 1960s Europe Lasers are developed and approved for soft-tissue procedures. 1961 USA/USSR Space dentistry is established as a

HISTORY 33 DENTISTRY 1900–2009 discipline. During extended stays in a zero-gravity environment, astronauts rapidly lose bone density, which can lead to tooth loss. 1962 USA Rafael Bowen develops a thermoset resin complex used in most modern composite resin restorative materials. 1965 Germany The first micromotor handpiece is presented by Siemens, finishing the era of the Doriot arm. 1971 Based on an earlier suggestion of the German Professor Joachim Viohl, the FDI two-digit tooth notation is introduced as a worldwide standard. 1975 Germany Articain is introduced as a standard substance for local anaesthesia in dentistry. 1980s Sweden Per-Ingvar Brånemark describes techniques for the osseointegration of dental implants and lays the foundation for dental implantology. 1980 Europe The first European Union Dental Directive harmonises training in European schools, enabling dental graduates to work anywhere in the Union. 1981 Switzerland/UK The World Health Organization (WHO) and the FDI jointly declare Global Goals for Oral Health by the Year 2000. 1989 USA The first commercial home toothbleaching product is marketed. 1990s USA New tooth-coloured restorative materials, plus increased usage of bleaching, veneers, and implants inaugurate an era of aesthetic dentistry. 1994 Switzerland/UK The World Health Organization (WHO) and the FDI declare the year 1994 the International Year of Oral Health, dedicating World Health Day on 7 April to oral health. 1997 USA FDA approves the Erbium-YAG laser, the first for use on dentin, to treat tooth decay. 2000 France During the FDI’s Annual World Dental Congress in Paris the centennial of the organisation is celebrated; France’s President Jacques Chirac receives the FDI Council on this occasion at the Elysée Palace.

2001 France The FDI establishes the World Dental Development & Health Promotion Committee in

order to respond to the growing disparities in oral health worldwide. 2002 USA Publication of the landmark report Oral Health in America: A report of the Surgeon General. 2003 Global Goals for Oral Health by 2020 are established jointly by WHO, FDI and IADR. 2004 The first Conference for Oral Health in Africa is organised by the FDI World Dental Federation and the World Health Organization (WHO) in Nairobi, Kenya. The Nairobi Declaration on Oral Health in Africa recognises oral health as a basic human right for the first time. 2005 WHO Framework Convention on Tobacco Control (FCTC) comes into force, using international law to improve public health by requiring governments to implement proven methods of reducing tobacco use. 2005 Tobacco or Oral Health, a joint FDI/WHO publication, is published in six languages.

2006 Egypt The tombs of three royal dentists are found in one of the oldest pyramids near Cairo. 2006 France/Switzerland An expert consultation convened by the World Health Organization (WHO), the FDI World Dental Federation and the International Association for Dental Research (IADR) recognises access to appropriate fluoride as a human right. 2007 Switzerland The Ministers of Health of 193 countries adopt the first resolution on oral health for 26 years during the 60th World Health Assembly in Geneva, calling for renewed attention to oral health worldwide. 2008 Switzerland The first World Noma Day is celebrated in Geneva on the occasion of the World Health Assembly. WHO, FDI and other organisations alert the world to this forgotten disease of poverty. 2008 The FDI declares World Oral Health Day, to be celebrated every year on 12 September (birthday of FDI’s founder Charles Godon and date of the historical Alma-Ata conference on Primary Health Care). 2009 Publication of the first Oral Health Atlas.

UNTRIES

HIGH-INCOME CO

Dental decay

Criteria

Periodontal diseases

Oral cancer

HIV/AIDS

Evidence for actio Data

Interventions al health Leadership for or

SCORECARD

Assessment of state of evidence for action, leadership, resources and health systems in important areas of oral health 2009 criteria mostly met criteria sometimes met

Agenda

criteria rarely met

Advocacy Resources

13%

s Financial resource s rce Human resou

88%

Health systems Prevention

world health world expenditure population high-income countries

Treatment Integration

MIDDLE-INCOME

COUNTRIES

Criteria Evidence for action

Dental decay

Periodontal diseases

Oral cancer

HIV/AIDS

Data Interventions Leadership for ora Agenda

l health

Advocacy

25%

Resources

10%

Financial resource s Human resources Health systems Prevention

world population

Treatment

middle-income countries

Integration

Failure to implement the available knowledge remains a serious impediment to progress. Robert Beaglehole & Ruth Bonita, 2008

world health expenditure

his Oral Health Atlas provides a global view of oral health and – as the subtitle of the book suggests – maps a neglected area of international health. The degree of neglect is visible in many areas and dimensions, predominantly in the huge inequalities in disease burden, exposure to risk factors and access to care between and within countries. The scorecard is intended to assess the current situation, provide a baseline, encourage debate of oral health issues, and highlight areas that require urgent and sustained action. Based on a concept of a scorecard for global public health (Beaglehole & Bonita, 2008), the authors of this atlas have used their informed judgement to assess the situation relating to important oral health areas. The scores

THE PRESENT: A SCORECARD 34 Oral diseases are a neglected issue in global health, particularly in lowand middle-income countries.

LOW-INCOME COUNTR

IES

Criteria

Dental decay

Evidence for action

Periodontal diseases

Oral cancer

HIV/AIDS

Data Interventions

62%

Leadership for oral hea

lth

Agenda Advocacy Resources Financial resources Human resources

world population

world health expenditure

low-income countries

Health systems Prevention

Evidence-based interventions for all major oral diseases exist, but they are not available or implemented in the majority of countries.

Treatment Integration

CRITERIA FOR SCORING Evidence for action Data: Are current data available for measuring the burden of oral disease and for tracking trends? Interventions: Do cost-effective interventions exist to address the disease burden? Leadership for oral health Agenda: Is oral health firmly on the health agenda? Advocacy: Is there strong and sustained evidence-based pressure for action? Resources Financial resources: Are adequate resources allocated to oral health? Human resources: Is the oral health workforce sufficient and appropriate? Health systems Prevention: Do health systems give due attention to prevention of oral diseases? Treatment: Do health systems provide appropriate curative treatment? Integration: Is oral health integrated with other health areas in national health plans? allocated reflect the current status in each of these areas. Although the division into high-, middle- and low-income countries is a generalisation, it nevertheless highlights the very different realities and challenges; the framework should ideally be used to develop scorecards for every country. Improving any area of global health requires evidence for action, leadership, resources, and appropriate health systems. The scoring criteria chosen address these areas by looking at more detailed aspects for each of the four main areas against four important disease areas â&#x20AC;&#x201C; dental decay, periodontal diseases, oral cancer and oral manifestations of HIV/AIDS. The scores presented do not show a precise measurement, but are indicative and will hopefully stimulate discussion.

Boys in a slum in Dhaka, Bangladesh.

A WORLD OF TEETH

Estimated number of teeth worldwide 2010–50 At current birth rates, billions approximately 6 million teeth come to life every day.

250bn 200bn 150bn 2010

2010–2019

2015

2020

2025

2030

2020–2029

Prevention

• Warnings on food and drink products about the dangers of sugar introduced in many countries. • In every country tax on tobacco is at least 75% of retail price. • WHO Framework Convention on Tobacco Control ratified. • WHO Global Strategy on Diet, Physical Activity and Health implemented by 40% of countries. • WHO Convention on Alcohol & Other Risk Factors comes into force. • Oral treatment developed to permanently kill or replace harmful oral bacteria.

• Dentists routinely involved in tobacco cessation. • Innovative fluoride delivery systems launched. • Governments remove all tax on fluoride toothpaste. • WHO Convention on Diet & Nutrition comes into force. • Tobacco banned in several countries. • Tax on sugar raised to promote public health in more progressive countries.

Treatment and Technology

• Products containing mercury phased out due to environmental concerns. • Robot-led implant surgery the norm. • Stem cells harvested from baby and wisdom teeth to grow body parts.

• Digital imaging replaces conventional x-ray film. • Regenerative treatment for periodontal disease developed. • Instant chair-side fabrication of dental appliances. • Tissue engineering treatment for periodontal . disease becomes standard treatment. • Pre-birth genetic testing and treatments for birth defects available. • New, safer forms of 3D imaging replace x-rays. • Home test kit available for oral diseases, cancer, gum diseases etc.

Workforce and Health Systems

• UN Millennium Development Goals end – replaced by new set of goals focused on non-communicable diseases.

• Health expenditure shifts from cure to prevention.

Tomorrow belongs to the people who prepare for it today. African proverb

he milestones featured on this page should not be taken as real facts, but rather as informed speculation on what is to come over the next 40 years. Populations today generally enjoy better oral health than their forebears a century ago. However, the fact that not all population groups have achieved the same level of oral health and well-being is still a major challenge. In high-income countries tooth decay, gum disease and toothlessness rates will fall, while oral cancer survival rates will improve as prevention, oral hygiene and early detection get better. Tooth decay will rapidly increase in low- and middle-income countries as people consume more sugar, have low

THE FUTURE 35

2035

2040

2045

Despite advances in science and technology, the challenge of inequalities in oral health status will remain.

2050

2030–2039

2040–2050

• WHO Framework Convention on Healthy Food negotiated. • Food is engineered with oral health benefits (bacterial or fluoride). • Caries vaccine reduces the global burden of disease. • Noma eliminated. • Half of all sugars replaced by sugar substitutes.

• Touch-free "toothbrush" eliminates only harmful oral bacteria. • Genetically modified sugar grown that does not harm teeth.

DEATH FROM DISEASE

Projected deaths worldwide 2008–30 deaths from noncommunicable conditions deaths from communicable conditions 50m 40m 30m 20m

• Lasers replace dental drills. • Stem-cell-generated replacement teeth becomes a treatment option. • Saliva replaces blood as standard diagnostic tool. • Pain-free dental treatment is the norm for all procedures everywhere in the world.

• Toothbrushes record health data, which are routinely analysed by dentists. • Sensors embedded in teeth monitor vital signs and transmit them to health care providers. • Life-long caries-protective coating of teeth available. • Mobile phones embedded in teeth. • Cranial nerves connect oral memory implants to brain.

• India has the most dentists.

10m 0

2008

2015

2030

The number of deaths resulting from communicable conditions is expected to continue to decline, while the number of deaths from non-communicable conditions, including most oral diseases, is expected to rise, resulting in a greater burden to public health in the future.

The FDI will celebrate its 150th anniversary in 2050.

exposure to fluoride and lack access to appropriate oral health care. High-income countries will see a growing elderly population who will require more care than the generations that follow them. Focusing on prevention is the only realistic way to address the epidemic of oral diseases worldwide. To help ease this burden, oral health products, such as toothpaste, will be exempted from taxes and sold in smaller quantities, to increase their affordability. Innovative ways of delivering fluoride will make it even easier and more effective to prevent dental decay. The market for oral health products and treatment will skyrocket as millions of new consumers rise out of poverty, particularly in India and China.

