Dentistry

The oral health chapter in , second edition, focused on noncommunicable disease models for health systems (Bratthall and others 2006). The current chapter provides a complementary approach based on the definition of health care delivery as the “effective provision of services to people with diseases for which proven therapies exist” (Kim, Farmer, and Porter 2013, 1060–61). These complementary approaches—top down and bottom up, respectively—are both necessary; neither alone is sufficient to improve oral health. More specifically, we focus on the effective provision of preventive services and the implications of this goal for global policy changes, and the upstream value and economic choices that must be made to effect these positive changes. Oral health maladies can be divided into four categories: Largely preventable bacterial or viral infections, for example, caries, periodontitis, noma, as well as oral manifestations of HIV/AIDS. Largely preventable cellular transformations, for example, oral cancer. Congenital defects, for example, cleft lip and cleft palate. Trauma. This chapter addresses the first category—the largely preventable bacterial infections of caries, periodontitis, and noma. It does not specifically address oral-systemic interactions or associations. The other maladies in the remaining three categories are addressed in other chapters and volumes in this series. We identify evidence-based, cost-effective, preventive interventions that community health care workers can deliver at the community level. These same workers provide better sanitation and clean water, as well as treat a range of diseases, such as diabetes, helminthiasis, HIV/AIDS, malaria, malnutrition, and tuberculosis. These community-based preventive interventions for oral health will increase access to care, improve health, and reduce the burden of disease and the costs of care, compared with traditional surgical approaches to care. However, in low- and middle-income countries (LMICs), access to the identified services, as well as the financial resources and infrastructure to deliver them, vary. Accordingly, in the initial stages, stakeholders need to be very selective in the starting points. We specifically selected caries and periodontitis for the following reasons (Marcenes and others 2013): They are the first and sixth most prevalent global diseases. They are increasing in prevalence because of population growth and aging. They are largely preventable bacterial infections of epidemic proportions. Additional considerations include the following: Preventing and controlling these maladies will address the goals of the World Health Organization’s (WHO’s) Basic Package of Oral Care (Frencken and others 2002). Cost-effective preventive measures can be implemented globally (Benzian and others 2012). Multiple effective training, workforce, and care models are available to support global implementation (Mathu-Muju, Friedman, and Nash 2013; Nash and others 2012). However, cross-cultural applications will need to be validated. Like caries and periodontitis, noma is a preventable infection. Unlike caries and periodontitis, which have high prevalence but low morbidity and low mortality, noma has a low prevalence (approximately 0.0005 percent; 0.5 per 100,000), but very high morbidity and mortality (approximately 80 percent) (Marck 2003). We focus on the critical few preventive measures with demonstrated benefit based on the following: Multiple systematic reviews of human trials (caries and periodontitis). Multiple human trials exhibiting similar quantitative and qualitative directionality (caries, periodontitis, and noma). For clarity of purpose, we do not address the other prevention and treatment modalities for which there are no systematic reviews or for which results from human trials differ from one another. Although we address specific effective preventive measures for oral maladies, these maladies are but one reflection of social determinants of health and disease (Lee and Divaris 2014; Watt 2012; Watt and Sheiham 2012). Other factors include the following: Tobacco use (Benedetti and others 2013; Fiorini and others 2014; Walter and others 2012). Nutrition (Moynihan and Kelly 2014; Palacios, Joshipura, and Willett 2009; Ritchie and others 2002; Touger-Decker, Mobley, and American Dietetic Association 2007). Bidirectional impacts of oral and systemic health (Cullinan and Seymour 2013; Friedewald and others 2009a; Linden, Lyons, and Scannapieco 2013; Lockhart and others 2012).