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GUEST EDITORIAL |
1 Division of Oral Medicine, Department of Odontostomatological and Maxillofacial Sciences, University of Naples "Federico II", Via Pansini n. 5, 80129, Naples, Italy; and
2 Oral Medicine, UCL Eastman Dental Institute, 256 Grays Inn Road, London, WC1X 8LD, UK
* corresponding author, mdmig{at}tin.it or mignogna{at}unina.it
KEY WORDS: chronic diseases • oral cancer • orofacial pain • oral diseases • periodontitis
As one of the most important independent and authoritative voices in global medicine, The Lancet is playing a unique and praiseworthy role in stimulating a global dialogue, involving health workers and policymakers, about the chronic disease burden worldwide. While representing a huge proportion of human illness, chronic diseases are surprisingly not among the eight Millennium Development Goals (Fuster and Voute, 2005). The new series of articles recently released by The Lancet are aimed at rectifying this omission and promoting the prevention of about 36 million deaths from chronic diseases as adjunctive global action on health during the next 10 years (Strong et al., 2005). The suggested goal consists of focusing efforts on the prevention and correction of risk factors for the four most prominent non-communicable chronic diseases: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes (Fuster and Voute, 2005; Horton, 2005).
We would like to comment on this issue, pointing out the important part that chronic diseases affecting the orofacial region play in the general group of human chronic diseases. We affirm that if the epidemic of chronic diseases is considered neglected (Horton, 2005), the burden of chronic orofacial diseases is even more neglected and needs particular consideration by health professionals, civil-society organizations, and policymakers because of several unique characteristics.
The global burden of oral diseases, in fact, has been outlined in a very recent Bulletin of the World Health Organization: The vast majority of diseases affecting the soft and hard tissues of the oral cavity, in fact, have a chronic nature, are strongly associated with socio-behavioral risk factors, and represent a larger problem in underprivileged groups in both developing and developed countries (Petersen et al., 2005). A first attempt at explaining the unique characteristics of oral diseases comes from epidemiological information available in WHO databanks. If only dental diseases are considered, analysis of current data shows that nearly 100% of the population in the majority of countries is affected by dental caries, and severe periodontitis is found in 5–20% of most adult populations worldwide (Petersen et al., 2005). Edentulism is also worthy of consideration: Figures from the USA alone indicate that an estimated 12,447,000 people (9.5% of the entire US civilian population), aged 25 years and older, reported wearing complete dentures (Nowjack-Raymer and Sheiham, 2003), and WHO data show that the percentage of edentulous adults aged 65 years or more ranges from 7% to 69% in some countries (Petersen et al., 2005). The global impact of oral mucosal lesions and oral cancer is also noteworthy, even if few epidemiological studies have been carried out. Although the global prevalence of oral pre-malignant lesions (mainly leukoplakia and erythroplakia) is estimated to be less than 5%, and oropharyngeal cancer is the eighth most common cancer worldwide, there are some countries where these conditions are at the top of the agenda (Petersen et al., 2005). In south-central Asia, for example, cancer of the oral cavity is among the three most common types of cancer, and a sharp increase in its incidence has been reported in central and eastern Europe, France, and Germany. In addition to these disorders, the prevalence of HIV/AIDS-related oral diseases (40–50% of HIV-positive individuals), the impact of debilitating orofacial gangrene known as Noma (estimated global incidence of 140,000 cases with a 1997 prevalence of 770,000 victims) (Petersen et al., 2005), and the (unfortunately) underestimated burden of chronic orofacial pain syndromes complete the unique epidemiologic picture of chronic oral diseases.
In contrast to the four major non-communicable chronic diseases, only a minority of chronic oral diseases are life-threatening. Nevertheless, this does not lower their global burden. Most chronic oral diseases, in fact, result in continuous pain and suffering, and the overall reduced quality of life they cause is considerable (US Department of Health and Human Services, 2000), especially if we consider their wide occurrence among countries. In addition, they are also known to potentially alter individual psychosocial well-being, because of interference with several fundamental human functions, such as speaking and smiling, sighing and kissing, and conveying feelings and emotions through facial expressions. The economic impact of chronic oral diseases is noteworthy: In many industrialized countries, oral diseases are the fourth most expensive diseases to treat, and costs are often borne by patients as out-of-pocket payments (Petersen et al., 2005); in most developing countries, it has been estimated that if treatment were available, the costs of dental caries in children alone would exceed the total health care budget for children (Petersen et al., 2005). Furthermore, there is a strong correlation between chronic oral diseases and the four major chronic diseases (cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes), due to common risk factors (dietary factors, tobacco and alcohol misuse) and probably because of a potential pathogenetic association (at least between chronic oral infections and both diabetes and cardiovascular diseases) (Elter et al., 2003; Petersen et al., 2005).
Overall, these characteristics should indicate that chronic oral diseases are major public health problems in all regions of the world and are worth careful consideration in the context of global health programs, especially those aimed at tackling chronic diseases. Nevertheless, their burden is largely neglected. Most countries suffer from a lack of health systems and preventive strategies focused on oral disease, notwithstanding several goals in common with those for other chronic diseases. This is in contrast to the well-known concept of the 'integrated common risk approach’, which consists of directing action toward common risks and their underlying social determinants to achieve more effective improvements in a range of chronic conditions, avoiding compartmentalized and uncoordinated approaches (Watt, 2005). Public information and professional education are largely inadequate, with those specialties specifically focused on managing chronic orofacial diseases, such as oral medicine, either not recognized or nonexistent in most countries. With respect to other chronic diseases, the situation is even more paradoxical, since a very few simple and inexpensive population-based interventions (such as community water fluoridation, oral visual screening, correction of tobacco/alcohol misuse, and improvement of poor dietary habits) would significantly reduce suffering and deaths due to oral chronic diseases. Finally, we suggest that chronic oral diseases, because of their prevalence, economic impact, and health consequences, lead to a huge but neglected burden in all regions of the world. It is not excessive to say that this somewhat parallels the burden caused by the four major chronic diseases. It is not illogical to suggest that this could be easily reduced through policy, community, professional, and individual strategies similar to those suggested for addressing the major chronic diseases.
Received December 15, 2005; Last revision June 10, 2006; Accepted March 3, 2006
REFERENCES
Elter JR, Offenbacher S, Toole JF, Beck JD (2003). Relationship of periodontal disease and edentulism to stroke/TIA. J Dent Res 82:998–1001.
Fuster V, Voute J (2005). MDGs: chronic diseases are not on the agenda. Lancet 366:1512–1514.[ISI][Medline]
Horton R (2005). The neglected epidemic of chronic disease. Lancet 366:1514.[ISI][Medline]
Nowjack-Raymer RE, Sheiham A (2003). Association of edentulism and diet and nutrition in US adults. J Dent Res 82:123–126.
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C (2005). The global burden of oral diseases and risks to oral health. Bull World Health Org 83:661–669.[Medline]
Strong K, Mathers C, Leeder S, Beaglehole R (2005). Preventing chronic diseases: how many lives can we save? Lancet 366:1578–1582.[ISI][Medline]
US Department of Health and Human Services (2000). Oral health in America: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.
Watt RG (2005). Strategies and approaches in oral disease prevention and health promotion. Bull World Health Org 83:711–718.[Medline]
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