There is no shame in not knowing; the shame lies in not finding out. Russian proverb

Part 8 ANNEX – WORLD TABLE 95

1 GNI

Per capita 2006 purchasing power parity $

Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Congo, Dem. Rep. of Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti

*see p 104 **see p 114

– 6,000 5,940 – 3,890 15,130 11,670 4,950 33,940 36,040 5,430 – – 1,230 – 9,700 33,860 7,080 1,250 4,000 3,810 6,780 11,730 8,700 49,900 10,270 1,130 320 1,550 2,060 36,280 2,590 690 1,170 11,300 4,660 6,130 1,140 270 – 9,220 1,580 13,850 – 25,060 20,920 36,190 2,180

2 HEALTH CARE Spending as percentage of GDP 2005 %

5.2 6.5 3.5 6.3 1.8 4.8 10.2 5.4 8.8 10.2 3.9 6.7 3.8 2.8 6.8 6.6 9.6 4.9 5.4 4.0 7.1 8.8 8.3 7.9 2.0 7.7 6.7 3.4 6.4 5.2 9.8 5.6 4.0 3.7 5.4 4.7 7.3 3.0 1.9 4.2 7.1 3.9 7.4 7.6 6.1 7.1 9.4 6.9

3 DMFT

Average score in 12-year-olds score

2.9 3.1 2.3 – 1.7 0.7 3.4 2.4 0.8 1.0 – 1.6 1.4 1.0 0.9 2.7 1.1 0.6 0.8 1.4 4.7 4.8 0.5 2.8 4.8 4.4 0.7 1.0 1.1 2.8 2.1 2.8 4.1 – 1.9 1.0 2.3 – – 0.4–1.1 2.3 1.8 6.7 1.4 1.1 2.5 0.7 0.9

data year

1991* 2005 1987 – 1981 1988–89 1987 1985–90 2000 2002 – 2000 1995 2000 2001 2000 2001 1999 1998 1985 1995 2004 1981 2002–03 1999 2000 1999 1987–88 2003–07 1996* 1996–97 1989 1986 – 2006–07 1995–96 1998 – – 1987–91 1999 1996 2005* 1998 2005 2002 2007 1990

4 DENTAL CARIES

5 EDENTULOUSNESS

In young people aged In people aged 65 or 6–19 years (highest value) more years % affected

80 – – – – 43 99.8 – 55.1 54.7 – – 52 46.4 37 94 75 – 38.8 76 87.7 91 – 89 88.7 80 – 50.6 48 93 76 89.6 – – 64.4 55.3 – – – 31 83 62.4 85.1 50 45 93.4 57.3 –

data year

1991 – – – – 1988–89 1995 – 2000 2006 – – 1995 2000 2001 1994 2001 – 1998 1985 1995 2004 – 2002–03 1999 2000 – 1987–88 2003–07 1996 1985 1988–89 – – 2006–07 1995–96 – – – 1982 1996 1999 1999 2005 2002 1998 2005 –

% affected

– 69 – – – – – – 20 15 – – – – – 14 41 – – – – 78 – 68 – 56 – – 15 – 58 – – – – 11 – – – – – – 45 – – 34 27 –

data year

– 1996 – – – – – – 2004–06 1992 – – – – – 2000 1998 – – – – 1998 – 2002** – 2000 – – 1990–91 – 1993 – – – – 1995–96 – – – – – – 2005** – – 2002 2000 –

6 ORAL CANCER

7 HIV/AIDS

Age-standardised In people incidence per 100,000 aged 15–49 population 2002 years 2007 men women % with HIV

6.8 7.0 2.5 – 9.7 – 5.4 5.5 11.1 6.6 3.0 6.6 4.7 13.4 4.9 12.9 7.7 6.7 2.5 12.8 6.7 8.7 23.1 8.3 3.6 6.5 2.7 5.9 10.2 6.1 6.9 2.5 4.4 4.4 2.7 1.1 3.8 5.9 1.7 2.3 2.1 2.2 12.5 6.4 2.4 6.8 7.0 5.9

5.9 2.4 1.1 – 4.7 – 1.3 1.2 4.7 1.8 1.3 2.3 1.8 16.8 1.5 1.8 2.5 2.4 1.3 8.4 3.8 2.5 9.5 1.7 3.1 1.6 1.8 4.8 2.7 1.5 2.9 1.3 2.2 2.2 0.9 0.7 2.6 4.8 2.0 1.9 1.7 2.1 2.7 2.8 1.6 2.0 3.3 4.8

– – 0.1 – 2.1 – 0.5 0.1 0.2 0.2 0.2 3.0 – – 1.2 0.2 0.2 2.1 1.2 0.1 0.2 <0.1 23.9 0.6 – – 1.6 2.0 0.8 5.1 0.4 – 6.3 3.5 0.3 0.1 0.6 <0.1 3.5 – 0.4 3.9 <0.1 0.1 – – 0.2 3.1

8 SUGAR

Annual consumption per person 2007 kg

2 30 37 – 15 – 47 29 50 44 22 39 – 7 51 44 – 47 4 – 37 36 23 65 33 19 6 2 8 7 44 34 3 8 42 10 34 6 21 1 53 12 44 61 43 49 56 –

data source†

1 1 1 1 1 – 1 1 1 2 1 – – 1 1 1 1 1 1 – 1 1 – 1 – 1 1 – – 1 1 1 1 1 1 1 1 – 1 1 1 1 1 1 2 2 – –

9 CIGARETTES

Number consumed per year by people aged 15 and older 2007

– 1,201 577 – 397 – 1,014 2,083 1,130 1,684 1,089 – – 172 – 1,846 1,763 – – – 178 2,145 – 580 – 2,437 – – 447 141 897 – – – 909 1,646 479 – – 131 552 198 1,849 1,010 1,830 2,368 1,495 –

10 DENTISTS

WORLD TABLE

2007

number working

900 532 842 51 225 13 9,000 550 9,131 4,458 500 60 148 4,500 63 1,860 5,902 32 57 65 1,000 400 60 223,000 70 15,087 80 14 450 70 11,513 11 13 15 2,800 16,232 3,000 29 20 300 3,200 100 8,018 3,080 731 8,184 5,698 60

population per dentist

30,161 5,996 40,211 1,471 75,662 6,538 4,392 5,458 2,272 1,876 16,934 5,517 5,088 35,259 4,667 5,209 1,772 9,000 158,474 10,123 9,525 9,838 31,367 860 5,571 980 184,800 607,714 32,098 264,986 2,856 48,182 334,077 718,733 5,941 82,296 15,385 28,931 5,450 208,787 1,396 192,620 568 3,658 1,170 1,245 955 13,883

data source†

4 3 3 3 3 4 3 3 3 3 3 3 3 3 4 3 3 4 3 4 3 3 3 3 4 3 3 4 3 3 3 4 4 4 3 3 3 4 – 3 3 3 3 3 3 3 3 4

see p 114

1 GNI

Per capita 2006 purchasing power parity $

Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong (SAR) Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia

*see p 104 **see p 114

– 5,550 7,850 6,810 4,940 5,610 16,620 680 18,090 630 4,450 33,170 32,240 11,180 1,110 3,880 32,680 1,240 30,870 – 5,120 1,130 460 3,410 1,070 3,420 39,200 16,970 33,740 2,460 3,310 9,800 – 34,730 23,840 28,970 7,050 32,840 4,820 8,700 1,470 6,230 – 22,990 – 1,790 1,740 14,840

2 HEALTH CARE Spending as percentage of GDP 2005 %

6.5 5.7 13.7 5.3 6.1 7.0 1.7 4.7 5.0 4.9 4.1 7.5 11.2 4.1 5.2 8.6 10.7 6.2 10.1 7.2 5.2 5.6 6.2 5.4 6.2 7.5 – 7.8 9.4 5.0 2.1 7.8 4.1 8.2 7.8 8.9 4.7 8.2 10.5 3.9 4.5 12.7 3.5 6.0 2.2 6.0 3.6 6.4

3 DMFT

Average score in 12-year-olds score

data year

2.0 1995 4.4 1997 – – 3.0 1996 0.4 2001–02 1.4 2000 – – – – 2.7 1998 1.0 1993 1.5 1998 1.2 2000 1.2 2006 4.4 2000 2.3 1995 2.4 1985–90 0.7 2005 0.4 1999–2000 2.2 2000 2.2 2000 5.2 2002 – – 0.5 1986 1.3 1995 0.7 1999 3.7 1997 0.8 2001 3.3 2001 1.4 2005 1.3 2005 2.2 1995 1.2 2003 1.7 2003 1.3 2002 1.7 2002 1.1 2004 1.1 1995 1.7 2005 3.3 1995 2.1 1985–90 1.8 1986 1.0 1994 3.0 1991 3.1 1995 2.6 2000 3.1 1973 2.0 1991 3.4 2004

4 DENTAL CARIES

5 EDENTULOUSNESS

In young people aged In people aged 65 or 6–19 years (highest value) more years % affected

– – – 77.6 37 – – – 76 45 68 76.9 80.9 – 77 – 53.9 22.4 72 – 82.3 – 75 55 46 83.4 37.8 84.5 86 83 89.4 48 62 74 53.9 59.1 40.9 15.7 76 – 50 – – 83 87.4 – 61.3 97.6

data year

– – – – 2001–02 – – – 1998 1990 1990 1991 1991 – 1995 – 2005 2006 2000 – 1989 – 1986 1995 1995 1999 1997 1996 1993 2003* 2005 2003 2003 2003 2002 2002 2004–05 1995 2004 2004 1987 – – 2000 2001 – 2000 1993

% affected

– – – – 17 – – – 37 – 6 41 16 – 6 21 23 – 25 – – – – – – – 9 26 70 19 24 – – 48 – 44 – – – – – – – – – 46 – –

data year

– – – – 1991 – – – 1987 – 1998 1998 2000 – 1995 1986 2005 – 1998 – – – – – – – 2001 2000 1992 2005* 1995 – – 1989 – 1995–98 – – – – – – – – – 1987 – –

6 ORAL CANCER

7 HIV/AIDS

Age-standardised In people incidence per 100,000 aged 15–49 population 2002 years 2007 men women % with HIV

– 3.0 – 1.6 0.7 0.4 4.4 5.9 8.4 7.7 1.9 5.3 14.8 14.1 1.0 9.0 11.1 2.5 3.0 – 2.5 2.9 2.5 2.6 2.4 2.5 – 19.1 4.3 12.8 1.5 2.9 3.9 5.3 5.1 7.1 4.1 2.8 2.2 14.9 6.9 – 3.4 3.4 2.6 8.1 2.6 8.3

– 2.1 – 1.4 0.2 0.2 2.2 4.8 2.1 7.9 1.5 2.7 2.7 3.8 1.4 1.4 2.8 1.3 1.2 – 1.4 1.5 1.3 0.9 1.0 1.4 – 4.5 3.9 7.5 1.0 1.7 3.5 1.6 2.6 1.9 2.4 2.0 1.1 2.7 3.6 – 1.8 1.8 1.2 1.7 6.1 1.0

– 1.1 – 0.3 – 0.8 3.4 1.3 1.3 2.1 0.1 0.1 0.4 5.9 0.9 0.1 0.1 1.9 0.2 – 0.8 1.6 1.8 2.5 2.2 0.7 – 0.1 0.2 0.3 0.2 0.2 – 0.2 0.1 0.4 1.6 – – – – – – <0.1 – 0.1 0.2 0.8

