For too long, oral health has hidden in the shadows of health discussions, yet Europe is facing a dire oral health crisis. Only recently has oral health started to receive recognition as a health issue and as a determinant of a person's wider wellbeing. In the spring of 2023, the World Health Organization (WHO) urged Member States to increase access to safe, effective, and affordable essential oral health care as part of universal health coverage. While access to quality oral healthcare is crucial, addressing the fundamental link between diet and oral health is essential to effectively tackle oral health inequalities and promote overall wellbeing.
Diet plays a significant role in oral health outcomes. The undeniable connection between oral health and nutrition is frequently shaped by socioeconomic inequalities, leading to increased inequalities. As a result, underserved communities often bear the brunt of these inequalities. Professor Richard Watt, Honorary Consultant in Dental Public Health at University College London, discusses the implications of oral health and why it should be front and centre of policymaking.
In public health there are many topics vying for the attention of policymakers, desperate to be considered a public health priority and deemed suitable for further future investment and policy development. Policymakers face many competing demands, limited resources and many challenges and pressures, putting them in an unenviable position. Subsequently, they often need to be convinced of the importance of new and emerging priorities.
The oral health sector provides a useful case study on the limitations of traditional clinical and biomedical approaches in the control and prevention of chronic diseases. Despite many frustrations and lost ‘battles’ over the decades, in recent years some very positive global policy developments have taken place in oral health. Opportunities are now opening up for innovation and transformative policy and system change in what has been a somewhat neglected and invisible area of public health.
From a personal point of view for nearly four decades, I've been immersed in the intricate world of public health dentistry, first as a clinician in England's community dental clinics and for the past three decades as a UCL academic and staunch advocate for oral health. Navigating this specialised and niche area of public health has granted me unique insights into the intricate dance of priority setting and policy formulation.
Oral diseases: the facts
Tooth decay, or dental caries, has taken a formidable bite out of Europe's oral health, afflicting a staggering 335 million people. This includes 294 million who bear the brunt of this decay on their permanent, adult, teeth. But even the youngest amongst us haven't been spared, with 41 million children between the ages of 1 and 9 falling victim to decay on their deciduous, or baby, teeth. These sobering numbers paint a grim picture of a dental disease that has firmly entrenched itself in the European landscape.
Oral diseases, despite being the most widespread of noncommunicable diseases (NCDs) affecting an estimated 3.5 billion people, or nearly half of the world's population throughout their lives, from early childhood to old age. Oral diseases namely dental caries, periodontal (gum) disease and oral cancers are all chronic, progressive and cumulative conditions. Dental caries can start early in life affecting very young children but as a progressive disease it also affects older children and young people alike, adults and increasingly, older people who are retaining more of their natural teeth into older age. This is unlike periodontal disease and oral cancers which mainly affect adults and older people. So, why haven't oral diseases received the attention that is needed?
The recently published WHO Oral Health Status Summary Report for Europe highlights that overall, 466 million people across the WHO European region are affected by oral diseases, (WHO, 2023).
Amongst adults and especially older people, approximately 88 million Europeans are totally edentate – that is they have no natural teeth, a debilitating condition that can affect their ability to eat certain foods such as fresh fruits and vegetables making it difficult to consume a healthy diet. Each year there are estimated to be nearly 70,000 new cases of oral cancer and over 26,000 oral cancer deaths across Europe (WHO, 2023).
Dental divide: social inequalities and oral health
Oral diseases have a profound impact on those affected and our wider society. Oral diseases can cause significant pain and discomfort, reduced quality of life impacting on on fundamental activities such as eating, speaking, and smiling, that in turn disrupts social and family life, leading to lost school days and reduced work productivity. In terms of economic impact, it is estimated that in Europe about US$113 billion is spent annually on the treatment of oral diseases and productivity losses due to oral diseases are estimated to be approximately US$104 billion (WHO, 2023).
Yet, despite their significant burden and impact, oral diseases are largely preventable. Oral diseases share common risks with other noncommunicable diseases (NCDs) including consumption of ultra-processed foods and drinks high in free sugars, tobacco use, personal hygiene practices and alcohol consumption, and the underlying social, economic and commercial determinants of these risk factors. To effectively prevent oral diseases a range of upstream integrated policies are required.
Oral diseases, despite being very common, are socially patterned and disproportionately affect disadvantaged and underserved populations. Numerous epidemiological studies across Europe have revealed stark inequalities in oral health, both within and between countries. Individuals grappling with poverty and low incomes, those living with disabilities, members of marginalised ethnic groups, frail older adults residing alone or in care homes, migrant populations, people in prisons, and those dwelling in remote rural communities, along with many other marginalised and underserved groups, are all disproportionately burdened by oral diseases.
Unlike many other health conditions, inequalities in oral diseases are very evident and visible, as the mouth is such an important and integral part of the face and a person’s social identity. People with poor oral health with obvious cavities and missing front teeth are often stigmatised and socially excluded in society, restricting their ability to gain employment and to form social relationships.
Oral health inequalities are caused by the broad interconnecting social, economic and commercial determinants – the underlying social and environmental conditions that drive these unjust, unfair but avoidable health inequalities in society. Achieving good oral health requires a combination of these determinant factors.
