The case for universal oral health coverage, according to a new WHO report

On Friday, oral health advocates across the globe got an early holiday gift from their longtime wish lists. They had been waiting their whole careers — for some STAT spoke with, up to nearly half a century — for oral health to be folded into conversations calling for health care access for all. The World Health Organization’s new Global Oral Health Status report took that first step.

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

The WHO report offers data on 194 countries’ oral disease caseload and mortality rates, highlighting differences in the prevalence of oral health problems across different regions. It also stresses the most common oral health issues, such as tooth decay, tooth loss, severe gum disease, and oral cancers. The report highlights barriers to access, including cost and the need for specialized providers, and opportunities to tackle disparities, all in service of the goal set by the World Health Assembly earlier this year: Universal oral health coverage by 2030.

Universal oral health coverage doesn’t necessarily mean free services or advanced dental care — such as implants or prosthetics — for all, said Habib Benzian, who worked on the WHO report and is research professor and co-director of the WHO Collaborating Center at New York University’s College of Dentistry. Rather, universal coverage is aimed at ensuring that all people have access to quality essential oral health services, no matter where they live or how poor they are. Essential services include oral disease prevention, pain relief, fillings, and some dental restoration.

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

Among high-, medium-, and low-income countries, the prevalence of major oral diseases, excluding oral cancers, didn’t differ much, based on 2019 Global Burden of Disease data. These numbers speak to how global the issues are, said Chaffee.

The data also drive home the importance of preventative care, no matter how wealthy a country is. “When a person goes to the dentist, it is often late and the oral problem is already there,” WHO global oral health lead Benoit Varenne told STAT via email.

For Varenne, the spark that lit what would become a 99-page, multi-year endeavor came by way of Burkina Faso more than 20 years ago. He was then a young WHO adviser working in remote regions in the West African country, where the closest dentist was nearly 500 kilometers away. There were no dental schools to train a new workforce, so Burkinabé had to head to Senegal for oral health care training.

Faced with these access issues, public health schools in Burkina Faso started training nurses to double as dental nurses. In the field, it didn’t matter whether they had gone through some fancy schooling. All that mattered to the patients was that nurses had the proper education to extract a tooth or supply pain relief for an infection.

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

But items such as fluoride toothpaste remain out of reach for many low-income people. A WHO action plan in the works to guide governments to launch oral health reforms might help. Announced Friday, the WHO Executive Committee is set to roll out the action plan in January 2023 and at the World Health Assembly in May 2023.

Relying on a less specialized workforce could also help improve access — perhaps by training medical providers in oral health care, Burkina Faso-style. It’s cheaper and takes less time to train people already working in health care in dentistry than to train novices.

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

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

“This is a big, slow challenge, because most of the models have been built based on specialized providers with high technology equipment,” Varenne said. “And all these things, of course, cost a lot.” Making oral health coverage less expensive could ease governments’ concerns around putting oral health under the same umbrella as universal medical access talks, laws and initiatives, said Varenne.

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

Even experts who collaborate with the WHO agree. It’s vital to include people from the informal sector, said Brittany Seymour, the global health discipline director for the Harvard School of Dental Medicine, which has contracts with the WHO African regional offices. Patients and advocates often get left out of research on the issues they’re most affected by, she said.

She and other researchers were struck less by the gloomy snapshot of global oral health care — and more by the fact that the report launched at last. Seymour cited a side session focused on oral health at the 2011 United Nations summit on non-communicable diseases as one early advocacy milestone.

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