8 SUGAR

Annual consumption per person 2007 kg

– 33 – 37 36 35 – 3 58 4 68 34 40 17 44 31 46 9 34 – 54 14 5 35 20 37 26 45 37 18 19 31 24 39 38 31 40 19 47 30 20 – 4 47 33 24 9 35

data source†

– 1 – 1 1 1 – – 2 1 1 2 2 1 1 1 1 1 – – 1 1 – 1 1 1 1 2 1 1 1 1 1 2 1 – 1 1 1 1 1 – 1 1 1 1 1 1

9 CIGARETTES

Number consumed per year by people aged 15 and older 2007

– 335 – 234 1,082 275 – – 1,718 52 – 956 876 – – 1,040 1,125 80 3,017 – 325 – – – – 450 499 1,623 – 99 974 764 784 1,391 1,173 1,596 480 2,028 846 1,805 167 – 714 1,733 1,509 1,017 544 1,890

10 DENTISTS

WORLD TABLE

2007

number working

4 6,000 42 3,000 26,000 800 15 16 688 65 70 4,863 20,800 20 20 1,125 52,202 100 17,900 20 2,046 60 13 20 60 500 1,630 2,000 327 34,500 9,500 12,500 2,323 1,360 4,300 28,857 212 63,236 982 500 250 3 8,315 21,788 1,168 146 196 1,860

population per dentist

16,750 1,627 – 4,447 2,904 8,571 33,800 303,188 1,940 1,278,446 11,986 1,085 2,964 66,550 85,450 3,907 1,582 234,780 623 5,300 6,527 156,167 130,385 36,900 159,967 14,212 4,421 5,015 920 33,885 24,382 5,697 12,481 3,163 1,611 2,040 12,802 2,024 6,033 30,844 150,152 31,667 2,725 1,092 2,441 36,418 29,893 1,224

data source†

4 3 3 3 3 3 4 4 3 3 3 3 3 3 3 3 3 3 3 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 4 4 4 3 3 4 3

see p 114

1 GNI

Per capita 2006 purchasing power parity $

Lebanon Lesotho Liberia Libya Lithuania Luxembourg Macau (SAR) Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Fed. States of Moldova Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda St Kitts and Nevis St Lucia

100

*see p 104 **see p 114

9,600 1,810 260 11,630 14,550 60,870 – 7,440 870 690 12,160 4,740 1,000 20,990 8,040 1,970 10,640 11,990 6,070 2,660 2,810 8,930 3,860 660 – 4,770 1,010 37,940 25,750 2,720 630 1,410 50,070 – 2,410 8,690 1,630 4,040 6,490 3,430 14,250 19,960 – 10,150 12,740 730 – –

2 HEALTH CARE Spending as percentage of GDP 2005 %

8.7 5.5 6.4 3.2 5.9 7.7 – 7.8 3.2 12.2 4.2 12.4 5.8 8.4 15.4 2.7 4.3 6.4 13.5 7.5 4.3 8.0 5.3 4.3 2.2 5.3 5.8 9.2 8.9 7.9 3.8 3.9 9.1 2.5 2.1 7.3 4.2 7.8 4.5 3.2 6.2 10.2 4.1 5.5 5.2 7.2 5.5 5.9

3 DMFT

Average score in 12-year-olds score

3.4 0.4 0.4 1.0 3.6 3.0 1.8 3.0 3.1 0.8 1.6 2.1 2.2 1.6 – 2.0 4.9 2.0 2.1 2.3 1.9 2.9–7.8 2.5 0.5–2.1 1.0 1.2 0.5 0.8 1.6 1.5 1.3 0.5 1.7 1.7 1.4 3.6 1.7 3.8 2.9 2.9 3.2 1.5 – 2.8 2.9 0.3 5.5 6.0

data year

2000 1991 1977 1994 2001 1990 2006 1999 1993 1992–94 1997 1984 1983 1985 – 1990 1993 2001 1984 1992 1997 1994 1999 1983 1999 1996–97 2004 2002 2006 2002 1997 2003–04 2004 2001 2003 1997 1995 1999 1996 2005–06 2003 1999 – 2000 1996–98 1993 1979–83 2004

4 DENTAL CARIES

5 EDENTULOUSNESS

In young people aged In people aged 65 or 6–19 years (highest value) more years % affected

86 20 – 59.6 84 – 82 95.2 92 – 83.9 97 – – 86.8 – 84 80.5 – – 75 – 86 50 86 59 67 45 54.3 72.6 55.5 46.2 59.8 84.5 – 92.8 57 – – 97.1 81.1 53 – 94 – – – –

data year

1991 1991 – 1989 2001 – 1996 1999 1993 – 1997 1984 – – 1990 – 1990 1997 – – 1997 – 1999 1997 1991 1996–97 1999–00 1992–93 1997 2002 1997 1990–91 2004 1994 – 1993 1995 – – 2005–06 2003 2000 – 1995 – – – –

% affected

35 – – – 39 – – – – – 42 – – – – – – 31 – – – – – – – – – 61 – – – 1 16 – 20 19 – – – – 35 70 – – – – – –

data year

1994 – – – 1998 – – – – – 2000 – – – – – – 2002–03 – – – – – – – – – 1998 – – – 1998–99 2008* – 2003 1993 – – – – 1999 2000 – – – – – –

6 ORAL CANCER

7 HIV/AIDS

Age-standardised In people incidence per 100,000 aged 15–49 population 2002 years 2007 men women % with HIV

6.0 2.9 4.3 3.3 8.5 9.0 – 7.1 5.9 1.3 3.4 – 1.1 8.9 – 2.5 6.9 2.7 4.4 10.1 1.2 7.0 2.6 2.0 8.6 16.1 12.8 5.6 5.6 1.3 2.4 2.6 5.5 2.3 14.7 3.9 40.9 5.1 2.7 5.7 7.3 13.4 2.6 7.2 6.9 6.2 – –

1.1 1.6 2.3 1.6 1.4 2.7 – 1.9 4.8 1.2 2.7 – 0.5 2.9 – 1.3 1.2 1.5 2.7 1.7 1.3 2.5 1.2 7.0 3.5 7.2 8.4 3.3 3.3 0.3 1.0 1.0 2.7 1.2 14.7 2.7 26.3 0.8 2.3 4.7 1.4 2.5 2.1 1.1 1.5 0.8 – –

0.1 23.2 1.7 – 0.1 0.2 – <0.1 0.1 11.9 0.5 – 1.5 0.1 – 0.8 1.7 0.3 – 0.4 0.1 – 0.1 12.5 0.7 15.3 0.5 0.2 0.1 0.2 0.8 3.1 0.1 – 0.1 1.0 1.5 0.6 0.5 – 0.1 0.5 – 0.1 1.1 2.8 – –

8 SUGAR

Annual consumption per person 2007 kg

37 14 4 45 42 – – 37 7 12 48 – 9 50 – 53 33 19 – 28 – 13 38 8 4 29 5 48 55 38 6 9 35 – 26 37 6 4 37 22 46 32 – 28 46 2 50 –

data source†

1 – – 1 2 2 – 1 1 1 1 – 1 2 – 1 1 1 – 1 – 2 1 1 1 1 1 – 1 1 1 1 1 – 1 1 1 1 1 1 2 1 1 1 1 1 1 –

9 CIGARETTES

Number consumed per year by people aged 15 and older 2007

1,837 – – 860 920 – – 2,336 276 – 646 – – 1,287 – – 846 470 – 2,239 – – 430 213 209 – 274 888 565 386 – 103 493 – 391 291 – 968 129 1,073 1,810 1,318 – 1,480 2,319 – – –

10 DENTISTS

WORLD TABLE

2007

number working

4,285 16 13 850 2,900 301 51 800 410 – 2,203 14 50 102 4 64 83 4,500 10 258 305 263 500 159 1,500 63 383 8,000 2,100 500 36 3,853 5,200 460 7,000 950 17 140 14,766 10,181 39,523 9,132 690 3,930 37,200 11 17 9

population per dentist

957 125,500 288,462 7,247 1,169 1,551 9,431 2,548 48,007 – 12,062 21,857 8,140 3,990 14,750 48,813 15,205 23,674 11,100 14,705 8,620 2,274 62,448 134,572 32,532 32,921 73,619 2,052 1,990 11,206 395,167 38,436 903 5,641 23,415 3,519 372,412 199,307 1,890 8,640 964 1,163 1,219 5,455 3,831 884,091 2,941 18,333

data source†

3 4 4 4 3 3 3 3 4 – 3 4 3 3 4 4 3 3 4 3 3 4 3 4 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 4 3 3 3 4 4

see p 114

101

1 GNI

Per capita 2006 purchasing power parity $

St Vincent and the Grenadines Samoa São Tomé and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe World

102

*see p 104 **see p 114 *see p 104 **see p 114

2 HEALTH CARE Spending as percentage of GDP 2005 %

3 DMFT

Average score in 12-year-olds score

data year

– 5,090 1,490 22,300 1,560 9,320 14,360 610 43,300 17,060 23,970 1,850 – 8,900 28,200 – 1,780 7,720 4,700 34,310 40,840 4,110 1,560 33,650 980 5,100 770 5,470 16,800 6,490 8,410 – – 880 6,110 – 980 44,070 9,940 2,190 3,480 10,970 2,310 2,090 1,140

6.0 4.9 9.8 3.4 5.4 8.0 6.8 3.7 3.5 7.1 8.5 4.3 – 8.7 8.2 4.1 3.8 5.3 6.3 9.2 11.4 4.2 5.0 5.1 3.5 5.3 5.0 4.5 5.5 5.7 4.8 8.8 7.0 7.0 2.6 8.2 15.2 8.1 5.0 4.3 4.7 6.0 5.1 5.6 8.1

3.2 1991 2.5 1994 – – 5.9 2002 1.2 1994 2.9–7.8 1994 1.5 2005 1.3 1986 1.0 2002 4.3 1998 1.8 1998 2.7 1994 1.0 1992 1.1 1999–2002 1.1 2000 1.4 1994–95 2.1 1990 1.9 2002 0.8 1994 1.0 2005 0.9 1998 2.3 1998 1.2 1985–90 0.3 2004 1.6 1999 0.3 1986 3.1 1998 0.6 2004 1.3 1994 2.7 1988 2.6 1985–90 2.0 1994 0.9 2002 4.4 1992 1.6 1995 0.7 2004–05 1.2 1999–2004 2.5 1999 1.4 1996 1.2 1994 2.1 1997 1.9 2001 3.1 1987 2.3 1982 1.3 1991

9,209

6.3

2.0

4 DENTAL CARIES

5 EDENTULOUSNESS

In young people aged In people aged 65 or 6–19 years (highest value) more years % affected

85 – – 96 82.1 – 70.9 65 – 88 95.1 – – 60.3 68 76.4 73.8 – – 42 52 – – 65 87.4 – 92.3 62 58 85 – – 80 – 76.1 53.7 78.2 90.3 83.4 – – 83.7 79 25.9 45

data year

1991 – – 2002–03 2000 – 2005 1991 – 1998 1998 – – 1999–2000 2000 1994–95 1990 – 1998 2005 200 – – 1999 2000–01 1998 1998 1994 1994 2001–02 – – 2002 – 2002 1997 1999–2004 1999 1996 – – 2001 1987 1989 1995

