Achieving oral health equity through evidence-informed approaches: past, present and future
‘Absence of evidence is not evidence of absence.’ This saying undisputedly holds true in the oral health field. Scientific advances and research in dentistry have been ensuring this domain maintains the momentum to keep up with general healthcare. From oral diseases being recognised as a major non-communicable disease to the global consensus to include oral health under universal health coverage,1,2 the success stories of this field are many.
The past
Remarkably, community water fluoridation transcends other dental public health achievements due to its strong evidence-based approach. Since 1938, when Dr. H. Trendley Dean tested his hypothesis that fluoride in drinking water prevents dental caries,3 there has been sufficient literature to show that this dental public health intervention is the most effective measure in achieving equity in oral health.4
Following several studies in various parts of the United States from the 1940s to 1960s, water fluoridation achieved unprecedented acceptance. Meanwhile, evidence from other parts of the world, like Britain, Brazil, Australia, Switzerland, Ireland and New Zealand, also strengthened Dean’s fluoride dental caries hypothesis.5 Community water fluoridation has been recognized as one of the 10 great public health achievements of the 20th century.
The present
Very little progress has been seen in global oral health equity since the introduction of water fluoridation in the early 20th century. The main reason behind this is the lack of political priority for oral health.6 This leads to persistent disparities in access to oral healthcare services, with vulnerable populations often experiencing the greatest barriers. With the increased burden of oral disease, the equity gap is now wider than ever.
Addressing these disparities may require substantial policy changes and investments, which requires political will. Advances have been made in public health interventions that are low cost and can be adapted to mass settings7 (e.g., pit and fissure sealants, atraumatic restorative treatment, school-based oral health education and supervised tooth brushing programs, as well as involvement of community health workers for oral health promotion8). But even with great strides in preventive dentistry and the availability of low-cost, high coverage interventions, very few developed countries have incorporated this into public health practice. One factor contributing to this situation might be that, with the exception of water fluoridation, none of the other interventions were able to accumulate sufficient high-quality evidence to support a policy change.
This underscores the critical importance of robust research evidence that can be synthesized and effectively implemented. There is a pressing need to train dental researchers in the art of generating and applying such evidence, a task that demands specialized technical knowledge. Organizations dedicated to evidence-based healthcare, like JBI, can play a pivotal role in accomplishing this mission. Additionally, the dearth of best practice guidelines and evidence summaries for dental health interventions further compounds the problem, hindering informed dental practice.
JBI offers valuable methodology guidance for various types of systematic reviews9 and evidence implementation.10 It is imperative to educate practicing dentists about these resources to enable evidence-informed, clinical decision-making.11 Moreover, policymakers must be enlightened about the current burden of oral diseases, which can be achieved through systematic reviews of prevalence and incidence. The journey towards global oral health equity has been hindered by political apathy and insufficient evidence for effective interventions.
The future
The future is not bleak though. Oral health is being discussed in global forums, with the World Health Organization releasing its Global Strategy for Oral Health,12 the FDI World Dental Federation with its Vision 2030 report13 and The Lancet publishing a series on oral health.14 This will enable further research in oral health and contribute to new evidence, especially in the health systems and policy domains. The definition of oral health has been rewritten and it now provides a more broader outlook unlike the traditional narrative, which was based on a bio-medical model of health.15
Two major barriers to translating evidence into policy are the treatment-focused approach of dentistry, and oral health/dentistry being looked upon as a stand-alone entity.16 With a growing body of evidence, there has been a renewed understanding of prevention and control of oral diseases. Synthesized evidence in the form of systematic reviews and meta-analyses, clinical practice guidelines and implementation research have increased substantially in the past few years, paving the way for their contribution to practice and policies. Achieving a common ground for all stakeholders is also a challenge in developing and implementing policies. Despite differences in type of evidence required to inform practice and policy, both play an important role and thus must be aligned.15
To reduce the growing burden of common and preventable oral diseases, like dental caries and periodontal disease, we need to formulate new policies and reorient health systems based on the latest evidence. Several institutions17,18 work to provide equitable oral health globally and link evidence to policy. Thus, with high quality evidence and stakeholder consensus, equity in oral health (once considered a distant dream) could be a closer reality.