In addition to the inequalities that exist in the burden of oral diseases, stark inequalities also exist in the availability, affordability and accessibility of oral health care across Europe. Communities burdened with the most severe oral health needs often encounter the most limited access to dental services – a stark demonstration of the 'inverse care law,' a fundamental principle that highlights the inequitable distribution of healthcare resources. But why is this? Across many European countries, dental care is largely provided by the private sector and patients often directly bear high 'out-of-pocket' treatment costs. This financial burden poses a formidable barrier to care for individuals living in poverty or on low incomes.
Commercial interests vs oral health promotion
In recent years increasing attention has been placed on the need to reduce sugar consumption due to the mounting evidence of the harmful effects of sugar on health. Based upon extensive reviews of the scientific evidence of the effects of sugar intakes on overweight/obesity and dental caries, WHO guidelines recommend that free sugar should not contribute more than 10% of total energy intakes. Across Europe a high proportion of the child and adult populations consume above the recommended levels of free sugars due to the high consumption of ultra-processed foods and drinks, such as energy drinks, which often contain considerable amounts of sugar. While we recognise the damaging impact of sugary food and drinks on our oral health, leading to problems such as tooth sensitivity and decay, curbing our intake of these items is not an easy feat.
Viewed through the lens of commercial determinants, trans global and national corporations use a variety of measures to promote sales of their sugary products. Eye watering budgets are spent to promote, market, advertise and sell sugar sweetened beverages, confectionary, breakfast cereals, infant foods and drinks and other highly processed sugary products. In addition, food and drink companies also use a wide range of corporate political activities to influence and shape government policy to protect their profit margins and sales.
Until recently, the dental profession globally has adopted a classic biomedical and clinical approach to prevention. In this traditional approach, individual patients visit a dentist for clinical preventive measures and receive health education in community settings such as schools and nurseries. Such a preventive approach has been shown to rarely produce long-term sustainable improvements in oral health and risks increasing, rather than decreasing oral health inequalities – a good example of intervention generated inequalities.
The food industry endorses this ineffective individualistic approach to prevention as they recognise it has minimal impact on their sales and profits, and puts the responsibility of oral health with the individual.
Upstream policies to foster healthier choices
Based upon the lessons learned from tobacco control and specifically the global impact of the Framework Convention on Tobacco Control, to effectively reduce sugar consumption at a population level requires a comprehensive package of integrated policy measures. Upstream legislation, regulation and fiscal policies are all needed to tackle the availability, price and marketing of sugary foods and drinks.
We need much tighter controls to improve food labelling to enable consumers to make informed healthier choices. Currently many highly processed food and drink products have misleading or confusing labels that essentially hide their high sugar contents.
Stricter regulations are also needed on the marketing strategies used by the food industry to promote their products specifically to children and young people. Advertising standards agencies need to restrict and regulate the marketing and promotion strategies used by the food industry. In several countries, advertising controls have been introduced to prohibit television adverts of sugary products targeted at young children from being shown before the 8pm watershed.
In an increasing number of countries government taxes or levies have been introduced on sugar-sweetened beverages to discourage their consumption. In countries such as Mexico these fiscal measures have been shown to be effective in reducing consumption of sugary drinks and levels of overweight. The introduction of the sugar levy in the UK in 2018 encouraged the food industry to reformulate their products to reduce their sugar contents to avoid price increases. However, despite encouraging evidence, across Europe only approximately a third of governments have introduced a sugar tax on sugar-sweetened beverages.
Action is also needed to restrict industry influence on policy development, research and the training of future health professionals. Currently sugar industry representatives and their supporters extensively lobby governments and scientific organisations to influence policy decisions and professional guidelines. Greater transparency and tighter control of financial conflicts of interest are urgently needed to limit the influence of industry in sugar reduction policies.
Seizing the moment: sugar reduction for a healthier future
In a significant development for global oral health, the World Health Assembly (WHO) adopted Resolution WHA74.5 in May 2021, spearheaded by Sri Lanka and backed by 41 other nations. This landmark resolution has paved the way for a series of WHO policy documents aimed at fostering national policies that promote oral health, address oral health inequalities, and revamp oral healthcare systems
This important window of opportunity provides an ideal time to take bold upstream policy action on sugar reduction. Individualised approaches to reducing sugar consumption are doomed to fail. Instead upstream legislation, regulation and fiscal policies are all needed to tackle the availability, price and marketing of sugary foods and drinks.
Richard Watt
Professor Richard G Watt is Director of Research, Development and Innovation at Central North West London NHS Foundation Trust and Professor and Honorary Consultant in Dental Public Health at UCL. In 2019 he was appointed as Director of the World Health Organisation Collaborating Centre for Oral Health Inequalities and Public Health at UCL.
After qualifying as a dentist from the University of Edinburgh he worked in the NHS community dental service and then studied for a MSc and PhD in Dental Public Health at UCL. For the past 28 years he has been an academic in the UCL Department of Epidemiology and Public Health. He is currently leading a NIHR funded trial evaluating a community based parenting intervention.