69.5

% affected

– – – 46 – – – – 33 – 16 – – 26 31 37 – – – 16 14 – – 13 16 – – – – 67 – – – – – 46 24 – 22 – – – – – –

data year

– – – 1992 – – – – 1995 – 1998 – – 1998** 2001** 1994–95 – – – 1996–97 2002 – – 2001* 1994 – – – – 2007** – – – – – 1998 1999–02* – 1996 – – – – – –

32.2

6 ORAL CANCER

7 HIV/AIDS

Age-standardised In people incidence per 100,000 aged 15–49 population 2002 years 2007 men women % with HIV

– 5.2 – 3.0 3.8 7.0 – 2.5 4.0 12.2 9.3 34.1 5.9 11.2 13.5 24.5 10.6 2.0 2.4 4.5 9.0 3.4 2.6 8.5 4.5 2.5 – 4.3 3.0 3.2 12.9 – 2.2 12.2 3.2 5.0 7.9 6.4 9.3 3.7 3.2 3.8 4.6 5.1 2.7

– 0.7 – 4.1 3.0 2.5 – 1.3 2.2 1.8 2.1 21.7 4.8 2.9 2.3 9.2 5.7 1.0 1.4 3.0 2.5 1.3 1.3 4.3 4.2 1.3 – 2.3 1.2 1.7 3.3 – 2.5 1.8 2.8 2.7 3.4 1.3 2.3 2.0 2.1 2.9 6.4 0.4 2.2

– – – – 1.0 0.1 – 1.7 0.2 <0.1 <0.1 – 0.5 18.1 0.5 – 1.4 2.4 26.1 0.1 0.6 – 0.3 6.2 1.4 3.3 – 1.5 0.1 – <0.1 – 5.4 1.6 – 0.2 0.6 0.6 0.1 – – 0.5 – 15.2 15.3

6.3

3.2

2.3

8 SUGAR

Annual consumption per person 2007 kg

– 21 – 32 16 33 – 5 72 32 15 – 25 46 33 35 24 48 102 44 75 42 17 8 39 10 25 56 36 27 18 – 8 51 37 41 30 39 19 – 39 15 23 10 18

data source†

9 CIGARETTES

Number consumed per year by people aged 15 and older 2007

10 DENTISTS

WORLD TABLE

2007

number working

– – – 1 1 1 – 1 1 2 2 – 1 1 – 1 1 1 1 2 1 1 1 1 1 1 – 1 1 1 1 – 1 1 1 – 1 1 1 – 1 1 1 1 1

– – – 648 380 – – – 406 1,430 2,537 – – 511 2,225 205 75 – – 751 1,698 1,067 – 108 634 306 – 1,337 1,532 1,499 496 – – 2,526 1,092 790 1,196 793 317 – 622 887 317 71 86

5 8 11 6,673 300 800 94 14 1,350 3,200 786 26 36 3,348 24,515 825 487 4 32 11,000 4,350 2,000 1,003 450 7,300 39 10 86 300 18,226 1,000 2 170 6,500 1,200 20,680 136,417 2,546 1,980 – 30,000 1,500 850 20 120

967

1,128,591

population per dentist

24,000 23,375 14,364 3,707 41,263 12,323 926 419,000 3,286 1,684 2,547 19,077 241,639 14,509 1,806 23,393 79,179 114,500 35,656 829 1,720 9,965 6,716 89,898 8,751 168,846 10,000 15,500 34,423 4,108 4,965 5,500 181,671 7,108 3,650 2,939 2,242 1,312 13,824 – 922 58,250 26,340 596,100 111,242

data source†

4 3 4 3 3 3 4 3 3 3 3 4 3 3 3 3 3 4 4 3 3 3 4 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 – 3 3 4 3 3

62,595

World † †

see p 114 see p 114

103

COMMENTS ON DATA Many people, even in public health, do not appreciate the value of sound and reliable health statistics. Others, on the contrary, overemphasise the need to have statistics before taking any action. Both extremes are probably not appropriate; at times, however, it is difficult to find a realistic middle ground. Collecting data on health is a complex undertaking that requires appropriate and agreed indicators, a health system strong enough to undertake surveys or data reporting on a regular basis, as well as political support to allocate sufficient budgets to statistics. While much progress has been made in general health and health systems performance data collection, particularly those related to measuring the Millennium Development Goals, much remains to be done in the areas of health workforce and especially in all areas related to oral health. Initiatives from WHO, the European Union and others to integrate appropriate oral health indicators in routine health data surveys are welcome steps in the right direction that have yet to be implemented at a national level in many countries. Including key oral health data in international health statistics is a task still to be tackled on a broader scale. The maps and charts of the Atlas reflect averages from disparate data sets of varying coverage and quality. Averages, unfortunately, obscure significant differences from the mean and may paint a rosier picture for some countries than may exist for significant portions of their respective populations. Those averages may consequently also obscure areas for future data collection and research, as well as associated recommendations for action. Some of the data sources used throughout this atlas are outdated, unreliable or not comprehensive in coverage. Researching the data revealed astonishing gaps in data availability and quality, ignorance of existing appropriate indicators, or simply absence of any data at all. On the other hand, for many countries or regions of the world, data ranging from acceptable to very good exists. In order for this gap to be addressed, significant political and financial efforts are required. However, despite the shortcomings of some underlying data, the sources used are generally the best available; and the maps highlight key issues in oral health that require international attention and action. Although all possible efforts were made to present the most recent and reliable data, errors and omissions will occur. We welcome suggestions and comments on specific data aspects and accuracy, but encourage all to read the following remarks first, outlining the source and limitation of specific data. After all “No one loves the messenger who brings bad news”! (Antigone, Sophocles, Greek tragedian, 496–406 BCE). 5 MAPPING DENTAL CARIES Despite dental caries being the most widespread chronic disease on the planet, the lack of reliable data are striking. The WHO Oral Health Country/Area Profile Programme, used for the map, is the only international source of data, yet 41% of data entries for caries are 10–19 years old, 16% older than 20 years, while only 8% of datasets are less than 5 years old. Furthermore, many datasets do not rely on a national survey and are thus not representative for an entire country, but rather present data from only one region, city or village. Differences within countries, i.e. between rural and urban or different socio-economic strata, are not reflected at all in this data. The focus of the data is on 5–6-year-old or 12–15-year-old children; while data for other age groups are not comprehensively

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recorded. In addition, there is a general critique of using the DMFT index to measure dental caries (for more details see: Fejerskov O, Kidd EAM. Dental caries: the disease and its clinical management. Oxford: Blackwell Munksgaard; 2008, p126). For some countries (Serbia, Mozambique, Montenegro, Democratic Republic of Congo), the WHO database only gives a DMFT range, and the map colour is determined by the average value. The graph indicating percentages of the different DMFT components according to country income group is a modified version of the data given by Baelum et al. 2007 (Baelum V, van Palenstein Helderman W, Hugson A, Yee R, Fejerskov O. A global perspective on changes in the burden of caries and periodontitis: implications for dentistry. J Oral Rehabilitation. 2007;34:872-906). 6 GUM DISEASES Periodontal disease is usually recorded using the (CPITN) index, which was too complex to be used in this publication. We therefore included data on total toothlessness (edentulousness/edentulism) as a proxy for the impact of gum disease, well aware that a number of other factors contribute to tooth loss. The data presented are based on the WHO Oral Health Country/Area Profile Programme, which is even more limited with regards to periodontal disease than for dental caries. Data are only available for 127 countries, and information on more than 60 is older than 10 years. As described in the comments for dental caries earlier, limitations apply to national representativeness, age groups and socio-economic differences within countries. It should also be noted that the data only refer to complete edentulism, although missing a few but not all teeth can have a significant impact on quality of life too. 7 ORAL CANCER Male and female age-standardised incidence and mortality rates for oral cancer were sourced from International Agency for Research on Cancer, which is part of the WHO system. Their GLOBOCAN database uses the latest available estimate figures for the year 2002. However, although the populations of the different countries are those estimated for the middle of 2002, the disease rates are not those for the year 2002, but from the most recent data available, generally 2–5 years earlier. Full details of the limitations of the GLOBOCAN 2002 data are available at: http://www-dep.iarc.fr/globocan/database.htm The GLOBOCAN 2002 database uses the ICD10 code C00-C08 to define oral cancer. This definition includes the following cancer localisations: lips, tongue, floor of the mouth, gingiva, palate, salivary glands and other oral mucosa areas. 8 NOMA There is a severe lack of global data on noma, due to the specific characteristics of the disease. The only figures accessible are the number of noma cases referred for treatment, which are dependent on the existence of a system of medical records for each patient. In 1994, the WHO organised an expert consultation using the Delphi method. It was estimated that only 10%–15% of noma cases were referred for treatment and that the mortality rate was 80%–90%. The total number of cases worldwide per year was estimated at 140,000. The inset map of Africa gives the latest available figures from 2006. The data are based on a survey undertaken by WHO/AFRO (unpublished) using reported numbers from 21 Sub-Saharan countries, and estimating the incidence assuming a scenario of 10% referred cases and

90% mortality rate; thus following the methods used by Fieger et al. (Fieger A, Marck KW, Busch R, Schmidt A. An estimation of the incidence of noma in north-west Nigeria. Trop Med Int Health. 2003;8:402-407) and the WHO Report on Noma (World Health Organization. Noma today: a public health problem? Report of an expert consultation organised by WHO using the Delphi method (WHO/MMC/ NOMA/98.1). Geneva: WHO; 1998). The resulting number of 42,800 cases in 2006 may be an underestimation, since only 21 countries of the WHO/AFRO region participated and key countries affected by noma, such as Sudan and Somalia, are not part of WHO/AFRO. 9 HIV/AIDS The map is based on the latest available data from UNAIDS and shows the estimated percentage of the population aged 15–49 who were HIV-positive in 2007 (Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global AIDS epidemic 2008. Geneva: UNAIDS; 2008) 10 BIRTH DEFECTS The incidence rates were taken from Gundlach KK, Maus C. Epidemiological studies on the frequency of clefts in Europe and world-wide. J Craniomaxillofac Surg. 2006 Sep;34 Suppl 2:1-2. In order to display the incidence rates visually, an average was calculated for each range, which served as the basis for the bar chart. The range is represented but not labelled on the chart for simplicity. The incidence data are expressed as average number of birth defects per 100,000 live births. Some terminology relating to ethnic groups was modified. The “Asian” group does not include data from Japan or Mongolia. 12 ECONOMICS The conversion basis for prices quoted in the Medical Tourism Survey 2007 US$ was based on a dollar conversion rate of US$1.75 = £1 and a Euro rate of a1.2 = £1. 13 IMPACT OF ORAL DISEASES The world map on percentage of children affected by dental decay relies mainly on data of the WHO Oral Health Country/Area Profile Programme. Similar limitations to those mentioned in relation to previous data from this source apply (see 5 MAPPING DENTAL CARIES and 6 GUM DISEASES). The World Table lists the different age groups and years used. Most data are not representative for an entire country or even specific groups within a country. The data are old: 28% is 5–9 years old, 50% is 10–19 years old, 10% is 20 years or more out of date; and only 10% is up to five years old. 15 SUGAR The map data are mainly based on statistics published by the International Sugar Organisation, a global organisation of the sugar industry, in their annual Sugar Yearbook 2008, reporting about 2007 (Source 1 as indicated in the World Table). These statistics include, for some countries, data on industrial sugar consumption as well as data for ethanol production. Sugar consumption per capita is calculated based on total sugar consumption as provided from the data source divided by the population, using the latest available population data from the United Nations Department of Economic and Social Affairs, Population Division, 2007. The resulting amount of sugar consumed per capita does not necessarily equal actual sugar intake, but proportions could also be consumed in other ways (food exports, ethanol, etc.). Data for countries in the European Union and several other countries were not available from the Sugar Yearbook 2008; instead, data from the FAO Statistical Yearbook 2005–2006 were used (Source 2 indicated in World Table). 16 TOBACCO Data on global cigarette consumption were used from: Mackay J, Eriksen M, Shafey O. The Tobacco Atlas, 3rd

