Role of Dentistry in Global Health: Challenges and Research Priorities.

Despite some improvements in the oral health of populations globally, major problems remain all over the planet, most notably among underprivileged communities of low- and middle-income countries but also in high-income countries. Furthermore, essential oral health care has been a privilege, instead of a right, for most individuals. The release of the Lancet issue on oral health in July 2019 built up some momentum and put oral conditions and dental services in the limelight. Yet, much work is still needed to bridge the gap between dental research and global health and get oral health recognized as a population health priority worldwide. Using the framework proposed by Shiffman, we argue that a global health network for oral health must be harnessed to influence global health policy and drive health system reform. We have identified challenges around 4 key areas (problem definition, positioning, coalition building, and governance) from our experience working in the global health arena and with collaborators in multidisciplinary teams. These challenges are outlined here to validate them externally but also to call the attention of interested players inside and outside dentistry. How well our profession addresses these challenges will shape our performance during the Sustainable Development Goals era and beyond. This analysis is followed by a discussion of fundamental gaps in knowledge, particularly in 3 areas of oral health action: 1) epidemiology and health information systems; 2) collection, harmonization, and rigorous assessment of evidence for prevention, equity, and treatment; and 3) optimal strategies for delivering essential quality care to all who need it without financial hardship.

The impact of the COVID-19 pandemic on dentistry.

The COVID-19 pandemic has affected the delivery of health services across the world. The World Health Organisation (WHO) declared the COVID-19 outbreak to be a global pandemic on 11th March 2020, prompting the closure of dental services worldwide. The main reason for this was the infection risk associated with Aerosol Generating Procedures (AGP), such as the use of high-speed drills (Al-Halabi et al., 2020). During this period, even access to emergency dental care has been limited. A review of the current guidance issued by international organisations and professional bodies regarding the re-opening of dental services showed considerable variation in the safety procedures required. Most sources recommended triage of patients and an emphasis on only emergency and urgent care; wearing filtering facepiece class 2 masks; reducing the risk of transmission; and avoiding AGP. All sources stressed the need to focus on activities that minimise risk to staff, patients and the public, and to support high quality clinical care (CoDER, 2020).

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study.

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank's classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

Global-, Regional-, and Country-Level Economic Impacts of Dental Diseases in 2015.

Up-to-date information about the economic impact of dental diseases is essential for health care decision makers when seeking to make rational use of available resources. The purpose of this study was to provide up-to-date estimates for dental expenditures (direct costs) and productivity losses (indirect costs) due to dental diseases on the global, regional, and country level. Direct costs of dental diseases were estimated using a previously established systematic approach; indirect costs were estimated using an approach developed by the World Health Organization Commission on Macroeconomics and Health and factoring in 2015 values for gross domestic product and disability-adjusted life years from the Global Burden of Disease Study. The estimated direct costs of dental diseases amounted to $356.80 billion and indirect costs were estimated at $187.61 billion, totaling worldwide costs due to dental diseases of $544.41 billion in 2015. After adjustment for purchasing power parity, the highest levels of per capita dental expenditures were found for High-Income North America, Australasia, Western Europe, High-Income Asia Pacific, and East Asia; the highest levels of per capita productivity losses were found for Western Europe, Australasia, High-Income North America, High-Income Asia Pacific, and Central Europe. Severe tooth loss was found to imply 67% of global productivity losses due to dental diseases, followed by severe periodontitis (21%) and untreated caries (12%). From an economic perspective, improvements in population oral health may be highly beneficial and could contribute to further increases in people's well-being given available resources.

Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors.

The Global Burden of Disease 2015 study aims to use all available data of sufficient quality to generate reliable and valid prevalence, incidence, and disability-adjusted life year (DALY) estimates of oral conditions for the period of 1990 to 2015. Since death as a direct result of oral diseases is rare, DALY estimates were based on years lived with disability, which are estimated only on those persons with unmet need for dental care. We used our data to assess progress toward the Federation Dental International, World Health Organization, and International Association for Dental Research's oral health goals of reducing the level of oral diseases and minimizing their impact by 2020. Oral health has not improved in the last 25 y, and oral conditions remained a major public health challenge all over the world in 2015. Due to demographic changes, including population growth and aging, the cumulative burden of oral conditions dramatically increased between 1990 and 2015. The number of people with untreated oral conditions rose from 2.5 billion in 1990 to 3.5 billion in 2015, with a 64% increase in DALYs due to oral conditions throughout the world. Clearly, oral diseases are highly prevalent in the globe, posing a very serious public health challenge to policy makers. Greater efforts and potentially different approaches are needed if the oral health goal of reducing the level of oral diseases and minimizing their impact is to be achieved by 2020. Despite some challenges with current measurement methodologies for oral diseases, measurable specific oral health goals should be developed to advance global public health.

