Redefining the non-communicable disease framework to a 6 × 6 approach: incorporating oral diseases and sugars.

The WHO Global Oral Health Status Report, published in 2022, highlighted the alarming state of oral health worldwide and called for urgent action by integrating oral health into non-communicable diseases (NCDs) and universal health coverage initiatives. 3·5 billion people have oral diseases, surpassing all other NCDs combined. The detrimental role of sugars as a risk factor for oral diseases and other NCDs has also been well documented. Despite the evidence, oral diseases and sugars are not part of the current NCD framing, which focuses on five diseases and five risk factors (ie, 5 × 5). Oral diseases and sugars remain sidelined, disproportionately affecting poor and disadvantaged populations. In this Viewpoint, we advocate for the integration of oral diseases and sugars into the current approach towards the prevention and control of NCDs. An expanded 6 × 6 framework would recognise growing evidence and would reiterate the need to strengthen action, resource allocation, and policy development for NCDs. We present the evidence and rationale for, and benefits of, an expanded NCD framework and detail recommendations to guide efforts towards improved priority, investment, and equitable health outcomes for NCDs, including oral health.

Effectiveness of school-based strategies to prevent tooth decay in Filipino children: A cluster-randomized trial.

OBJECTIVES: Evidence for affordable and pragmatic programmes to address the burden of untreated tooth decay in children in low- and middle-income settings is limited. This study aimed to (1) assess the effect of a government-run, school-based daily group toothbrushing programme compared to standard school-based oral health education on the incidence of dental caries and odontogenic infections in Filipino children over a period of 3 years; and (2) assess the additional preventive effect of on-demand oral urgent treatment (OUT) and weekly fluoride gel application. METHODS: A cluster-randomized trial was conducted in Camiguin, Philippines. Schools in three regions were randomly assigned to one of three intervention groups: The Essential Health Care Programme (EHCP), which includes daily toothbrushing with fluoride toothpaste; EHCP plus twice-yearly access to on-demand urgent oral treatment (EHCP + OUT) and EHCP plus weekly application of high-concentrated fluoride gel (EHCP + Fluoride). Schools in a nearby province with a similar child population were selected as external concurrent control group. Clinical oral examinations were performed by calibrated dentists from a random sample of 682 seven-year-old students who were examined at baseline and over the following 3 years. Outcome variables were the number of decayed primary teeth, the number of decayed, missing and filled permanent teeth (DMFT) and surfaces (DMFS), and the number of permanent teeth with pulpal involvement, ulcerations, fistula or abscess (PUFA). Data were analysed using multilevel mixed-effects negative binomial regression. RESULTS: Three years after implementation, increments in dental caries and odontogenic infections in permanent teeth did not significantly differ between the EHCP and control group, yet the incidence of DMFT was lower by 22% in children receiving EHCP. Compared to controls, children receiving EHCP + Fluoride had a significantly lower increment of DMFT, DMFS and PUFA by 40%, 40% and 47%, respectively. Children receiving EHCP + OUT had lower incidence rates of DMFT and DMFS than control children by 23% and 28%, respectively. A lower incidence rate was also found for PUFA, but the effect was not statistically significant. CONCLUSIONS: Findings suggest that the weekly application of fluoride gel and urgent oral treatment, in addition to daily school-based toothbrushing with fluoride toothpaste, are realistic and effective strategies to lower the burden of dental caries in Filipino children. Implementation challenges may explain why no substantial caries-preventive benefits were demonstrated for school-based toothbrushing only. Intervention compliance should be considered in future programme implementation and evaluation research.

Affordability of essential medicines: The case of fluoride toothpaste in 78 countries.

BACKGROUND: Fluoride toothpaste (FT) has recently been included in the WHO Model List of Essential Medicines. Whereas it is essential for preventing dental caries, its current affordability around the globe remains unclear. This study aimed to analyse the affordability of FT in as many as possible countries worldwide, to capture the extent of variations in FT affordability between high-, middle- and low-income countries. METHODS: A standardized protocol was developed to collect country-specific information about the characteristics of the cheapest available FT at a regular point of purchase. 82 members of the WHO Global Oral Health Network of Chief Dental Officers (CDOs), directors of WHO Collaborative Centres and other oral health experts collected data using mobile phone technology. In line with established methodologies to assess affordability, the Fluoride Toothpaste Affordability Ratio (FTAR) was calculated as the expenditure associated with the recommended annual consumption of FT relative to the daily wage of the lowest-paid unskilled government worker (FTAR >1 = unaffordable spending on fluoride toothpaste). RESULTS: There are significant differences in the affordability of FT across 78 countries. FT was strongly affordable in high-income countries, relatively affordable in upper middle-income countries, and strongly unaffordable in lower middle-income and low-income countries. The affordability of FT across WHO Regions was dependent upon the economic mix of WHO Regions' member states. CONCLUSION: FT is still unaffordable for many people, particularly in low-income settings. Strategies to improve the universal affordability of FT should be part of health policy decisions in order to contribute to reducing dental caries as a global public health problem.

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention.

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals.

Global Health Partnerships and the Brocher Declaration: Principles for Ethical Short-Term Engagements in Global Health.

Short- term experiences in global health (STEGH), also known as short-term medical missions continue to be a popular mode of engagement in global health activities for students, healthcare providers, and religious groups, driven primarily by organizations from high-income countries. While STEGH have the potential to be beneficial, a large proportion of these do not sustainably benefit the communities they intend to serve, may undermine local health systems, operate without appropriate licenses, go beyond their intended purposes, and may cause harm to patients. With heightened calls to "decolonize" global health, and to achieve ethical, sustainable, and practical engagements, there is a need to establish strong guiding principles for global health engagements. The Advocacy for Global Health Partnerships (AGHP), a multi-sectoral coalition, was established to reflect on and address the concerns relating to STEGH. Towards this end, AGHP created the Brocher Declaration to lay out six main principles that should guide ethical and appropriate STEGH practices. A variety of organizations have accepted the Declaration and are using it to provide guidance for effective implementation of appropriate global health efforts. The Declaration joins broader efforts to promote equity in global health and a critical reevaluation of volunteer-centric, charity-based missions. The current state of the world's health demands a new model of collaboration - one that sparks deep discussions of shared innovation and builds ethical partnerships to address pressing issues in global health.