edition. American Cancer Society; 2009, courtesy of the American Cancer Society. 17 SOCIO-ECONOMIC STATUS Caries prevalence and income data in the inset are based on a paper by Hobdell & Ortiz (2009, submitted) using the WHO Oral Health Country/Area Profile Programme and World Bank GDP data from 2002. The diagram relating Care Index and GDP (Country Income and Dental Care) is modified from: Brunton PA, Vrihoef T, Wilson NH. Restorative care and economic wealth: a global perspective. Int Dent J. 2003 Apr;53:9799. Their data are based on data from the World Health Report 1999 (GDP, adjusted for purchasing parity) for selected countries where detailed DMFT data was available from the WHO Oral Health Country/Area Profile Programme. The diagram displaying the strength of the relationship of different oral diseases to socio-economic status (SocioEconomic Factors) is modified from: Hobdell MH, Oliveira ER, Bautista R, Myburgh NG, Lalloo R, Narendran S, Johnson NW. Oral diseases and socio-economic status (SES). Br Dent J. 2003 Jan 25;194:91-6; discussion 88. The graphic “Responsibility for Oral Health” was modified from: Boufford J. Leadership development for global health. In: Foege WH, Daulaire N, Black R, Pearson C, editors. Global health leadership and management. San Francisco: Jossey-Bass; 2005. p. 241. 19 FLUORIDE The world map detailing the percentage of the population within countries benefiting from optimal levels of fluoride in the water is based on data provided by the British Fluoridation Society in their publication One in a million – the facts about water fluoridation, 2004. Much of the data, particularly that relating to naturally occurring fluoride in water date from before 1990. Newer data were used when available. There is very little data on the percentage of populations within countries benefiting from fluoridated salt since this fluoride delivery system depends upon consumer choice. The availability of fluoridated salt was based on information contained in the PAHO publication Promoting Oral Health. The Use of Salt Fluoridation to Prevent Dental Caries, 2005, and on more recent data from publications and other sources. The Borrow Foundation was kind enough to provide information on the number of children covered by their international milk fluoridation programmes. Information on global fluoride use was based on estimations made for the year 2000 by Rugg-Gunn (2001), but was updated where more recent estimations had been made. Care should be taken in interpreting this data since populations might be benefiting simultaneously from multiple sources of fluoride. Thus, for example, the majority of those who are exposed to fluoridated water are probably also benefiting from the use of fluoride toothpaste. A simple summation of the number of people using different modes of fluoride delivery therefore cannot provide a reliable estimate of the number of people globally benefiting from fluoride. The proportion of children reached with milk fluoridation was calculated as a percentage of the total child population. The total child population was taken from the 2009 CIA World Factbook and included people aged 0–14 years. 20 FLUORIDE TOOTHPASTE Since fluoride toothpaste is a commercial commodity, data on fluoride toothpaste sales and use are not easily available. This lack of even simple market figures is striking, considering that fluoride toothpaste is the most widespread mode of fluoride delivery worldwide. Data on the average annual expenditure per person on toothpaste were sourced from Stamm (2007). It should be noted that

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the average annual expenditure on toothpaste is related not only to the price of toothpaste per region but also to the number of people using toothpaste and the amount used per person per year. In addition, non-fluoridated toothpastes will contribute to a limited extent to the data presented on annual expenditure on toothpastes per region. Data on the annual cost of fluoride toothpaste in terms of the number of days of household expenditure were based on a study conducted by Goldman et al. (2008). Annual supply was based on 182 g/person. 23 ADVOCACY AND INTEGRATION The world map indicating presence of a Chief Dental Officer or similar person dedicated to oral health within the government is based on the FDI database of World Chief Dental Officers. This collection relies on: • Self-reported data from governments • A regular questionnaire survey undertaken by the FDI’s Section of Public Health • Data provided by WHO/AFRO • Data from the Directorio odontologico del latinoamerica y del caribe (DOLAC) compiled by the Pan American Health Organzation (PAHO). The accuracy of the information cannot be guaranteed. 24 THE DENTAL TEAM No comprehensive world statistics for dental assistants, dental hygienists, dental therapists and dental laboratory technicians exist. While two publications (Kravitz & Treasure. Survey of the dental workforce in the Commonwealth. London: Commonwealth Dental Association; 2007 and Manual of dental practice. Brussels: Council of European Dentists; 2008) give some detail about Commonwealth and European Union member states, data for the rest of the world are not easily available. Two recent papers indicate about 450,000 dental hygienists in 21 countries (Johnson PM. International profiles of dental hygiene 1987 to 2006: a 21-nation comparative study. Int Dent J. 2009;59:63-77) and 14,500 dental therapists in 54 countries (Nash DA, Friedman JW, Kardos TB et al. Dental therapists: a global perspective. Int Dent J. 2008;58:61-70.) The numbers for dental personnel reported by the WHO World Health Statistics 2008 are not detailed enough, as they group all dental team members in the same category. In addition, their data sources are not revealed. 25 DENTISTS The statistics about the numbers of dentists for each country come from two different sources: • Self-reported data from member associations of the FDI (2002–09; indicated as source 3 in the World Table) • The WHO World Health Statistics 2008 (indicated as source 4 in the World Table. The WHO source gives numbers of dentistry personnel (including dental nurses, hygienists and dental laboratory technicians), rather than pure dentist numbers. Among all statistics for health professionals from the WHO World Health Statistics, only the “dentist” category uses such an undifferentiated approach, while figures for physicians, nurses and pharmacists are well separated. The reason for this difference in statistical recording is unclear. Where possible, the highest self-reported National Dental Association member numbers from the FDI membership database between 2002 and 2009 were used in order to cover fluctuations in membership of national dental associations. However, not all dentists in a given country are mandatory members of the National Dental Association, so the numbers tend to be lower than in reality. Nevertheless, we preferred them over the numbers from the WHO World Health Statistics, since the WHO numbers grossly overrate the number of dentists by lumping all dental personnel together in this category. To highlight the problem: the figure for dentists in the USA reported by the American Dental Association is 117,822

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(2008); the US Labour Office reports 161,000 (2006, see http://www.bls.gov/oco/ocos072.htm), while the WHO source mentions 463,663 (2000–06)! Where no data from an FDI member association were available, or the country was not a member of the FDI (2002–09), the figure from the WHO World Health Statistics 2008 was used, as indicated in the World Table. The calculation of the dentist:population ratio used the same population figures as mentioned previously (United Nations, 2007). The ratios for countries with small numbers need to be interpreted with caution, since little differences in the number of dentists greatly affect the ratio. In addition, the world map gives an average for the respective countries and thus generalises the usually huge geographical differences within countries. The dentist: population ratios tend to be much greater in rural areas than in urban areas; as illustrated with the inset map for the African region. The inset relating to gender ratios are taken from the WHO’s Global Health Atlas and uses information from 2000 or later (see http://www.who.int/globalatlas/docs/ HRH/HTML/Sex_occ.htm). It is interesting to note that no comprehensive data on gender distribution for the global oral health workforce exists. Total dentist numbers given in this study do not match the data about country dentist numbers given in the World Table since different years and sources were used. 26 WORKFORCE CHALLENGES The cartogram uses the total number of dentists per country (calculated as described above) and shows it as a function of the country surface on the map. One square of the map represents 1,000 dentists. There is virtually no data on international migration of dentists, despite considerable international effort to collect data on migration of nurses or physicians. This may be due to the overall small volume of dentist migration, yet for smaller countries migration can be a significant problem. The table indicating the migration streams is based on a publication of the OECD (Dumont JC, Zurn P. Part III: Immigrant health workers in OECD countries in the broader context of highly skilled migration. International Migration Outlook SOPEMI 2007 Edition. Paris: OECD; 2007). Their estimations, however, are based on data from 1999–2000. It is thus justified to say that the map presented is only a snapshot of a situation about 10 years ago – yet no more recent data could be identified. The migration data have been simplified and condensed; only the major migration streams of 100+ dentist, source countries and destination countries are represented on the map. 27 DENTAL EDUCATION The statistics of dental schools worldwide are based on a number of sources, mainly the FDI World Directory of Dental Schools, last updated in 2006; the FDI Basic Country Facts from 2004, a collection of self-reported data from FDI member associations; and the Directorio odontologico del latinoamerica y del caribe (DOLAC) from the Pan American Health Organization (PAHO). Additional sources, as indicated in the World Table, complement this data. For most countries, the number of dental schools has remained stable over the last 10 years, particularly in highincome countries. In specific countries, such as Brazil, India, Pakistan and others, the number of dental education institutions has increased significantly, mainly due to a boom in private dental schools. 29 FDI WORLD DENTAL FEDERATION The map of FDI member countries uses the latest available data from April 2009.