Global Economic Impact of Dental Diseases.

Reporting the economic burden of oral diseases is important to evaluate the societal relevance of preventing and addressing oral diseases. In addition to treatment costs, there are indirect costs to consider, mainly in terms of productivity losses due to absenteeism from work. The purpose of the present study was to estimate the direct and indirect costs of dental diseases worldwide to approximate the global economic impact. Estimation of direct treatment costs was based on a systematic approach. For estimation of indirect costs, an approach suggested by the World Health Organization's Commission on Macroeconomics and Health was employed, which factored in 2010 values of gross domestic product per capita as provided by the International Monetary Fund and oral burden of disease estimates from the 2010 Global Burden of Disease Study. Direct treatment costs due to dental diseases worldwide were estimated at US$298 billion yearly, corresponding to an average of 4.6% of global health expenditure. Indirect costs due to dental diseases worldwide amounted to US$144 billion yearly, corresponding to economic losses within the range of the 10 most frequent global causes of death. Within the limitations of currently available data sources and methodologies, these findings suggest that the global economic impact of dental diseases amounted to US$442 billion in 2010. Improvements in population oral health may imply substantial economic benefits not only in terms of reduced treatment costs but also because of fewer productivity losses in the labor market.

Global burden of untreated caries: a systematic review and metaregression.

We aimed to consolidate all epidemiologic data about untreated caries and subsequently generate internally consistent prevalence and incidence estimates for all countries, 20 age groups, and both sexes for 1990 and 2010. The systematic search of the literature yielded 18,311 unique citations. After screening titles and abstracts, we excluded 10,461 citations as clearly irrelevant to this systematic review, leaving 1,682 for full-text review. Furthermore, 1,373 publications were excluded following the validity assessment. Overall, 192 studies of 1,502,260 children aged 1 to 14 y in 74 countries and 186 studies of 3,265,546 individuals aged 5 y or older in 67 countries were included in separate metaregressions for untreated caries in deciduous and permanent teeth, respectively, using modeling resources from the Global Burden of Disease 2010 study. In 2010, untreated caries in permanent teeth was the most prevalent condition worldwide, affecting 2.4 billion people, and untreated caries in deciduous teeth was the 10th-most prevalent condition, affecting 621 million children worldwide. The global age-standardized prevalence and incidence of untreated caries remained static between 1990 and 2010. There is evidence that the burden of untreated caries is shifting from children to adults, with 3 peaks in prevalence at ages 6, 25, and 70 y. Also, there were considerable variations in prevalence and incidence between regions and countries. Policy makers need to be aware of a predictable increasing burden of untreated caries due to population growth and longevity and a significant decrease in the prevalence of total tooth loss throughout the world from 1990 to 2010.

Is there a role for community pharmacists in promoting oral health?

AIM: The main aim of the present study was to investigate whether pharmacists recognised that they have a role in the promotion of oral health advice within the community. METHODS: A cross sectional survey was conducted using a structured questionnaire which was distributed to randomly selected pharmacies (n = 1,500) in the London area. RESULTS: Six hundred and forty-five pharmacies (43%) responded to the initial invitation and 589 (39%) of pharmacy participants acknowledged that pharmacists should have a role in oral health promotion. Participants from 354 pharmacies (23.6%) subsequently agreed to complete the questionnaire. Of those pharmacies completing the questionnaire, 99.4% of the pharmacy participants recognised that there was a role for pharmacists in oral health promotion. Although 91.5% of the pharmacists reported a fairly high level of knowledge for most of the common oral conditions, they also indicated that they were interested in receiving further training on oral conditions through continuing professional development (CPD) courses. A number of the pharmacies (72.5%) expressed a willingness to incorporate oral health promotion within the NHS pharmacy contract. CONCLUSION: Pharmacies may be used effectively in oral health promotion by virtue of their frequent contact with members of public. As a result of their established role in promoting and improving the health within the community, it may possible to incorporate oral health within the existing NHS contract.

School bullying and traumatic dental injuries in East London adolescents.

