Mapping Oral Health Worldwide

Lois K. Cohen, PhD and Habib Benzian, DDS, PhD

Dr. Benzian, how would you describe the state of oral health in the world?

The state of oral health is a world of disparities and inequities—between and among regions and countries, but also within countries and communities. Some populations enjoy good oral health, while the majority of the world’s populations suffer unnecessarily from the consequences of caries, periodontal diseases, oral cancer, and other disabling oral conditions. Very often oral health is not recognized for its proper importance in relation to general health in facilitating daily functioning and well-being.

On the other hand, there are simple and very effective measures available to tackle the growing burden of oral diseases and disabilities—but policymakers are often not aware of them. One could speak of a dual problem: the huge negative impact of oral diseases on quality of life is not recognized or known; and at the same time, the solutions available are not applied or not appropriately applied.

Has globalization affected the state of oral health?

That is difficult to say, but it is clear that the risk factors for oral diseases do not stop at national borders. Tobacco, sugar consumption, and other risk factors are global issues that increasingly require international responses. In addition, the traditional division of the world into “developed” and “developing” is increasingly losing meaning. Health and disease are no longer related to where you are born, but rather to the socioeconomic setting in which you live. Oral diseases demonstrate a strong relationship to socioeconomic status, with the highest burden being carried by those living in low socioeconomic situations. Any rich country has large populations that are disadvantaged and whose oral health status is very low; while at the same time, well-off populations in poor counties can enjoy good oral health. Other social determinants, from cultural values to social mores and practices, play significant roles in influencing health and disease generally.

You were a co-author on the FDI publication The Oral Health Atlas. What makes this publication so important?

The atlas format responds to a growing need for concise and factually correct information that is, at the same time, easy to access and understand. With a unique visual mix of data, graphics, and maps, the atlas combines information in a new and unusual way, allowing both lay and professional audiences to find relevant content. In addition to a series of world maps, the publication features an extensive table of health and specifically oral health indicators for every country for which these data are available. This makes comparison easy and transparent.

What are the most striking facts shown in the atlas?

There are too many to choose from. Dental decay is the most common chronic disease on the planet, affecting more than 90% of the world’s population. It is the most prevalent childhood disease, affecting more than 70% of school children worldwide. In some countries, such as the Philippines, dental pain is the most frequent reason for absenteeism from school. These striking facts are rarely noted, yet they happen right before everybody’s eyes.

How was this incredible amount of data collected for the atlas?

This was indeed a rather complex task. As the title of the atlas suggests, oral health is a neglected global health issue. As a consequence, oral health data are limited and often out of date, particularly for low- and middle-income countries. Unfortunately, it was not possible to work directly with agencies or institutions responsible for assembling national statistics; therefore, we had to rely on international data collection repositories associated with the World Health Organization, the FDI World Dental Federation, the International Union of Cancer, and many others. All data presented are as up-to-date as possible; however, some of the data collected from other agencies were incomplete or had not been updated. There is a chapter in the atlas in which the authors clearly highlight the limitations of the underlying data so that the reader understands the difficulties that are unavoidable in this context.

Can you give a practical example of the kind of difficulties that were encountered?

One example is that there are no definitive data on how many dentists there are in the world. What seemed to be a simple question turned out to be one of the most difficult ones—and there is still no authoritative answer. The “official” number of dentists in the US is a good example: the US Bureau of Labor Statistics reports 161,000 (2006), while the World Health Organization cites 463,663 (highest number in a single year during the period 2000-2006), counting dentists with all allied oral health workers. The American Dental Association, on the other hand, reports fewer than 120,000 members in 2008. So which number is the correct one?

The atlas includes this famous quote from Antigone: “No one loves the messenger who brings bad news.” What exactly is the bad news?

The atlas itself does not attempt to present new or unknown research. Because the authors combed through an enormous quantity of data, research papers, publications, and archival resources, we were able to condense the key issues in oral health from a new and, at times, surprising perspective. Unfortunately, this compilation of existing data very often results in uncovering the deficiencies of the basic data, and drawing attention to the enormous gaps in health status and availability of care. The example about the actual number of dentists highlights the importance of collecting data in a way that is relevant, standardized, and simple, in order to facilitate comparisons between and among countries, as well as over time. In almost all areas of oral health and dentistry, there are serious gaps in and problems with available data collection. I hope that health statistics related to oral health will improve and will better inform researchers, educators, practitioners, and policymakers as they engage in evidence-based strategies to enhance health through oral health.

Do you believe that better data would help in addressing the problems in a more effective way?

Yes and no. Better data alone do not help in any way. Statistics and information can only be the basis for informed decisions or policy choices. If these decisions are not made, the situation will not improve. If you look at the US, which has one of the more sophisticated oral health data collection systems in the world, you will understand that data alone are not changing anything. Although the disparities in oral health status are well documented, 50% of US citizens are still without dental insurance, and children from poor families have a five-fold risk of untreated cavities over children from high-income families. The interface of data, policy decisions, and leadership is very complex, and often those three elements may lack coherence and logic.

What was the objective of the FDI World Dental Federation in publishing The Oral Health Atlas?

It is one of the FDI’s missions to promote optimal oral and general health for all people. The atlas is a very appropriate tool in advocating for more attention to oral health worldwide. It is hoped that the publication may raise the visibility of oral health issues and make it easier for people to understand that oral diseases and disabilities impact everybody’s life as well as health systems. In addition, there are a range of interventions and policy options for prevention and care, both realistic and affordable for rich and poor countries and rich and poor people within countries.

In your opinion, who is the ideal reader of The Oral Health Atlas?

There are several prototypes of readers: the interested dentist who wants to learn more about oral health and dentistry internationally; the policymaker who needs to be sensitized about the need to tackle disparities in oral health status; the lay person who is interested in dental matters; the dental educator who wishes to teach and learn about advances and opportunities worldwide; the dental student who needs a primer in dental public health and global oral health issues; the dental association functionary who needs international orientation; the public health planner who is looking for basic oral health orientation and further reading; the public service dentist who wishes to advocate more for oral health with colleagues and institutions; the dental researcher who wants to address his or her research to reducing global health inequalities; and so on. In other words, there is no ideal reader—everyone can find something of interest in this book.

To order The Oral Health Atlas, please call the Aegis Bookstore at 877-423-4471.

About the Authors

Lois K. Cohen, PhD
Paul G. Rogers Ambassador for Global Health Research
Washington, District of Columbia

Habib Benzian, DDS, PhD
Director
The Health Bureau Ltd.
Buckingham, United Kingdom

Lecturer
Dental Public Health
University College
London, United Kingdom

Co-author
The Oral Health Atlas