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World Health Organization. World Health Statistics 2008. Zillèn PÅ, Mindak M. World Dental Demographics. Int Dent J. 2000;50:194-234. 26 WORKFORCE CHALLENGES Beiruti N, van Palenstein Helderman WH. Oral health in Syria. Int Dent J. 2004;54:383-388. Buchan J. International recruitment of health professionals. BMJ. 2005 Jan 29;330:210. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M, Dare L, Dussault G, Elzinga G, Fee E, Habte D, Hanvoravongchai P, Jacobs M, Kurowski C, Michael S, Pablos-Mendez A, Sewankambo N, Solimano G, Stilwell B, de Waal A, Wibulpolprasert S. Human resources for health: overcoming the crisis. Lancet. 2004 Nov 27-Dec 3;364:19841990. Corbet E, Akinwade J, Duggal R, Gebreegziabher G, Hirvikangas H, Hysi D, Katrova L, Karaharju-Suvanto T, McGrath C, Ono K, Radnai M, Schwarz E, Scott J, Sixou JL, Soboleva U, Uoshima K, Yaneva-Ribagina K, Fox C. Staff recruitment, development and global mobility. Eur J Dent Educ. 2008 Feb;12 Suppl 1:149-160. Dumont JC, Zurn P. Part III: Immigrant health workers in OECD countries in the broader context of highly skilled migration. International Migration Outlook SOPEMI 2007 Edition. Paris: OECD; 2007. FDI World Dental Federation. Ethical international recruitment of oral health professionals. FDI World Dental Federation Policy Statement. 2006 Ozar DT. Basic oral health needs: a public priority. J Dent Educ. 2006 Nov;70:1159-1165. Watkins S. Migration of healthcare professionals: practical and ethical considerations. Clin Med. 2005 May-Jun;5:240-243. 27 DENTAL EDUCATION Brown LJ, Meskin LH. The economics of dental education. Chicago: American Dental Association; 2004. Donaldson ME, Gadbury-Amyot CC, Khajotia SS, Nattestad A, Norton NS, Zubiaurre LA, Turner SP. Dental education in a flat world: advocating for increased global collaboration and standardization. J Dent Educ. 2008;72:408-421. FDI World Dental Federation. World Directory of Dental Schools. Ferney Voltaire: FDI World Dental Federation; 2006. Fu Y, Ling J, Jang B, Yin H. Perspectives on dental education in mainland China. Int Dent J. 2006 Oct;56:265-271. Gallagher JE, Wilson NH. The future dental workforce? Br Dent J. 2009;206:195-199. Karim A, Mascarenhas AK, Dharamsi S. A Global Oral Health Course: Isn’t It Time? J Dent Educ. 2008;72:1238-1246. Mahal AS, Shah N. Implications of the growth of dental education in India. J Dent Educ. 2006 Aug;70:884-891. Schofield DJ, Fletcher SL. Baby boomer retirement and the future of dentistry. Aust Dent J. 2007;52:138-143. Sgan-Cohen HD. Principles for planning the teaching of dental public health in an MPH course. Public Health Rev. 2002;30:303-309. Zarkowski P, Gyenes M, Last K, Leous P, Clarkson J, McLoughlin J, Murtomaa H, Gibson J, Gugushe T, Edelstein B, Matthews R, Vervoorn M, Van Den Heuvel JL. 5.1 The demography of oral diseases, future challenges and the implications for dental education. Eur J Dent Educ. 2002;6 Suppl 3:162-166. 28 DENTAL RESEARCH Gil-Montoya JA, Navarrete-Cortes J, Pulgar R, Santa S, MoyaAnegon F. World dental research production: an ISI database approach (1999-2003). Eur J Oral Sci. 2006;114:102-108. Greenspan D. Oral health is global health. J Dent Res. 2007;86:485. Langer A, Diaz-Olavarrieta C, Berdichevsky K, Villar J. Why is research from developing countries underrepresented in international health literature, and what can be done about it? Bull World Health Organ. 2004;82:802-803. Petersen PE. Priorities for research for oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Health. 2005;22:71-74. Yang S, Needleman H, Niederman R. A bibliometric analysis of the pediatric dental literature in MEDLINE. Pediatr Dent. 2001;23:415-418.

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29 FDI WORLD DENTAL FEDERATION Benzian H, Nackstad C, Barnard JT. The role of the FDI World Dental Federation in global oral health. Bulletin of the World Health Organization. 2005;83:719-720. Conrod B, Cohen L. Transforming dentistry’s commitment to global oral health. Journal of the Canadian Dental Association. 2007;73:653-655. FDI. The past, the present and the future. FDI World. 2000;3:14-16. Freihofer HH. The Fédération Dentaire Internationale, 19001975. Int Dent J. 1975;25:157-165. Gonzales-Giralda R. Dentistry of today and in the future. In: Simonsen RJ, editor. Dentisty in the 21st century - a global perspective. Chicago: Quintessence; 1991. p. 235-237. 30 WORLD HEALTH ORGANIZATION Hobdell M, Petersen PE, Clarkson J, Johnson N. Global goals for oral health 2020. Int Dent J. 2003;53:285-288. Petersen PE. The World Oral Health Report: continuous improvement of oral health in the 21st century - the approach of the WHO Global Programme. Community Dentistry and Oral Epidemiology. 2003;31:3-24. Petersen PE. World Health Organization global policy for improvement of oral health - World Health Assembly 2007. Int Dent J. 2008;58:115-121. Petersen PE. Promotion of oral health and integrated disease prevention in the 21st century - the WHO approach. Developing Dentistry. 2008;9:3-5. Petersen PE, Bourgeois D, Ogawa H, Estupiñan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005;83:661-669. Petersen PE, Estupiñan-Day S, Ndiaye C. WHO’s action for continuous improvement in oral health. Bull World Health Organ. 2005;83:642. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2005;33:8192. PetProductNews.com. The world pet market exceeds $56 billion. 2009 (accessed March 2009) Available from: www. petproductnews.com World Health Organization. Oral health: action plan for promotion and integrated disease prevention. World Health Assembly Resolution WHA60/R17 2007. World Health Organization. Working for health - an introduction to the World Health Organzation. Geneva: WHO; 2007 World Health Organization. Medium-term strategic plan 20081010: Programme Budget 2008-2009. Geneva: WHO; 2000 31, 32, 33 HISTORY Cohen RA. Lilian Lindsay, 1871-1960. Br Dent J. 1971;131:121122. Coppa A, Bondioli L, Cucina A, Frayer DW, Jarrige C, Jarrige JF, Quivron G, Rossi M, Vidale M, Macchiarelli R. Palaeontology: early Neolithic tradition of dentistry. Nature. 2006;440:755756. Ennis J. The story of the Fédération Dentaire Internationale 1900-1962. 1967. Fischman SL. The history of oral hygiene products: how far have we come in 6000 years? Periodontol 2000. 1997;15:714. Hoffman-Axthelm W. History of dentistry. Berlin: Quintessence; 1981. Ring ME. Dentists famous in other fields. J Calif Dent Assoc. 2002;30:901-907. Savage DK. A brief history of aerospace dentistry. J Hist Dent. 2002;50:71-75. Wynbrandt J. The excruciating history of dentistry toothsome tales & oral oddities from Babylon to braces. New York: St. Martin’s Press; 1998. Zillen PA. 1994--the World Year of Oral Health. FDI World. 1994;3:13-15. 34 THE PRESENT: A SCORECARD Beaglehole R, Bonita R. Global public health: a scorecard. Lancet. 2008 Oct 20

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35 THE FUTURE American Dental Association. The future of dentistry: Today’s vision - tomorrow’s reality. Executive summary. Chicago: American Dental Association Health Policy Resources Center; 2002 Belt D. Time in space puts astronauts’ teeth at risk. J Calif Dent Assoc. Nov 2001 Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3: e442. Schofield DJ, Fletcher SL. Baby boomer retirement and the future of dentistry. Aust Dent J. 2007 Jun;52:138-143. Schweisheimer W. Dental problems and dental care during moon flights. Quintessence Int. 1970 Apr;1:97-99. Shivakumar KM, Vidya SK, Chandu GN. Dental caries vaccine. Indian J Dent Res. 2009 Jan-Mar;20:99-106. WORLD TABLE Column 1: GNI per capita, PPP (current international $) 2006, UNDP Human Development Report 2007/2008 Column 2: % of GDP spent on health, WHO World Health Statistics 2008, published health expenditure data for 2000 and 2005 (accessed March 2009). Available from: www.who. int Column 3: DMFT data per country, WHO Country/Area Profile Programme (accessed May 2009). Available from: www. whocollab.od.mah.se; data with * refers to 5yr-olds; data for Afghanistan relates to 7–12yr-olds/Cameroon relates to 9–12yr-olds/Croatia 7–14yr-olds. Columns 4 and 5: WHO Country/Area Profile Programme (accessed May 2009). Available from: www.whocollab. od.mah.se; specific countries in Column 5: Brazil – Colussi CF, Freitas SF. [Epidemiological aspects of oral health among the elderly in Brazil]. Cad Saude Publica. 2002;18:1313-13; Croatia – Simunkovic SK, Boras VV, Panduric J, Zilic IA. Oral health among institutionalised elderly in Zagreb, Croatia. Gerodontology. 2005;22:238-241; South Africa – Department of Health, Medical Research Council. Chapter 14: oral health and oral care in adults. South Africa Demographic and Health Survey 1998. Pretoria: Department of Health; Spain – Oral health issues of Spanish adults aged 65 and over. The Spanish Geriatric Oral Health Research Group. Int Dent J. 2001;51:228-234; Turkey – Unluer S, Gokalp S, Dogan BG. Oral health status of the elderly in a residential home in Turkey. Gerodontology. 2007;24:22-29. Column 6: International Agency for Research on Cancer. GLOBOCAN 2002 Database (accessed April 2009). Available fromL www-dep.iarc.fr Column 7: UNAIDS. Report on the global AIDS epidemic 2008. Geneva: UNAIDS; 2008. Column 8: International Sugar Organisation. Sugar Year Book 2008. London: ISO; 2008 (data source 1); FAO Statistical Yearbook 2005-06 (data source 2) Column 9: Mackay J, Eriksen M, Shafey O. The Tobacco Atlas, 3rd edition. American Cancer Society; 2009. Courtesy of the American Cancer Society. Column 10: Self-reported data from member associations of the FDI (2002-2009; data source 3); WHO World Health Statistics 2008 (data source 4) COMMENTS ON DATA Abouzahr C, Gollogly L, Stevens G. Better data needed: everyone agrees, but no one wants to pay. Lancet. 2009 Jan 14 [Epub ahead of print] Bourgeois DM, Llodra JC, Nordblad A, Pitts NB. Report of the EGOHID I Project. Selecting a coherent set of indicators for monitoring and evaluating oral health in Europe: criteria, methods and results from the EGOHID I project. Community Dent Health. 2008;25:4-10. Petersen PE, Bourgeois D, Bratthall D, Ogawa H. Oral health information systems--towards measuring progress in oral health promotion and disease prevention. Bull World Health Organ. 2005;83:686-693.

