global trends in oral diseases with emphasis on 1
TRANSCRIPT
1
GLOBAL TRENDS IN ORAL DISEASES WITH EMPHASIS ON LAST TWO DECADES
Dr.Priyanka Sharma
II year MDS
Dept of Public Health Dentistry
JSS Dental College & Hospital
2
CONTENTS
1. Introduction
- Definition
- Brief overview on Epidemiology
2. Global goals for oral health 2020
- Goals
- Objectives
- Targets
3. Public health aspects of oral diseases and disorders:
- Dental caries
- Periodontal diseases
3
- Oral cancer and oro-pharyngeal cancer
- Trauma
- Erosion
- Dento-facial anomalies and orthodontic treatment needs
- Dental fluorosis
- Noma
- HIV – Oral manifestations
4. Oral health inequality
5. Concept of global health
5. Conclusion
6. References4
INTRODUCTION
Health : WHO 1948 defined as “a state of complete physical, mental and
social well being and not merely the absence of disease or infirmity.”
Oral health is a state of being free from chronic mouth and facial pain,
oral and throat cancer, oral sores, birth defects such as cleft lip and palate,
periodontal disease, tooth decay and tooth loss, and other diseases and
disorders that affect the oral cavity. Risk factors for oral diseases include
unhealthy diet, tobacco use, harmful alcohol use, and poor oral hygiene.
- WHO (2014)
5
Global trend is based on the combination of researches on various oral
diseases and scientific developments as well as schemes for reducing
them.
The objectives of looking through the global trends :
- To give a world oral health picture by 2020.
- To show the main trends leading the world.
So that by the end, the dentists/investigators will be able to apply their
ideas/plans in a prospective trend.
6
Disease is a particular abnormal, pathological medical condition that
affects a part or whole organism and is associated with signs and
symptoms.
(EMBO reports VOL 5 | NO 7 | 2004|What is a disease?|Science
and society viewpoint)
Categories of oral diseases :
1) Dental caries and periodontal diseases, both of which are acquired
conditions.
2) Acquired oral conditions other than DC and Periodontal diseases such as
oral cancer, HIV/AIDS and opportunistic infections.
3) Craniofacial disorders (conditions ranging from hereditary to accidents)
- [Primary preventive dentistry book – Norman O Harris- 8th edi]
7
In order to call a disease a public health problem, one should know
the followings :
1) Is the disease widespread?
2) Is the disease increasing?
3) What individual or group to be susceptible?
4) What causes it?
5) Can it be prevented?
6) Impact of disease on individual and society?
The epidemiology of oral diseases can provide some details.
- [Essentials of Public Health, Daly & Watt,2002]
Hence, methods for assessing the distribution of oral diseases is
“EPIDEMIOLOGY”.
8
EPIDEMIOLOGY
Definition : epidemiology has been defined by John. M. Last in 1988 as
“the study of the distribution and determinants of health-related quality
of states or events in specified populations, and the application of this
study to the control of health problems.”
Aim of epidemiology:
1. To describe the distribution and size of diseases in human population.
2. To identify etiological factors in the pathogenesis of disease.
3. To provide data essential to the planning, implementation and
evaluation of services for the prevention, control and treatment of
disease.
9
GLOBAL GOALS FOR ORAL HEALTH 2020
FDI and WHO had set goals in 1981 for the year 2000.
Recently FDI,WHO and IADR have embarked on the activity of preparing goals
for the new millennium , for the year 2020.
Aim: To provide a framework for healthy policy makers at different levels –
regional, national and local.
By being focused broadly on global level, it is hoped that it will encourage
local action in the spirit of the United Nations Development Programme’s
report : ‘Think globally act locally’.
Hence, its an instrument for local and national health care planners to specify
realistic goals and standards for oral health to be achieved by the year 2020.
[International Dental Journal (2003) 53, 285–288]
10
OR
AL
HEA
LTH
2020
GOALS
OBJECTIVES
TARGETS
11
GO
ALS
To minimize the impact of oral diseases of
oral and craniofacial origin on health and
psychosocial development, giving emphasis
to promote oral health and reducing oral
disease amongst populations with greatest
burden of such conditions and diseases.
To minimize the impact of oral and
craniofacial manifestations of systemic
diseases on individuals and society and to
use these manifestations for early diagnosis,
prevention and effective management of
systemic diseases.