AIM: To explore the association between school bullying and traumatic dental injuries (TDI) among 15-16-year-old school children from East London. DESIGN: Data from phase III of the Research with East London Adolescents Community Health Survey (RELACHS), a school-based prospective study of a representative sample of adolescents, were analysed. Adolescents provided information on demographic characteristics, socioeconomic measures and frequency of bullying in school through self-administered questionnaires and were clinically examined for overjet, lip coverage and TDI. The association between school bullying and TDI was assessed using binary logistic regression models. RESULTS: The prevalence of TDI was 17%, while lifetime and current prevalence of bullying was 32% and 11%, respectively. The prevalence of TDI increased with a growing frequency of bullying; from 16% among adolescents who had never been bullied at school, to 21% among those who were bullied in the past but not this school term, to 22% for those who were bullied this school term. However, this association was not statistically significant either in crude or adjusted regression models. CONCLUSION: There was no evidence of an association between frequency of school bullying and TDI in this sample of 15-16-year-old adolescents in East London.

Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression.

We aimed to consolidate all epidemiologic data about severe periodontitis (SP) and, subsequently, to generate internally consistent prevalence and incidence estimates for all countries, 20 age groups, and both sexes for 1990 and 2010. The systematic search of the literature yielded 6,394 unique citations. After screening titles and abstracts, we excluded 5,881 citations as clearly not relevant to this systematic review, leaving 513 for full-text review. A further 441 publications were excluded following the validity assessment. A total of 72 studies, including 291,170 individuals aged 15 yr or older in 37 countries, were included in the metaregression based on modeling resources of the Global Burden of Disease 2010 Study. SP was the sixth-most prevalent condition in the world. Between 1990 and 2010, the global age-standardized prevalence of SP was static at 11.2% (95% uncertainty interval: 10.4%-11.9% in 1990 and 10.5%-12.0% in 2010). The age-standardized incidence of SP in 2010 was 701 cases per 100,000 person-years (95% uncertainty interval: 599-823), a nonsignificant increase from the 1990 incidence of SP. Prevalence increased gradually with age, showing a steep increase between the third and fourth decades of life that was driven by a peak in incidence at around 38 yr of age. There were considerable variations in prevalence and incidence between regions and countries. Policy makers need to be aware of a predictable increasing burden of SP due to the growing world population associated with an increasing life expectancy and a significant decrease in the prevalence of total tooth loss throughout the world from 1990 to 2010.

Global Burden of Severe Tooth Loss: A Systematic Review and Meta-analysis.

The goal of the Global Burden of Disease 2010 Study has been to systematically produce comparable estimates of the burden of 291 diseases and injuries and their associated 1,160 sequelae from 1990 to 2010. We aimed to report here internally consistent prevalence and incidence estimates of severe tooth loss for all countries, 20 age groups, and both sexes for 1990 and 2010. The systematic search of the literature yielded 5,618 unique citations. After titles and abstracts were screened, 5,285 citations were excluded as clearly not relevant to this systematic review, leaving 333 for full-text review; 265 publications were further excluded following the validity assessment. A total of 68 studies-including 285,746 individuals aged 12 yr or older in 26 countries-were included in the meta-analysis using modeling resources of the Global Burden of Disease 2010 Study. Between 1990 and 2010, the global age-standardized prevalence of edentate people decreased from 4.4% (95% uncertainty interval: 4.1%, 4.8%) to 2.4% (95% UI: 2.2%, 2.7%), and incidence rate decreased from 374 cases per 100,000 person-years (95% UI: 347, 406) to 205 cases (95% UI: 187, 226). No differences were found by sex in 2010. Prevalence increased gradually with age, showing a steep increase around the seventh decade of life that was associated with a peak in incidence at 65 years. Geographic differences in prevalence, incidence, and rate of improvement from 1990 to 2010 were stark. Our review of available quality literature on the epidemiology of tooth loss shows a significant decline in the prevalence and incidence of severe tooth loss between 1990 and 2010 at the global, regional, and country levels.

A theory led narrative review of one-to-one health interventions: the influence of attachment style and client-provider relationship on client adherence.