PHOTO CREDITS The authors would like to thank the following photographers and organisations who have supplied images. We have made every effort to obtain permission for the use of copyright material. If there are any omissions, we apologise and shall be pleased to make appropriate acknowledgment in any future edition. Part 1 Introduction – Pages 12–13 Smiling man: ©Ken Weingart/Corbis; 1 Oral Health – 14 Can you hear me?: Atno Ydur/iStockphoto; Kiss: Iconogenic/iStockphoto; Water: Tammy616/iStockphoto; Daisy kisses: Darren Baker/iStockphoto; Woman eating an apple: Joe Lena/iStockphoto; Two musicians play around: Ken Hurst/iStockphoto; Dandelion with girl: Graffizone/ iStockphoto; Teeth erupt: Youra Pechkin/iStockphoto; 2 Teeth for Life – 16 Teething baby: B Scott/iStockphoto; Boy: Michael Courtney/iStockphoto; 17 Woman: Jennifer Trenchard/iStockphoto; Family: Monkey Business Images/iStockphoto Part 2 Burden and Inequalities – Pages 20–21 Teeth of a betel nut chewer, Thailand: ©Nevada Wier/Corbis; 4 Tooth Decay – 22 Human lips: Youra Pechkin/ iStockphoto; Bacteria: Chris Dascher/iStockphoto; Sugar cube: lepas2004/iStockphoto; Tooth decay: jimbycat/ iStockphoto; 23 Early Childhood Caries: Bella Monse; Microscope: janrysavy/iStockphoto; 6 Gum Diseases – 26 Calculus: Free license Wikipedia.com; Elderly man: wibs24/iStockphoto; 7 Oral Cancer – 28 Paan: DKimages; Tongue cancer: Kevin Kavanagh/www. entusa.com; 8 Noma – 31 NomaDay poster: ©NoNoma Federation; Child with noma: ©Charlotte Faty Ndiaye: WHO/AFRO; 9 HIV/AIDS – 33 Candidiasis palate: ©Su Naidoo; 10 Birth Defects – 34 Cleft lip: Dr. M.A. Ansary/Science Photo Library; 11 Trauma – 35 Kick the ball: Alex Nikada/iStockphoto; Broken teeth: Riverlim/ iStockphoto; 13 Impact of Oral Diseases – 38 Lugo Graphics/iStockphoto; 39 ©Lane L. Erickson/Shutterstock Part 3 Risk Factors – Pages 40–41Sugar-cane juice stand, Singapore: ©DK Limited/Corbis; 14 Risk Factors – 42 Cake: bluestocking/iStockphoto; Smoker: Twirl/ iStockphoto; Slow down: Lightguard/iStockphoto; Alcoholism: Ryerson Clark/iStockphoto; Biker crash: AhavatHaEmet/iStockphoto; Running shoes: Magnet Creative/iStockphoto; Dirty hand: Inakiantonana/ iStockphoto; Crutch: diane39/iStockphoto; 16 Tobacco – 46 ©Habib Benzian; 47 footie/iStockphoto Part 4 Solutions – Taking Action – Pages 50–51 Northern India: ©Karen Kasmauski/Corbis; 18 Behaviour and Choices – 52 Toothbrush: Kyle Maass/iStockphoto; Teeth: Dr. Bouz/iStockphoto; Whiskey: Bluelab studio/ iStockphoto; Hockey player: Walik/iStockphoto; At the dentist: webphotographeer/iStockphoto; 53 Dental floss: Emin Ozkan/iStockphoto; Mouthwash bottle: Interact Publishing/iStockphoto; Electric toothbrush:

Synergee/iStockphoto; Toothbrush: Oliver/iStockphoto; Smiling African girl: Peeter Viisimaa/iStockphoto; 19 Fluoride – 55 Water tap: duncan1890/iStockphoto; 20 Fluoride Toothpaste 56 Toothbrush: SDenson/ iStockphoto; Tube: jallfree/iStockphoto; 21 Treatment – 58 Dentist: Diego Cervo/iStockphoto; Tooth extraction: ChoiceGraphX/iStockphoto; Drilling a tooth: Gary Sludden/iStockphoto; Dentist: Lou Oates/iStockphoto; 59 Bridge © Endostock/Dreamstime; Dental implants © Lucian Coman/Dreamstime; Dental plate: 123foto/ iStockphoto; Smile with braces: Qwasyx/iStockphoto; 22 Oral Health & Primary Health Care – 60 Cambodia: ©Jo Frencken; ART: ©Jo Frencken; 61 School brushing: ©Bella Monse; 23 Advocacy and Integration – MDG symbols: www.mikeyleung.ca Part 5 Oral Health Workforce – Pages 64–65 Dentist checking patient’s teeth, China: ©Jim Richardson/ Corbis; 24 The Dental Team – 66 Dentist: Emre Ogan/ iStockphoto; Comparing patient teeth: factoria singular sl/iStockphoto; Dentist’s surgery: Erel Photography/ iStockphoto; Professional teeth cleaning: See Hear Media, Inc./iStockphoto; Dental examination: annedde/ iStockphoto; 67 At the dentist: webphotographeer/ iStockphoto; Dentist inspection: Tjerrie/iStockphoto; 27 Dental Education – 75 Dental dummy: ©Jon Crail Part 6 Actors and Organisations – Pages 72–73 Street dentists in Calcutta, India: ©Frédéric Soltan/Sygma/ Corbis; 28 Dental Research – 77 William J. Gies: ©IADR; 29 FDI World Dental Federation – 78 Charles Godon: ©FDI World Dental Federation; 79 FDI Council: ©FDI World Dental Federation; 30 World Health Organization – 80 World Health Assembly: ©Habib Benzian; Margaret Chan ©World Health Organization Part 7 Past, Present and Future – Pages 82–83 Suyo man wearing lip plate, Brazil: Claire Leimbach/Robert Harding World Imagery/Corbis; 31 History – 84 jade tooth, Mayan skull: Anything and Everything Blog; Halin teeth: Myanmar Archaeology Students Blog; Bridge: What’s behind a smile?/ Discovery Museum, Newcastle, UK; 32 History – 86 Laughing gas: David Pearce, BLTC Research; Waterloo teeth: British Dental Association; Vulcanite dentures: British Dental Association; 87 Beaman Hobbs: Kansas Historical Society; 33 History – 88 Irene Newman: Find A Grave, Inc.; Ritter chair: Ritter Dental; FDI Paris: FDI World Dental Federation; 34 The Present: A Scorecard – 91 Gilles Delmotte/iStockphoto; 35 The Future – 93 Geoffery Holman/iStockphoto Part 8 Annex – Pages 94–95 Plotting village health statistics, Sierra Leone: ©Liba Taylor/Corbis

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GLOSSARY amalgam – common filling material consisting mainly of silver, copper, mercury and tin alloy; can be packed into a prepared tooth cavity before setting. antiretroviral drugs – medications used to treat infection with HIV/AIDS. Atraumatic Restorative Treatment (ART) – a caries-management approach, consisting of a preventive (fissure sealant) and a restorative component (filling). Basic Package of Oral Care (BPOC) – concept developed by the WHO for providing essential oral care in resource-poor settings, consisting of emergency care, tooth-brushing with fluoride toothpaste and Atraumatic Restorative Treatment (ART). braces – appliances used to align teeth in the mouth; used on children and teenagers, but can also be placed on adults. bridge – cemented replacement for one or more teeth using the teeth adjacent to the missing ones as anchor crowns; manufactured individually in the dental laboratory. bruxism – involuntary grinding of the teeth often associated with pain in the temporomandibular joint. bulimia – psychological eating disorder characterised by excessive eating followed by self-induced vomiting. The acid from the stomach fluids can damage teeth and cause erosion. candidiasis – fungal infection caused by the yeast Candida. cardiovascular diseases (CVD) – diseases of the heart and blood vessels. The risk of suffering from a CVD is increased by a number of risk factors including high blood pressure, obesity, smoking, psychological stress, and lack of exercise. caries (tooth decay) – demineralisation leading to destruction of tooth structure; the result of a multi-factorial process involving specific oral bacteria, fermentable carbohydrates, time and other factors. calculus – accumulation of calcified dental plaque that adheres to the tooth surface; also known as tartar.

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cosmetic dentistry – the branch of dentistry that aims at improving the appearance of the mouth. Community Periodontal Index of Treatment Needs (CPITN) – a complex assessment index used to establish periodontal treatment priorities for individuals or population groups. composite filling – tooth-coloured filling made of resin. country income classifications – economic classification of the World Bank based on Gross National Income (GNI) per capita, expressed in US dollars. In 2007, low income was classified as $935 or less; middle income as $936 – $11,455; and high income as $11,456 or more. cross-infection control – all hygiene and protective measures taken to avoid transmission of a communicable disease from one person to another during dental treatment. crown – restoration that is placed over a tooth and is used to rebuild decayed or broken teeth or to improve the cosmetic appearance of a tooth; also known as a cap. dentine – the mineralised substance that makes up most of the tooth structure. It is covered at the crown by enamel, at the root by cementum and protects the sensitive inner pulp. dentition – (1) the process of tooth eruption; (2) the entire set of teeth present in a person’s mouth. fluorosis – condition of the tooth enamel resulting from excessive fluoride exposure. Mild and moderate fluorosis can hardly be detected; only the rare severe forms are characterised by visible mottling. dental plaque – the biofilm the develops on the surface of teeth, made up of bacteria. dento-alveolar trauma – injury or damage to teeth or supporting bone structure, usually caused by excessive force from outside. dentures – partial or complete set of artificial teeth for the upper and/or lower jaw. DMFT – index used to measure the decayed, missing and filled teeth of individuals or population groups in epidemiological surveys.

Early Childhood Caries (ECC) – The American Academy of Paediatric Dentistry defines ECC as “the presence of one or more decayed, missing or filled tooth surface in a child 71 months or younger”. edentulism – the absence or complete loss of all natural teeth. epidemiology – the science of the causes, distribution, and control of disease in populations.

Primary Health Care – Primary Health Care, as defined by the World Health Organization in 1978 is “essential health care, based on practical, scientifically sound, and socially acceptable methods and technology, universally accessible to all in the community through their full participation, at an affordable cost, and geared toward self-reliance and self-determination”. public health – science concerned with the health of communities and populations.

fillings – restorations made of amalgam, resin (composite), metal, ceramics or other material, used to replace lost tooth tissue.

root-canal treatment – procedure to remove diseased or damaged pulp tissue from inside a tooth and seal it with special filling material.

fissure sealant – resin material that is placed in the pits and fissures of teeth in order to prevent the development of dental decay.

squamous cell carcinoma – a cancer developing from epithelial cells. It is the most common form of oral cancer.

fluoride – mineral that helps prevent tooth decay if used in recommended dosage.

Streptococcus mutans – common bacteria found in dental plaque and mainly responsible for dental decay.

gingivitis – inflammation of the gum; clinical signs may include swelling, bleeding upon probing or brushing, and/or pain. Gross Domestic Product (GDP) – total market value of all the goods and services produced within a country during a specified period. halitosis – medical term for bad breath. It can result from a number of factors such as poor oral hygiene, decayed teeth and gum disease, but also from general health problems. orthodontics – the branch of dentistry concerned with the development and treatment of malformations of teeth, jaws and facial structures. periodontal diseases (periodontitis) – group of diseases affecting the tissues that support and anchor the teeth.

temporomandibular joint disorder (TMJ) – term summarising a group of symptoms involving the joint and muscles between lower and upper jaw. Symptoms include headaches, soreness in the chewing muscles, and clicking or stiffness of the joints. wisdom teeth – the teeth at the back of the dental arch. They are the last teeth to erupt, typically in early adulthood. Due to lack of space they are often impacted (stuck) and need to be removed surgically. xerostomia (dry mouth) – the condition of not having enough saliva to keep the mouth wet. It can cause difficulties in tasting, chewing, swallowing, and speaking, and is often associated with increased levels of tooth decay.

periodontium – the tissues surrounding a tooth and anchoring it in the supporting bone.