12
OBJECTIVES
To reduce mortality from oral
& craniofacial diseases
To reduce morbidity, thereby
increase the quality of life
To promote sustainable,
priority driven policies and
programs
To develop accessible cost
effective oral health system
To integrate oral health
promotion and care with the
other sectors that influence
health, using the common
risk factor approach
To develop the oral health
programs that will empower
people to control
determinants of health
To strengthen systems and
methods for oral health
surveillance, both processes
and outcomes
To promote social
responsibility and ethical
practices of care givers
To reduce disparities in oral
health between different SE
groups within a country and
inequalities in oral health
across countries
To increase the number of
health care providers who
are trained in accurate
epidemiological surveillance
of oral diseases and
disorders
13
TARGETS
Functional
disordersPain
Infectious
diseases
Oro-pharyngeal
cancerNoma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
14
PUBLIC HEALTH ASPECTS OF ORAL DISEASES AND DISORDERS
Functional
disordersPain
Infectious
diseases
Oro-pharyngeal
cancerNoma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
15
DENTAL CARIES :
Definition: According to Shafer, Hine, Levy : is defined as a progressive,
irreversible microbial disease of multifactorial nature, affecting the calcified
tissues of the teeth, characterized by demineralization of the in-organic
portion and destruction of the organic portion of the tooth.
Epidemiology :
There have been dramatic changes in the pattern and distribution of
dental caries in children and adults over the past 20 years.
WHO global data bank confirms a decline in the prevalence of dental
caries in children and adolescents in developed countries and there is an
increase in some developing countries. (2004)
16
Distribution of caries in the world
17Oral Health Care – Pediatric, Research, Epidemiology and Clinical Practices;2012
average
worldwide
DMFT
SCORE was
2.11 (± 1.32)
1.8 teeth
decayed,
missing or
filled
Values
ranged from
0.2 to 7.8
Dental decay in
children is relatively
more prevalent in
the Americas and
in the European
Region, according
to the WHO Global
Oral Health
Databank.
Global Health Education Consortium | 2009]
18
Dental caries experience (DMFT*) of 12-year olds according to WHO regional offices - 2000
DMFT* (= Decayed, Missing, Filled teeth)
Show similar pattern
(AFRO: African; AMRO:
the Americas; EMRO:
Eastern Mediterranean;
EURO: European;
SEARO: Southeast Asian;
WPRO: Western Pacific).
Global Health Education Consortium | 2009]
19
All data – all yearsCaries - Prevalence (%) for 12 years old -http://www.fdiworldental.org/data-hub/map-for-all-years.aspx
United state of America 2004 51% (National health & nutritional examination survey)
Canada 2010 39% (Malmoe university)
Brazil 2010 57%
Columbia 2010 70%
Bolivia 1995 88%
Mongolia 2012 81% (national survey 2012)
Russian federation 2008 73%
Finland 2009 74%
Sweden 2011 65%
20
France 2006 61%
Norway 2013 44% (Norwegian dental association)
Spain 2010 45%
China 2005 29%
Australia 2007 39%
Pakistan 2011 51%
Iran 2004 60%
Iraq 2003 62%
Turkey 2005 61%
Egypt 2003 28%
Libya 2008 58%
Thailand 2012 49%
Myanmar 2009 15%
Indonesia 2007 36%
21
Saudi Arabia 2002 5.9
Peru 2002 3.7
Indonesia 2013 4.5
Australia 2009 1.4
India 2003 2.2
Pakistan 2011 3.1
22
Dental caries trends in 12-year-olds
In most developing countries,
dental caries levels have been
low until recent years.
However, with the growing
consumption of sugar in the
developing world as a result of
westernization, the levels of
dental decay are likely to rise.
However, an opposite trend
has been observed in
industrialized countries where
effective public health
measures such as appropriate
use of fluoride have been
implemented.
Global Health Education Consortium | 2009]
23
At present, distribution and severity of caries vary in different parts of the
world and within the same region or country.
In most developing countries the level of dental caries were low until
recent years but prevalence rate are tending to increase.
This is due to increased uptake of sugar and inadequate exposures to
fluorides.
In contrast a decline in caries has been observed in most industrialized
countries over past 20 years.- [ Bulletin of WHO | Sept 2005|83(9) ]
24
This pattern was the result of a no. of public health
measures, including effective use of fluorides, together
with changing living conditions, lifestyles and
improved self care practices.
However , dental caries in children has not been
eradicated , but only controlled to a certain degree.
