Oral health is paramount to overall health and well-being, yet inequalities in oral health continue to pose a major threat to global public health. To strengthen health in the United States, it is essential that we recognize the factors driving the unequal burden of oral disease and leverage advances in science and technology to guide responses. A new report from the National Institutes of Health,1 which was compiled by the National Institute of Dental and Craniofacial Research, aims to address these issues and provide solutions.
In 2000, Oral Health in America: A Report by the Surgeon General affirmed the importance of oral health for overall health and captured the attention of researchers, policy makers, practitioners and the general public. Although the past two decades have seen progress in this area, dental and oral diseases remain problematic for many Americans. According to the Centers for Disease Control and Prevention (CDC), 47% of American adults age 30 or older have periodontal disease. Human papillomavirus (HPV)-associated oropharyngeal cancer has become more common than HPV-associated cervical cancer, with men more than five times more likely to be affected than women. Nine out of 10 adults between the ages of 20 and 64 have had tooth decay, a figure that hasn’t changed significantly over the past 20 years. Caries of permanent teeth is still among the most common childhood diseases. Untreated carious lesions cause bone and soft tissue pain and infection, perpetuating the cycle of lost productivity and the use of emergency services instead of preventive care.
We believe that a reform agenda should include strategies to address high costs and inequity in access to oral health care. Over the past 20 years, dental costs per person have increased by 30% in the United States; in 2018, Americans paid $55 billion in dental costs, which accounted for more than 25% of all healthcare spending. The greatest burden of dental and oral disease, nationally and globally, is borne by marginalized and chronically underserved populations.2
The Covid-19 pandemic has highlighted the need to re-examine health and well-being through the lens of social and systemic determinants. The groups that have been most affected by SARS-CoV-2 in the United States appear to be the same groups that have disproportionately high rates of oral disease. The oral cavity is a potential site of SARS-CoV-2 infection and a site of Covid-19 symptoms,3 and impaired immune status in people with periodontal disease may make oral tissues more prone to SARS-CoV-2 infection. Such observations support the long-standing argument that the connections between the oral cavity and other body systems require better integration of health care delivery practices. Covid-19 has permanently affected the delivery of care and exacerbated existing inequalities. Moving forward, we must chart a course for oral health care that prioritizes overall health, prevention, expanding access, affordability and equity.
Communities disproportionately affected by oral disease often have limited access to health services. Policy changes are needed to integrate oral health, medical and behavioral care and preventive services into community health centers, schools, assisted living facilities, primary health care facilities and dental clinics. Access to care has improved for children from low-income families thanks to strengthened collaborations between oral health professionals and paediatricians. Examples of these collaborations include promoting dental visits in the first 3 years of life, conducting well-designed risk assessment studies for dental disease, and the use of fluoride sealants and varnishes – expenses covered by Medicaid and the Children’s Health Insurance Program. Along with broad policy initiatives such as fluoridation of public water supplies, these integrative approaches have the greatest potential to mitigate oral diseases of high public health importance and should be reinforced in health care programs. education and training of health professionals.4
Collaboration between communities, dental professionals and other clinicians is essential to eliminate inequities that impede access to culturally appropriate care.5 Community leaders are experts on the needs of their people and should be included in the planning, design and implementation of oral health care systems. One area where community engagement is particularly important is the intersection of dental care and opioid abuse. For many people, especially adolescents and young adults undergoing wisdom tooth extraction, their first exposure to opioids occurs during oral surgery. Although dental practitioners have changed their opioid prescribing practices significantly over the past 20 years, opioid prescriptions remain common when patients seek treatment for dental problems in hospital emergency departments. This phenomenon reflects the need for expanded, affordable and equitable access to routine dental care, especially in vulnerable communities. Opioid use disorder continues to be a serious public health concern: CDC data indicates that in the 12 months ending April 2021, more than 100,000 Americans died of drug overdose, an increase of almost 30% over the previous year.
Tobacco and other inhalants and consumables can cause oral cancer, periodontal disease and other oral health problems. Additionally, the relationship between mental health and oral health deserves further investigation. People with schizophrenia, other psychoses and bipolar disorders have particularly high rates of gum disease and cavities and are three times more likely than people without mental disorders to become toothless. Prevention and treatment of oral diseases precipitated by mental disorders requires an understanding not only of the oral cavity, but also of overall health and the environmental, psychosocial and behavioral factors that shape health and well-being.
Over the past 20 years, science has transformed our understanding of the molecular and cellular mechanisms that underlie disease and sparked clinical applications that improve health and prevent disease. Recently proposed government initiatives are poised to propel “use-driven” research, which aims to solve practical, real-world public health problems. These approaches could lead to interventions aimed at preventing, detecting and treating complex diseases such as diabetes, cancer and Alzheimer’s disease. Such innovation could also help reduce inequities and improve the accuracy of oral health care. Recent advances in science and technology provide opportunities to tailor oral health care based on a person’s genomic, environmental, and socioeconomic risk factors.
A better understanding of oral and gut microbiomes, combined with other “omics”, will provide the basis for therapies such as probiotics and mouthwashes that can be used to treat oral microbial ecosystems and biofilms associated with disease and in create healthier ones. In-depth phenotyping approaches that integrate clinical data, digital biomarkers, imaging, tissue and biological sample analyses, and advanced analytics could improve prevention and health promotion efforts, prognoses, and treatment of hereditary and acquired dental, oral and craniofacial diseases.
Advances in research cannot be isolated. It is essential that we mobilize people and communities to address the social, economic and environmental determinants of poor oral health, such as lack of access to healthy food. At the same time, health care systems should recognize inequalities in oral health care and other services and resources in the context of the complex challenges that affect marginalized populations, including structural and interpersonal racism. To significantly improve oral health in the United States, policy changes are needed to reduce or eliminate social, economic, and other systemic inequities. Oral diseases are preventable, and social and other determinants of health must be considered in prevention and treatment strategies. Policy makers need to make oral health care more accessible, affordable and equitable. It will also be essential to diversify the country’s oral health workforce so that clinicians reflect the communities they serve, to meet the rising costs of educating and training the next generation of oral health professionals and to ensure a strong research enterprise dedicated to improving oral health. .
This century began with the recognition that oral health is central to overall health. Now it is essential that we build on this knowledge and the scientific advances we have made to ensure that oral health is fully integrated into this new era of discovery and to harness policy changes and technological advances to to break systemic inequalities. Only then will we truly improve the health of individuals, families and communities.
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