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INDEX abscess 22, 26, 39, 58 absenteeism 23, 37, 38, 39, 62 Affordable Fluoride Toothpaste (AFT) 60 Africa 61, 68, alcohol 34, 42, 46, 52, 81 Alma-Ata Conference 63 American Dental Association 57 American Heart Association 26 anaesthetic 59, 60, 96, 86, 87, 88, 89 Angle, Edward 87 Atraumatic Restorative Treatment (ART) 60 Bangkok Charter on Health Promotion in a Globalised World 63 Basic Package of Oral Care (BPOC) 60 Beaglehole, Robert 90 Beijing Declaration 63 Benin 68 Berlin Declaration 63 birth defects 14, 15, 34, 39, 76 Black, G.V. 88 Bonita, Ruth 90 Brånemark, Per-Ingvar 89 Brazil 70, 74 bridge 58, 84, 85 bulimia 18 Cambodia 60 cancer (see also oral cancer) 42 Carmona, Richard 60 Castillo-Morales Manual Orofacial Therapy 19 cavity (see tooth decay) Chan Margaret 80 chewing (see oral functions) Chief Dental Officer 62–63, 88, 106 China 37 chronic pain 14 cleft lip/palate 34, 85, 105 Community Periodontal Index of Treatment Needs (CPITN) 26

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Congo, Democratic Republic of 45 Crete Declaration on Oral Cancer Prevention 63 crown 58, 85, 86 Cuba 68 Davis, Adelle 42 Dean, Trendley 88 dental care (see oral care services) caries (see tooth decay) education 74–75, 86, 87, 88, 106 (see also training) equipment 86, 87, 88, 89 floss 53, 86, 87 forensics 86 implants 46, 59 pain 14, 19, 22, 23, 38, 39, 52, 60–61, 62, 63, 85 research 76–78 tourism (see medical tourism) dental infection 19, 26, 32, 39, 62 dentistry 58–59 aesthetic 89 future of 92–93 restorative 33, 34, 35, 87 space 89 dentists 27, 39 dentist:physician ratio 70 dentist:population ratio 68–69 global distribution of 68–69, 106 in history 84–85, 86–87, 88–89 migration of 68, 70, 106 role in dental team 66–67 role in primary health care 60–61 role in screening 29, 33 role in treatment 58–59 rural:urban ratio 68 (see also training; oral health professionals) dentition 16, 17 dentures 59, 86 diabetes 18, 26, 27, 42, 44 diet (see nutrition)

DMFT Index (Decayed, Missing, Filled Teeth index) 24, 25, 48, 62, 88 DNA 19 Doriot, Constant 88 Down Syndrome 18, 19 drug abuse 18 early childhood caries (see tooth decay, child) economics (see oral care services) edentulousness (see tooth loss) enamel 17, 22 Eritrea 69 Evans, Caswell A. 20, 64 extraction 58 Fauchard, Pierre 85 FDI Annual World Dental Congress 79 FDI World Dental Federation 24, 31, 33, 47, 54, 62, 63, 68, 69, 70, 74, 78–79, 80, 88, 105 Fejerskov Ole 24 Ferney-Voltaire Declaration on Global Oral Health 63 filling 22, 24, 25, 27, 37, 48, 49, 58 historic 84, 88, 89 Fischer, Martin H. 27, 36 fluoride 54–55, 56–57, 92, 105 in toothpaste 23, 52, 53, 54, 56–57, 88, 105 in water 54–55, 88 preventive use of 23, 24, 49, 52, 54, 62, 63, 81 shortage of 22 France 68, 70, 78 gangrene 30 Garetto, Lawrence 63 general health 14, 18–19, 27, 37, 42, 52, 62, 80 Gertrud Hirzel Foundation 30 Gies, William J. 76, 77, 88 gingivitis 26, 27 global burden of oral diseases 23, 42, 55

Global Goals for Oral Health 24, 62–63, 89 Godon, Charles 63, 68, 78, 87, 88, 89 Gonzales-Giralda, Ruperto 78 Greenspan, Deborah 77 gum disease (periodontal disease) 15, 19, 42, 46, 47, 49, 104 gingivitis 26, 27, 47 historic treatment of 84 periodontitis 26 gums 14, 26, 52 halitosis 47 heart disease 26, 27, 42 historic treatment of 84–85, 86–87, 88–89 HIV/AIDS 18, 26, 31, 46, 52, 62, 76, 81, 105 distribution of 32–33 global assessment of 90–91 Hunter, John 86 impact of poverty on 48–49 India 28, 29, 47, 55, 57 injuries (see trauma) International Association for Dental Research (IADR) 76– 77, 80, 89 International Federation of Dental Education Associations (IFDEA) 66, 74, 75 International Year of Oral Health 89 Japan 45, 76, 77 jaw 14, 17, 26 European Journal of Dental Education 74 Journal of Dental Research 77 Kidd, Edwina 24 lasers 88, 93 leukaemia 18, 26 lifestyle (see risk factors) 63 lips 14, 26, 28 malnutrition (see nutrition) Marmot, Michael 48 measles 18, 31 medical tourism 37, 58, 59 Medline 76

miswak (chewing sticks) 53 mouth 14, 18, 30, 44 dry mouth (xerostomia) 18, 23, lesions 18, 32, 33 mouth rinse 53 Myanmar 57 Nairobi Declaration on Oral Health in Africa 63 National Institute of Dental and Craniofacial Research 76 Ndiaye, Charlotte Faty 31 Nepal 57 Netherlands 57, 60 New Zealand 45, 49, 67, 75 Niger 30, noma 19, 30–31, 39, 62, 89, 93, 104 non-communicable disease 14 NoNoma Federation 30, 31 nutrition 24, 27, 31, 34, 42, 48, 49, 52, 80, 81 effect of inadequate nutrition 22 historic recognition of importance 84 oral cancer risk 28 sugar consumption 44–45 obesity 34, 42, 44 oral bacteria 19, 22, 23, 26, 32, 44, 53, 92 oral cancer 14, 46, 47, 49, 52, 76, 86, 104 distribution of 28–29 global assessment of 90–91 oral care measures 52, 53 oral care services 23, 33, 36–37, 48–49, 58–59 access to 48–49, 59, 67 cost of 35, 36–37, 38, 55, 58–59, 60 expenditure on 36–37 global assessment of 90–91 global dental market 36 jobs relating to (see also dentists; oral health professionals) 36–37, 66–67 screening for oral cancer 29 oral diseases cost of treatment 36–37, 38 determining factors 48–49 economic impact of 38–39

historic treatment of 84–85, 86–86, 88–89 impact on quality of life 38– 39, 42–43, 105 prevention of 62–63, 90–91, 92, 93 oral functions chewing 14, 17, 26, 38 speaking 15, 38 swallowing 38 oral health data 90–91, 96–103, 104–05 oral health products 93 oral health professionals 26, 27, 33, 47, 66–67, 106 distribution of 70–71 global number of 67, 70–71 migration of 70–71 role in oral care education 52, 53 role in primary health care 60–61, 62–63 training of (see training) oral health programmes 19, 31, 54–55, 60–61, 78, 79, 80, 89 oral hygiene 22, 26, 84, 87 Oral Urgent Treatment (OUT) 60 orthodontics 59, 87 paan 28 Paré, Ambrose 85 Pasteur, Louis 28 periodontal disease global assessment of 90–91 (see also gum disease) Petersen, Poul Erik 81 Pfaff, Philipp 86 Philippines 23, 39, 61, 70 Phuket Declaration on Oral Health and HIV/AIDS 63 plaque 23, 26, 27 poverty (see also oral diseases, economic impact of ) 31, 42–43, 48–49, 56, 62 pregnancy 19, 27, 34 primary health care 31, 60–61, 62 public health initiatives 54–55, 62–63 respiratory disease 42 risk factors (see also tobacco; sugar; alcohol; nutrition; socio-economic status) 42–49

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root caries 22 saliva 14, 17, 18, 26, 84 low flow of 22, 23 use in diagnostics 19, 76, 93 Sambo, Luiz Gomez 30 Satcher, David 18, 54 Scandinavia 76 scorecard 90–91 scurvy 18 Shanley, Diarmuid 74 Sheiham, Aubrey 40 socio-economic status 48–49, 105 assessment of oral services by 90–91 cost of fluoride toothpaste 56 relation to oral health 48–49 risk factor for gum disease 27 (see also poverty; oral diseases, economic impact of) soft drinks 44–45, 52 South Africa 39 South-East Asia 29 Sri Lanka, 39, 75 Stein, Richard 26 Streptococcus mutans 23, 44 Sub-Saharan Africa 32, 33 sugar consumption of 44–45, 105 impact on dental caries 22, 23, 24, 25 in blood 18 promotion of 45 risk factor for oral health 43, 52 substitutes 23, 44, 45, 93 sugar-cane production 44–45, 84, 85 tax on 87, 92 warning labels about 92 surgery 19, 29 dental 58, 85 reconstructive 31, 34, 35

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Sweden 35 Switzerland 55 syphilis 18 Tanzania 39 The Journal of Dental Education 84 teeth 14, 78 brushing/cleaning of 26, 27, 52–53, 22 canines 14, 17 crooked 27 incisors 14, 17 malformation of 18 molars 14, 17, 23 periodontium 26 permanent (adult teeth) 17, 24, 25 primary (baby teeth, milk teeth, deciduous) 16, 48 wisdom 17, 36 tetanus 18 Tetracycline 18 Thailand 39 throat 28 tobacco use/smoking cessation of 29, 47, 52, 92 consumption 46–47, 49, 105 effects on oral health 18, 26, 27, 28, 34, 42, 43, 46–47, 52, 81 pictorial pack warnings 46 Tomes, John 87 tongue 14, 28 tonsils 14 tooth bleaching 89 extraction 37, 39, 84, 85 loss (edentulousness) 17, 18, 19, 22, 26–27, 35, 47 worms 84, 86 tooth decay/dental caries 15, 17, 22–23, 104 common risk factors for 42, 43, 44–45 distribution of 24–25, 38–39

early childhood caries 23 global assessment of 90–91 toothache (see dental pain) toothbrush 26, 53, 85, 88, 93 toothpaste 23, 24, 47 52–53, 54, 56–57, 60 composition of 56 cost of 56, 92 development of 84, 85, 88 market 57 training 66–67, 74–75 cost of 74–75 privatisation of 75 trauma 35, 42, 52 treatment (see oral care services) United Kingdom 35, 39, 45, 70, 76, 77 UN Millennium Development Goals 62, 92 United States of America 23, 29, 35, 36, 38, 44, 54, 55, 58, 59, 70, 74, 76, 77 uvula 14 Watt, Richard 40 WHO Framework Convention on Tobacco Control 63, 89, 92 Willoughby, Dayton 87 Winds of Hope Foundation 30 World Health Organization 14, 24, 26, 30, 31, 46, 48, 49, 54, 58, 62, 63, 70, 80–81, 89, 92 World Oral Health Day 63, 89 wound healing 46 x-ray 87, 92 Yamada, Tadataka 62 Yoder, Karen 63

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THE ORAL HEALTH ATLAS

Oral health is an integral part of general health and wellbeing, yet more than 90% of the world’s population experience oral or dental problems in their lifetime.

ORAL HEALTH

The

Atlas

Mapping a neglected global health issue

Roby Beaglehole Habib Benzian Jon Crail Judith Mackay