- [ Bulletin of WHO | Sept 2005|83(9) ]
25
26
MEAN dfs SCORES OF CHILDREN AGE 2–11 YEARS AND FEDERAL POVERTY LEVEL STATUS: US, 1988–1994 AND
1999–2004
27
PREVALENCE OF DENTAL SEALANTS ON PERMANENT TEETH FOR 6–11 YEARS OF AGE AND FEDERAL POVERTY
STATUS LEVELS: US, 1988–1994 AND 1999–2004
28
DMFT FOR ADOLESCENTS 12–19 YEARS OF AGE AND POVERTY STATUS: US, 1988–1994 AND
1999–2004
Worldwide the prevalence of dental caries among adults is high as the
disease affects nearly 100% of the population in majorities of the
countries.
Most industrialized countries and countries of Latin America shows high
DMFT values(14 teeth or more), where as levels of dental caries
experiences are much lower in developing countries.
- [ Bulletin of WHO | Sept 2005|83(9) ]
29
WHO Region of South East Asia (SEARO)
30
The DMFT
index showed
an average of
1.95 (± 1.24)
and a median
of 1.65.
The minimum
and
maximum
values were
0.50 to 3.94,
respectively.
Indian scenario :
Dental caries have been constantly increasing both in prevalence and severity from past 5 decades.
31
32
STUDIES REPORTING DMFT IN 12 YEAR OLDS FROM DIFFERENT STATES OF INDIA DURING 1986
TO 2005
WHY IS IT DECLINING IN DEVELOPED COUNTRIES
• The decline of dental caries started in both fluoridated and non-fluoridated areas .
• Water fluoridation started in 1945 in USA.
• Other preventive program were initiated in 1950s and 1960s.
• Fluoride toothpaste was introduced in 1960s and was being used extensively from 1970s onwards.
33
WHY IS IT INCREASING IN DEVELOPING COUNTRIES
Diets rich in sugars
Neglected oral hygiene
Less or no use of fluorides
Limited health services
No preventive measures
Lack of awareness
Reason for urbanized population having more caries in developing countries:
They consume refined sugar comparatively more than the rural population.
- [C.M.Marya,Textbook of Public Health Dentistry,Edi 1]
34
Functional
disordersPain
Infectious
diseases
Oro-pharyngeal
cancerNoma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
35
PERIODONTAL DISEASES
Is an inflammatory disease of the supporting tissues of the teeth caused
by specific microorganisms or groups of specific micro organisms,
resulting in progressive destruction of the periodontal ligament and
alveolar bone with pocket formation, recession or both.
-[ Carranza book of periodontology]
36
Gingivitis : Is inflammatory process of the gingiva in which the junctional epithelium, although altered by the disease, remain attached to the tooth at its original level.
Periodontal diseases : periodontitis describes a group of inflammatory diseases that affects all the periodontal structures. It results in the destruction of the attachment apparatus and the development of a periodontal pockets.
-[C.M.MARYA-Textbook of public health dentistry-2011]
37
Classification of Periodontal diseases
Workshop 1999 (Armitage GC 1999)
38
Host Agent Environment
•Age
•Sex
•Race/Ethnicity
•Genetics
•Intra-oral variations
•Endocrine changes
•Local host factors
•Occupational habits
and neuroses
•Concomitant disease
•Emotional disturbance
•Bacteria
•Plaque
•Calculus
•Chemical and physical
hazards
•Geographic areas
•Nutrition
•Fluoride
•Degree of urbanization
•Education
•Socio economic status
•Cultural factors
•Professional dental care
Epidemiological triad
39
Etiologic factors
Local factors
Deposits in teeth
Abnormal habits
Food impaction
Non detergent diet
Other irritants
Abnormal anatomy
Abnormal occlusion
Systemic factors
Faulty nutrition
Debilitating disease
Blood dyscrasias
Endocrine dysfunction
Allergies and drug idiosyncrasies
Psychogenic factors
Iatrogenic factors
40
Forms of Periodontitis
Chronic adult Periodontitis
Rapidly progressive Periodontitis Type A
Rapidly progressive Periodontitis Type B
Juvenile Periodontitis
Post juvenile Periodontitis
Prepubertal Periodontitis
-Over 26 years
- 14 – 26 years
- Over 26 years
-12 – 26 years
-26 – 35 years
-Under 14 years
Age
41
Epidemiology of Periodontal diseases
Current concept in relation to periodontal diseases have changed
considerably in past 20-30 years.
The traditional ‘progressive’ disease model has been replaced by the
‘burst theory’.
i.e.) periodontal diseases have sudden burst of activity followed by long
periods of remission and healing [Goodson et al 1982,Socransky et al
1984].
For the majority of population periodontal progression is slow [Pilot
1997].