A theory-led narrative approach was used to unpack the complexities of the factors that enable successful client adherence following one-to-one health interventions. Understanding this could prepare the provider to anticipate different adherence behaviours by clients, allowing them to tailor their interventions to increase the likelihood of adherence. The review was done in two stages. A theoretical formulation was proposed to explore factors which influence the effectiveness of one-to-one interventions to result in client adherence. The second stage tested this theory using a narrative synthesis approach. Eleven studies across the health care arena were included in the synthesis and explored the interplay between client attachment style, client-provider interaction and client adherence with health interventions. It emerged that adherence results substantially because of the relationship that the client has with the provider, which is amplified or diminished by the client's own attachment style. This occurs because the client's attachment style shapes how they perceive and behave in relationships with the health-care providers, who become the 'secure base' from which the client accepts, assimilates and adheres with the recommended health intervention. The pathway from one-to-one interventions to adherence is explained using moderated mediation and mediated moderation models.

Family relationships as an explanatory variable in childhood dental caries: a systematic review of measures.

It is widely acknowledged that parental beliefs (self-efficacy) about oral health and parental oral health-related behaviours play a fundamental role in the establishment of preventative behaviours that will mitigate against the development of childhood dental caries. However, little attention has been given to the wider perspective of family functioning and family relationships on child oral health. For oral health researchers, exploration of this association requires the use of reliable, valid and appropriate assessment tools to measure family relationships. In order to promote methodologically sound research in oral health, this systematic review aims to provide a guide on self-report psychometric measures of family functioning that may be suitable to utilize when exploring childhood dental caries. This systematic review has identified 29 self-report measures of family functioning and evaluated them in terms of their psychometric support, constructs measured and potential utility for oral health research. The majority of the measures reported adequate levels of reliability and construct validity. Construct evaluation of the measures identified five core domains of family functioning, namely 'communication', 'cohesion/engagement', 'control', 'involvement' and 'authoritative/rigid parenting style'. The constructs were subsequently evaluated with respect to their potential relevance to child oral health. Herewith this review provides a framework to guide future research to explore family functioning in furthering our understanding of the development of childhood dental caries.

Ethnic disparities in the oral health of three- to four-year-old children in East London.

AIM: To report ethnic differences related to caries experience among three- to four-year-old children living in three of the most deprived boroughs in the UK in Inner North East London: Tower Hamlets, Hackney and Newham. METHODS: This cross-sectional survey used a cluster sampling study design following the British Association for the Study of Community Dentistry protocol. Twenty nurseries from each borough were randomly selected and all three- to four-year-old children in selected nurseries were invited to participate (n = 2,434). Calibrated dentists examined children. Demographic information was obtained from schools. RESULTS: One thousand, two hundred and eighty-five children were examined in 60 nurseries (response rate = 52.8%). Twenty-four percent of three- to four-year-old children had caries experience (mean dmft = 0.92). Few children (2.1%) had filled teeth. Children living in Hackney had significantly lower dmft scores (mean = 0.63) than children living in Newham (mean = 1.06) and Tower Hamlets (mean = 1.06). White European (mean = 1.91), Bangladeshi (mean = 1.05) and Pakistani (mean = 1.11) children had a significantly higher number of untreated carious teeth than White British children (mean = 0.56). CONCLUSION: Preschool children from a White Eastern European, Bangladeshi and Pakistani background are likely to experience significantly poorer oral health than their White British counterparts. These findings have profound implications for commissioning dental services and oral health promotion.

Global burden of oral conditions in 1990-2010: a systematic analysis.

The Global Burden of Disease (GBD) 2010 Study produced comparable estimates of the burden of 291 diseases and injuries in 1990, 2005, and 2010. This article reports on the global burden of untreated caries, severe periodontitis, and severe tooth loss in 2010 and compares those figures with new estimates for 1990. We used disability-adjusted life-years (DALYs) and years lived with disability (YLDs) metrics to quantify burden. Oral conditions affected 3.9 billion people, and untreated caries in permanent teeth was the most prevalent condition evaluated for the entire GBD 2010 Study (global prevalence of 35% for all ages combined). Oral conditions combined accounted for 15 million DALYs globally (1.9% of all YLDs; 0.6% of all DALYs), implying an average health loss of 224 years per 100,000 population. DALYs due to oral conditions increased 20.8% between 1990 and 2010, mainly due to population growth and aging. While DALYs due to severe periodontitis and untreated caries increased, those due to severe tooth loss decreased. DALYs differed by age groups and regions, but not by genders. The findings highlight the challenge in responding to the diversity of urgent oral health needs worldwide, particularly in developing communities.

The role of psychosocial factors in predicting orthodontic treatment outcome at the end of 1 year of active treatment.