Authors
Venkitachalam Ramanarayanan, Vineetha Karuveettil, Parvathy Balachandran, Chandrashekar Janakiram
Amrita Centre for Evidence Based Oral Health: A JBI Affiliated Group, Ernakulam, Kerala, India
References
1. Petersen PE, Baez RJ, Ogawa H. Global application of oral disease prevention and health promotion as measured 10 years after the 2007 World Health Assembly statement on oral health. Community Dent Oral Epidemiol. 2020;48(4):338–48.
2. FDI. Universal health coverage [internet]. FDI; n.d. [cited 2023 Sep 19]. Available from: https://www.fdiworlddental.org/universal-health-coverage.
3. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep. 1938;53(33):1443–52.
4. National Institute of Dental and Craniofacial Research. The story of fluoridation [internet]. NIH; n.d. [cited 2023 Sep 20]. Available from: https://www.nidcr.nih.gov/health-info/fluoride/the-story-of-fluoridation.
5. Ward JW, Warren C, editors. Silent victories: the history and practice of public health in twentieth-century America. Oxford University Press; 2007. 484 p.
6. Benzian H, Hobdell M, Holmgren C, Yee R, Monse B, Barnard JT, et al. Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J. 2011;61(3):124–30.
7. Innes NPT, Chu CH, Fontana M, Lo ECM, Thomson WM, Uribe S, et al. A century of change towards prevention and minimal intervention in cariology. J Dent Res. 2019;98(6):611–17.
8. Soares RC, da Rosa SV, Moysés ST, Rocha JS, Bettega PVC, Werneck RI, et al. Methods for prevention of early childhood caries: overview of systematic reviews. Int J Paediatr Dent. 2021;31(3):394–421.
9. Aromataris E, Munn Z. JBI Manual for Evidence Synthesis [internet]. JBI, 2020 [cited YYYY MMM DD]. Available from: https://synthesismanual.jbi.global.
10. Porritt K, McArthur A, Lockwood C, Munn Z. JBI Handbook for Evidence Implementation [internet]. JBI, 2020 [cited YYYY MMM DD]. Available from: https://implementationmanual.jbi.global.
11. Tandon C, Singh PK, Singh I, Verma SC. Evidence-based dentistry: effectual tool in decision-making. Indian J Dent Sci. 2019;11:180–4.
12. World Health Organization. Draft global oral health action plan (2023–2030) [internet]. WHO; 2022 [cited 2023 Sep 19]. Available from: https://www.who.int/publications/m/item/draft-global-oral-health-action-plan-(2023-2030).
13. Glick M, Williams DM. FDI Vision 2030: delivering optimal oral health for all. Int Dent J. 2021;71(1):3–4.
14. Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S, et al. Ending the neglect of global oral health: time for radical action. Lancet Lond Engl. 2019;394(10194):261–72.
15. Listl S, Baltussen R, Carrasco-Labra A, Carrer FC, Lavis JN. Evidence-informed oral health policy making: opportunities and challenges. J Dent Res. 2023;00220345231187828.
16. Verdugo-Paiva F, Bonfill X, Ortuño D, Glick M, Carrasco-Labra A. Policymakers’ perceived barriers and facilitators in the use of research evidence in oral health policies and guidelines: a qualitative study protocol. BMJ Open. 2023;13(2):e066048.
17. NCD Alliance. Center for Integrative global oral health [internet]. NCD Alliance; 2022 [cited 2023 Sep 19]. Available from: https://ncdalliance.org/center-for-integrative-global-oral-health.
18. NYU Dentistry. NYU Dentistry Center for Oral Health Policy and Management [internet]. NYU Dentistry; n.d. [cited 2023 Sep 19]. Available from: https://dental.nyu.edu/content/nyudental/en/research/cohpm.
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