Only 5% of population experience destructive periodontal diseases and
this is declining [Burt 1988].42
Inte
rnatio
nal E
ncy
clopedia
of P
ublic H
ealth
, First E
ditio
n (2
008), v
ol. 4
, pp
.
677-6
85
43
Tooth loss in adult life may also be attributable to poor periodontal
health. Severe periodontitis, which may result in tooth loss, is found in 5%
to 20% of most adult populations worldwide.
The prevalence of symptoms of disease among 35- to 44-year-olds by
WHO region (Petersen, 2003; WHO, 2004; Petersen and Ogawa, 2005),
using the so-called Community Periodontal Index is given.
Score 0 - individuals with healthy periodontal conditions;
Score 1 - individuals with bleeding from gums;
Score 2 - individuals with bleeding gums and calculus;
Score 3 - individuals with shallow periodontal pockets (4–5mm);
Score 4 - individuals with deep periodontal pockets (6mm or more).
Inte
rnatio
nal E
ncy
clopedia
of P
ublic H
ealth
, First E
ditio
n (2
008), v
ol. 4
, pp
.
677-6
85
44
Inte
rnatio
nal E
ncy
clopedia
of P
ublic H
ealth
, First E
ditio
n (2
008), v
ol. 4
, pp
.
677-6
85
45
Symptoms of periodontal disease are highly prevalent among adults
within all regions; furthermore, from a global perspective, most children
and adolescents have signs of gingivitis(WHO, 2004).
Aggressive periodontitis, a severe periodontal condition affecting
individuals during puberty and that may lead to premature tooth loss,
affects about 2% of youth (Albander, 1997).
Inte
rnatio
nal E
ncy
clopedia
of P
ublic H
ealth
, First E
ditio
n (2
008), v
ol. 4
, pp
.
677-6
85
46
Consistent with previous reviews of literature on periodontal disease
trends , reviewed studies support the assumption that periodontal disease
prevalence is declining, though to a varying degree.
The precise magnitude of the decline is difficult to ascertain due to high
variability in periodontal disease definitions with sometimes questionable
methodological quality.
Thus, one should be cautious about drawing conclusions on any global
trends.
- [Is Periodontitis Prevalence Declining? A Review of the Current
Literature; Birte Holtfreter et al. Curr Oral Health Rep.Springer
Sept 2014]
47
Contribution of Periodontal Trends to Improved Tooth Retention : Given that the majority of studies reported a marked decline in periodontal disease prevalence, this decline might have partially contributed to positive developments in tooth retention, though to a minor degree compared with
caries.
Interpretation of Trend Data with Regard to the Whole Population : For future resource planning and estimation of future periodontal treatment needs, two aspects need to be considered. Reasoning on the increasing number of teeth with periodontal treatment needs and the expected demographic changes, we will probably face higher treatment demands in the future, which will, in turn, present a major challenge for health policy planners.
Trends in Periodontal Risk Factors : Periodontal diseases commonly share various modifiable risk factors related to lifestyle. These risk factors mainly include oral hygiene and care, smoking, diabetes and obesity. changes in periodontal disease prevalences also depend on time trends of modifiable periodontal risk factors. And, indeed, declining prevalences of smoking, especially in men, improved dental hygiene and care, and improved social conditions might have contributed to the declining prevalence of periodontitis. Consequently, there is a high potential to benefit from prevention measures aimed at common risk factors.
48
J Ind
ian
So
cPerio
do
nto
l. 2011 Ja
n-M
ar; 1
5(1
): 29–34.
Various epidemiological studies in India
49
Risk factors of periodontal disease
Host factors
1. Age… directly proportional to age
2. Sex… males > females
In juvenile Periodontitis… females > males
3.Race
National Health survey - Blacks > whites
Spanish Americans had more severe periodontal disease than blacks & whites.
4. Place of residence : Higher in rural areas
5. Diet
More in vegetarians than non vegetarians as they tend to consume more carbohydrate containing sticky foods.
50
6. Education & occupation
Inversely proportional to education.
Lower in office personnel than factory workers.
7. Socioeconomic status
Higher in lower SES and lower income groups
Due to…… high cost of dental services
poor diet
poor oral hygiene status
lack of dental awareness.
51
8. Geographic area
India has highest prevalence of periodontal disease.
Russel classified world population into 3 groups
a. Relatively high group…. Chile, Lebanon, Jordan, Thailand, Burma
Vietnam, Malaya, Ceylon, India & Trinidad
b. Intermediate group… US black population, Ecuador, Columbia & Ethiopia.
c. Relatively low groups… US white population, primitive Eskimos of Alaska.