The role of psychosocial factors in predicting orthodontic treatment outcome has not been investigated before. Thus, the current study aimed to test whether psychosocial factors, namely 'daily hassles', resiliency, and family environment, can predict orthodontic treatment outcome at the end of 1 year of active treatment. A hospital-based, prospective, longitudinal design was adopted including 145 consecutively selected 12- to 16-year-old male and female adolescents. Baseline psychosocial data were collected by a validated child self-completed questionnaire before the placement of fixed appliances. Thereafter, adolescents were followed up on a monthly basis to collect information relating to their daily hassles and treatment adherence. After 1 year of treatment, orthodontic treatment outcome was measured by the amount of improvement in occlusion achieved. Logistic regression analysis was used. The response rate was 98.6 per cent and the dropout was 5.6 per cent. Maternal support was an important predictor of improvement in occlusion. Adolescents with high levels of maternal support were more likely to achieve a high improvement in occlusion than those with low levels of maternal support (odds ratio = 3, 95 per cent confidence interval = 1.53-6.27, P = 0.002). Paternal support, maternal and paternal control, daily hassles, and resiliency were not significantly associated with improvement in occlusion (P > 0.05). The regression model confirmed the significance of maternal support as a predictor of orthodontic treatment outcome at the end of 1 year of active treatment.

A school-based epidemiological study of dental neglect among adolescents in a deprived area of the UK.

OBJECTIVE: To assess the prevalence of two types of dental neglect (DN) for adolescents attending secondary schools in a deprived inner city area: neglect of the prevention of oral disease (DPN) and neglect of dental treatment (DTN). DESIGN: This study used cross-sectional data from Phase III of the research with East London adolescents community health survey (RELACHS); a longitudinal school-based epidemiological study that followed up a representative random sample of pupils in 29 secondary schools across three boroughs of inner North East London. Participants were clinically examined and answered a supervised questionnaire. DN was assessed in relation to DPN (measured by reference to experience of dental conditions and/or dental pain) and DTN (measured by reference to experience of at least one untreated dental condition and/or dental pain). Dental conditions included dental caries and traumatic dental injuries. RESULTS: Four in ten adolescents in the study experienced DPN and five in ten experienced DTN. Adolescents with special educational needs without a statement, refugee and those 'looked after' by a local authority experienced a higher proportion of both types of DN. CONCLUSIONS: In an inner city deprived area, the proportion of adolescents with DN (either DPN or DTN) was of significance. Refugee adolescents and looked after children may be more at risk of DN.

Child dental neglect: is it a neglected area in the UK?

This commentary focuses on the condition of dental neglect (DN) in children in the UK. It is divided into three sections: the first section defines DN in children and its consequences, the second section discusses who may be responsible for dental diseases in children as a result of neglect and the third section proposes a holistic approach to address DN in children in the UK.

Religiosity, spirituality, social support, health behaviour and dental caries among 35- to 44-year-old Jerusalem adults: a proposed conceptual model.

The aim of this study was to assess the relationship between religiosity and dental caries, and whether oral health-related behaviours, spirituality and social support are included in the potential pathways which explain the association between religiosity and dental caries. The present cross-sectional study employed a stratified sample, according to religiosity level (33.1% secular, 33.1% religious and 33.9% orthodox), of 254 Jewish adults in Jerusalem. The objective was to examine the pathway between religiosity, spirituality and social support and its effect on oral health outcomes by DMFT, controlling for socio-economic position and health behaviour determinants. Religiosity was determined and validated by self-definition. Social support was assessed by the Multidimensional Scale of Perceived Social Support. Spirituality was estimated by the Hebrew version of the SpREUK Questionnaire for Religiosity, Spirituality and Health. The mean caries experience (DMFT) was 10.75. Secular people revealed significantly higher DMFT than their religious and orthodox counterparts (78.0 vs. 43.9 and 39.3%, respectively, p < 0.01). A conceptual logistic regression model revealed a possible pathway, wherein a higher level of religiosity was distally associated with superior dental health outcomes, mediated by high spirituality, strong social support and positive oral health behaviours. The present study identified a strong statistical association between caries experience and religiosity. The direction of the association suggested that being religious had a protective effect on caries experience. Our conceptual hierarchical approach suggests a pathway to explain the association between the level of religiosity and dental caries experience. In this study this association was mediated by extrinsic (i.e. social support) and intrinsic (i.e. spirituality) pathways.