9.Nutrition
Vitamin A, B, C, D, calcium & phosphorus are associated with periodontal tissues.
In areas of vitamin A deficiencies & protein calorie malnutrition - Higher prevalence
Nutrition is a secondary factor.
52
10.Oral hygiene practices
1/3rd of Indian population uses tooth brush & tooth paste
50% of tooth brush users are not aware of proper brushing techniques & other oral hygiene aids like dental floss
11.Emotional disturbances
Directly proportional to periodontal disease
12.Psychological & cultural factors
Anxiety & fear about dental treatment
Misconceptions & taboos
Harmful cultural habits like chewing tobacco, betel chewing, severe smoking
etc.
13.Professional dental care
Incidence & severity is lower in individuals who receive regular dental care.
53
Functional
disordersPain
Infectious
diseasesOral cancer Noma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
54
ORAL CANCER
Cancers of the oral cavity and oropharynx are among the most common cancers worldwide, with an estimated 400,000 incident cases and 223,000 deaths during 2008.
Tobacco and alcohol are strong risk factors.
HPV is an established cause of OPC (including the tonsil, base of the tongue, and other parts of the pharynx) whereas its etiologic role in OCC is unclear.
The incidence of OCC has declined in recent years in most parts of the world, consistent with declines in tobacco use.
In contrast, OPC incidence has increased over the last 20 years in several countries, including Australia, Canada, Denmark, the Netherlands, Norway, Sweden, the United States, and the United Kingdom.
- [J Clin Oncol 31. © 2013 by American Society of Clinical Oncology]
55
The prevalence of oral cancer is particularly high among men , the eight most common cancer worldwide.
The incidence rate of oral cancer vary in men from 1 to 10 per 100000 population in many countries.
In USA cancer of the oral cavity comprises approximately 30% head and neck region tumors and 3% of all cancer.
In South central Asia, oral cancer ranks among 3 most common types.
The cancer epidemic in developed countries and increasingly in developing countries is due to combined effects of ageing of populations and high and increasing levels of prevalence of cancer risk factors.
It has been estimated that 43% of cancer deaths worldwide are due to tobacco use , unhealthy diet, physical inactivity and infections.
- [J Clin Oncol 31. © 2013 by American Society of Clinical
Oncology]
56
-[J C
linO
nco
l31. ©
2013 b
y A
merica
n S
ocie
ty o
f Clin
ical O
nco
logy]
57
Incidence of
oral cavity
cancer among
males (age-
standardized
rate (ASR)
per100 000
world
population).
Green ≤ 3.2
yellow3.3-6.8
Pink≥6.9
White No data
available
Petersen PE (2003) The World Oral Health Report 2003: Continuous improvement of oral health in the 21st
century – the approach of the WHO Global Oral Health Programme. Community Dentistry and Oral
Epidemiology 31(Suppl 1): 3–24; WHO (2004) Global Oral Health Data Bank. Geneva, Switzerland: WHO.
58
Incidence of
oral cavity
cancer among
females (age-
standardized
rate (ASR) per
100 000 world
population
Green ≤ 3.2
yellow3.3-6.8
Pink≥6.9
White No data
available
Petersen PE (2003) The World Oral Health Report 2003: Continuous improvement of oral health in the 21st
century – the approach of the WHO Global Oral Health Programme. Community Dentistry and Oral
Epidemiology 31(Suppl 1): 3–24; WHO (2004) Global Oral Health Data Bank. Geneva, Switzerland: WHO.
59
Incidence increases with age , 80% aged 50 and above [Cancer research compaign 2012]
In India carcinoa of tongue in males is more common. 14.6 incidence rate.
In UK tongue is the most common site , while floor of the mouth ranks second.
According to Cancer research compaign 2012, age-standardized European rates have increased by 25% in men and 28% in women.
Treatment : while progress has been made in the treatment of oral cancers, survival rates have improved only slightly.
Survival is higher for early detection.
5 years survival rate for oral cavity is 55% for women and 48% for men.
-[Daly and Watt]
60
Implications for the future of trends in oral cancer :
It would appear that incidence and mortality rate for oral cancer may have increased.
The best strategy for the future would appear to lie in the early detection of oral cancers and health promotion activities aimed at reducing the consumption of alcohol and tobacco products.
61
Functional
disordersPain
Infectious
diseasesOral cancer Noma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
62
Oro-Dental Trauma
In contrast to dental caries and periodontal disease, reliable data on the
frequency and severity of oro-dental trauma are still lacking in most
countries, particularly in developing countries (Andreasen and Andreasen,
2002).
`Some countries in Latin America report dental trauma in about 15% of
schoolchildren, while prevalence rates of 5% to 12% are found in children
aged 6 to 12 years in the Middle East.
63
Furthermore, studies from certain industrialized countries have revealed
that the prevalence of dental traumatic injuries is on the increase, ranging
from 16% to 40% among 6-year-old children and from 4% to 33% among
12- to 14-year-old children (Andreasen and Andreasen, 2002).
A significant proportion of dental trauma relates to sports, unsafe
playgrounds or schools, road accidents, and violence
- [Petersen P E Oral Health. In: Kris Heggenhougen and Stella Quah,
editors International Encyclopedia of Public Health, Vol 4. San Diego:
Academic Press; 2008. pp. 677-685.]
64
Functional
disordersPain
Infectious
diseasesOral cancer Noma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
65
Noma – Cancrum Oris
Noma, a debilitating oro-facial gangrene, is an important disease burden
in many developing countries, particularly in Africa and Asia (Figure 8)
(Petersen, 2003).
Noma primarily begins as a localized gingival ulceration and spreads
rapidly through the oro-facial tissues, establishing itself with a blackened
necrotic center (Enwonwu, 1995).
About 70% to 90% of cases are fatal in the absence of care. Fresh noma is
seen predominantly in the age group 1–4 years, although late stages of
the disease occur in adolescents and adults.
Poverty is the key risk condition for development of noma; the
environment inducing noma is characterized by severe malnutrition and
growth retardation, unsafe drinking water, deplorable sanitary practices,
residential proximity to unkempt animals, and a high prevalence of
infectious diseases such as measles, malaria, diarrhea, pneumonia,
tuberculosis, and HIV/AIDS.
66
Cases of noma
(cancrum oris)
reported
around the
world
Orange-Cases
reported before 1980
Violet- Cases
reported 1981–1993
Green- Cases
reported 1994–2000
Stars- Sporadic cases
recently reported
67
Dental Erosion
Dental erosion is the progressive, irreversible loss of dental hard tissue
which is chemically etched away from the tooth surface by extrinsic
and/or intrinsic acids.
Dental erosion appears to be a growing problem in several countries,
affecting 8% to 13% of adults (ten Cate and Imfeld, 1996), and increasing
levels are thought to be due to higher consumption of acidic beverages
(i.e., soft drinks, fruit juices).
Worldwide, there is a need for more systematic population-based studies
on the prevalence of dental erosion using a standard index of
measurement.
- [Petersen P E Oral Health. In: Kris Heggenhougen and Stella Quah,
editors International Encyclopedia of Public Health, Vol 4. San Diego:
Academic Press; 2008. pp. 677-685.]
68
Functional
disordersPain
Infectious
diseasesOral cancer Noma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
69
DEVELOPMENTAL AND CRANIOFACIAL ANOMALIES
Congenital diseases of the enamel or dentine of teeth, problems related
to the number, size, and shape of teeth, and craniofacial birth defects
such as cleft lip and/or palate (CL/P) are most important.
The incidence of CL/P varies tremendously worldwide. Native Americans
in North America show the highest incidence rates at 3.74 per 1000 live
births, whereas a fairly uniform incidence of 1:600 to 1:700 live births are
reported among Europeans (WHO, 2002).
70
The incidence rates appear high among Asians (0.82–4.04 per 1000 live
births), intermediate in Caucasians (0.9–2.69 per 1000 live births), and low
in Africans (0.18–1.67 per 1000 live births).
The causes of CL/P are complex, involving multiple genetic and
environmental risk factors. Risk factors such as folic acid deficiency,
maternal smoking, and maternal age have particularly been implicated in
the formation of clefts (WHO, 2002).
71
Malocclusion is not a disease but rather a set of dental deviations that in
some cases can influence quality of life.
Estimates of different traits of malocclusion are available from a number of
countries, primarily in Northern Europe and North America. For example,
prevalence rates of dento-facial anomalies in Northern Europe and North
America are reported at about 10%, according to the Dental Aesthetic Index
(Chen et al., 1997).
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Other conditions that may lead to special health-care needs include
Down syndrome, cerebral palsy, learning and developmental disabilities,
and genetic and hereditary disorders with oro-facial defects.
There is no consistent evidence of time trends in development disorders,
nor is there consistent variation by socioeconomic status, but these
aspects have not been adequately studied (WHO, 2002).
In addition, there are many parts of the world in which there is little or no
information available on the frequency of developmental disorders, in
particular, parts of Africa, Central Asia, Latin America, the Middle East, and
Eastern Europe.
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Functional
disordersPain
Infectious
diseasesOral cancer Noma
Oral
manifestations
of HIV infections
TraumaCraniofacial
anomalies
Developmental
anomalies of
teeth
Dental caries
Periodontal
diseases
Oral mucosal
diseases
Tooth lossSalivary gland
disorders
Health care
services
Health care
information
systems
Oral Health in HIV/AIDS
A number of studies have demonstrated the negative impact on oral health of HIV
infection (Coogan et al., 2005).
Approximately 40% to 50%of HIV-positive persons have oral fungal, bacterial, or viral
infections often occurring early in the course of the disease. Oral lesions strongly
associated with HIV infection are pseudo-membranous oral candidiasis, oral hairy
leukoplakia, HIV gingivitis and periodontitis, Kaposi sarcoma, and non-Hodgkin’s
lymphoma.
Dry mouth as a result of decreased salivary flow rate may not only increase the risk of
dental caries but negatively impact quality of life because of difficulty in chewing,
swallowing, and tasting food.
The need for oral health care in terms of immediate care and referral, treatment of
manifest oral disease, prevention, and health promotion is particularly high among the
under-served, disadvantaged population groups of developing countries, including HIV-
infected people (Coogan et al., 2005).
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Fluorosis of Teeth
Dental fluorosis develops during formation of teeth when children are young.
Drinking water with more than 1.5 ppm (parts per million) of fluoride can give
rise to enamel defects and discoloration of teeth leading to endemic fluorosis
in the population.
These may differ in intensity from mild to severe. For example, in East Africa,
in the Great Rift Valley area, and in some parts of India and north Thailand,
the groundwater has very high levels of fluoride. In such areas, dental
fluorosis may be found in the majority of people (WHO, 1994).
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Fluorosis of teeth can also occur in individuals in developed countries due
to widespread use of certain forms of fluorides for prevention of dental
caries, although the degree of fluorosis is mostly very mild when
compared with endemic fluorosis.
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The Economic Impact of Oral Disease
Traditional treatment of oral disease is extremely costly, the fourth most
expensive disease to treat in most industrialized countries. In industrialized
countries, the burden of oral disease has been tackled through establishment
of advanced oral health systems which primarily offer curative services to
patients.
Most systems are based on demand for care and oral health care is provided
by private dental practitioners to patients, with or without third-party
payment schemes. Some countries, including those of Scandinavia and the
United Kingdom, have organized public health services, particularly providing
oral health care to children and disadvantaged population groups.
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Traditional curative dental care is a significant economic burden on many
industrialized countries where 5% to 10% of public health expenditure relates
to oral health (U.S. Department of Health, 1998; Widstro¨m and Eaton, 2004).
Over the past years, savings in dental expenditures have been noted for
industrialized countries which have invested in preventive oral care and where
positive trends are observed in terms of reduction in the prevalence of oral
disease.
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In most developing countries, investment in oral health care is low. In
these countries, resources are primarily allocated to emergency oral care
and pain relief; if treatment were available, the costs of dental caries in
children alone would exceed the total health-care budget for children
(Petersen, 2003).
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ORAL HEALTH INEQUALITY
In documenting oral health needs, we in the oral health community face
the dual challenge of lack of awareness and poor understanding of the
extent and implications of oral, dental, and craniofacial diseases by the
general public, policy-makers, and funders of research.
Concerted efforts are needed to monitor and track oral diseases on a
global level, including documentation of their economic burden,
sequelae, and impact on quality of life using similar measures and
compatible systems.
[Adv Dent Res. May 2011; 23(2): 207–210]
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How do global disparities arises?
• “Differences in the quality of care received within the health care system
• Differences in access to health care, including preventive and curative services
• Differences in life opportunities, exposures, and stresses that result in differences in underlying health status.” [social and environmental determinants]
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Concept of Global Health
84
85
Global health
“Global health is an area for study, research, and practice that places a priority
on improving health and achieving equity in health for all people worldwide.
Global health emphasises transnational health issues, determinants, and
solutions; involves many disciplines within and beyond the health sciences
and promotes interdisciplinary collaboration; and is a synthesis of population
based prevention with individual-level clinical care.”
- Jeff rey P Koplan and al. Lancet 2009
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Journey to scale up NCDs including Oral Diseases– from individual disease programmes to integrated NCDs programme…
87
WHO Global NCD Action Plan 2013-2020
88
Principals of global health policy1.STEPS FOR DISEASE PREVENTION
1. Participation in tobacco control & actions against abusive alcohol consumption to prevent oral diseases, cancers & other health consequences.
2. Promotion of a healthy diet including a decrease in consumption of sugar, salt, fat & an increase in consumption of fruits & vegetables.
3. Promotion of legislation favourable to the production, distribution & accessibility to quality fluoride toothpaste.
4. Promotion of access to safe water & improved sanitation for proper oral hygiene.
5. Promotion of living & working environments conducive to healthy lifestyles.
6. Promotion of optimal exposure to fluoride
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2.Scale up universal access to oral diseases control at PHC
Early detection, diagnosis, and essential quality care delivered at
community and referral hospital level for all
Capacity building of health personnel in the control of oral diseases as
part of training in integrated NCD prevention and control at PHC
Development of essential interventions to prevent & treat oral diseases at
PHC
Production, distribution of affordable essential medical consumables &
drugs for the management of NCDs including oral diseases
Supporting innovative financing systems for oral health care including
move towards Universal health coverage
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3.Reinforce Oral Health information systems& surveillance of common risk factors
Generate quality data on oral health conditions to support advocacy,
planning and monitoring
Compilation of Oral Health Indicators as markers for health status, system
performance and process or available resources
Strengthening of national health information systems on NCDs, including
oral diseases
Integration of oral health components into existing NCD survey tools
(STEPS, NCD Country Capacity Surveys, GSHS,…)
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4.Build inter-sectoral actions
Successful efforts to tackle oral diseases should rely on a wide range of
government departments, key industries, civil society & the population.
Other areas include cross-cutting public policies involving transport,
education, sport & urban design to encourage physical activity &
comprehensive diet, alcohol and tobacco control measures to promote
healthy life style.
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5.Advocate for political leadership
Top-level political commitment is key for success
High level political support and strong leadership are critical for
sustaining progress.
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Oral health upstream measures :
Legislation, Regulation and Policies
– Fluoridation programs
– Prevention and Control of Non-communicable diseases (i.e.,
tobacco, food safety, labeling, advertising)
• Workforce and Prevention Programs
– Include oral health services as part of primary care, school
programs and prevention programs (i.e. HIV/AIDS, cancer
control, trauma prevention, immunization, nutrition)
• Surveillance and monitoring
– Incorporate oral health
• Multi-national Research
• Communication and Dissemination of Knowledge
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Caries Prevention Programs in Asia
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Fluoride Varnish Program Example
Adapt to local conditions, resources, community
needs and preferences
• Conduct in conjunction with immunization,
vitamin distribution, or other public health
program
• US programs – single unit dose FV application
packets often preferred
• Developing countries – concern about excess
trash, environmental impact
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CONCLUSION
Oral diseases are the major public health problems and are the fourth most
expensive to treat in most industrialized countries. Treatment of dental caries
in children alone would exceed the total child health care budget.
The greatest burden of all diseases is on the disadvantaged, socially
marginalised.
Education is the most powerful weapon which can be used to change the
world.
Trends and Ideas for Future Global Efforts by Making the benefits of
Information and Communications Technology available to all.
Newbrun in 1992 stated that “ the dentist of future will still have to treat
caries, but unquestionably the emphasis will be on early diagnosis and
preventive intervention. Times change and we change with time”.
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References
I. Garcia and L.A. Tabak. Global Oral Health Inequalities. Adv Dent Res. May 2011; 23(2): 207–210.
II. Anil K. Chaturvedi et al. Worldwide Trends in Incidence Rates for Oral Cavity and Oropharyngeal Cancers. J Clin Oncol 31. © 2013 by American Society of Clinical Oncology
III. Nanda Kishor KM. Public health implications of oral health – inequity in India. Journal of Advanced Dental Research VolI : Issue I: October, 2010
IV. Oral Health as an Essential Component of General Health.World Health Organization’s Strategic Orientations.5TH ADEA International women leadership conference.
V. Jane A. Weintraub. Reducing Global Oral Health Inequalities. National Oral Health Conference May 2, 2012
VI. Poul Erik Petersen. Challenges to improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. International Dental Journal (2004) 54, 329–343
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VII Rafael da Silveira Moreira (2012). Epidemiology of Dental Caries in the World,
Oral Health Care - Pediatric,
Research, Epidemiology and Clinical Practices, Prof. Mandeep Virdi (Ed.).
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