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GUEST EDITORIAL |
1 Department of Orofacial Sciences, School of Dentistry, The AIDS Research Institute and Global Health Sciences, University of California-San Francisco, CA 94143, USA;
2 President, IADR
Oral and dental conditions and diseases are among the most pervasive health problems of mankind and also are among the most neglected (Petersen et al., 2005; Greenspan, 2007). Caries in adults and children, acute oral viral infections and noma, oral lesions of HIV/AIDS, periodontal diseases, craniofacial and dental developmental defects, and oropharyngeal/salivary gland neoplasms occur largely unchecked in resource-poor nations. Most oral diseases are clearly linked in incidence, prevalence, and even severity to a common set of predisposing and causative risk factors. These are dominated by the themes of poorly balanced diet, inadequate food intake, poor oral hygiene practices, and alcohol, tobacco, and areca product use. In their turn, all those factors are linked to the overriding themes of poverty and socio-economic disadvantage (Petersen, 2005; Edelstein, 2006; Mignogna and Fedele, 2006).
The Council of Science Editors has organized a Global Theme Issue on Poverty and Human Development for October, 2007. Science journals throughout the world are simultaneously publishing papers on this topic, one of worldwide interest and significance. The goal is to raise awareness, to stimulate interest, and to promote research into this crucial topic. Over 150 journals in a large number of languages and ranging from the illustrious (BMJ, JAMA, Nature and 8 of its offshoots, PNAS) to those with only a modest and focused circulation are participating. This effort by the scientific publishing community is a fine example of how concerted worldwide effort can be used to draw attention to crucial issues in global health. Here, we draw attention to the place occupied by oral and dental disease in this challenge.
Dental caries still affects most children and adults worldwide. Its prevalence in resource-poor nations appears to be increasing, probably due to increasing sugar ingestion and the low availability or use of fluorides. Certain populations in resource-rich nations are also disproportionately affected, mostly the disadvantaged, such as the poor, emigrants, those who are medically compromised, and the elderly. Following a somewhat similar pattern, oral precancer and cancer are rampant in certain developing countries, notably, but not exclusively, those where topical chewing tobacco and areca nut products are used widely (Trivedy et al., 2002). Thus, the prevalence of oral submucous fibrosis (OSF, a premalignant lesion) ranges from 0.5 to 3% of the population in India, South Africa, and China, a total of almost 2.5 billion people. Areca habits confer a relative risk of OSF of 30- to 500-fold in India, Pakistan, and Taiwan, while the relative risk for oral cancer in those who chew areca and/or tobacco products is 4-to 400-fold in Taiwan, Pakistan, and South Africa. If we add to those startling numbers the very high prevalence of Epstein-Barr virus (EBV)-associated nasopharyngeal carcinoma in some of the same Asian countries where habit-associated squamous cell carcinoma is so common, the caseload of oral and related cancer is clearly an overwhelming problem.
Solid data on the epidemiology of herpes virus and other mucosal infections and conditions are harder to come by, with the possible exception of noma, which is associated with malnutrition and poverty in Asia and Africa. However, there is a wealth of data on the mouth and HIV/AIDS. Almost all of the 50 million people living with HIV infection, not to mention the millions who continue to become infected each year, are destined to experience one or several of the opportunistic infections, neoplasms, autoimmune conditions, and treatment complications associated with HIV/AIDS. These include candidiasis, hairy leukoplakia due to EBV, herpes simplex, and zoster, severe aphthous-like ulcers, unusual and severe periodontal disease, salivary gland enlargement and xerostomia, lymphoma, lip cancer, and Kaposi’s sarcoma. The global extent of this problem is barely reduced at all by antiretroviral therapy, since only about 15–20% of those with HIV infection currently receive that treatment on a reliable, well-monitored, and long-term basis. The major burden of HIV/AIDS, and thus of the associated oral diseases, falls on resource-poor nations and on the socio-economically disadvantaged in many resource-rich nations.
Thus, it is clear that much of the global burden of oral disease affects the poor and neglected segments of humanity in both rich and poor countries. In one sense of the term "human development", the notion of economic human development, the relationship between oral health or disease and poverty is quite clear. In the other sense of the term, there is a specific group of human conditions to be considered. We refer, of course, to developmental disorders of teeth and the craniofacial structures. Here the data are still coming in, but, for example, cleft lip or palate is associated with folic acid deficiency and with smoking during pregnancy, both probably more often found among the poor and disadvantaged segment of the population, although maternal age also seems to be a factor. The enormous and growing burden of oral disease globally has huge economic implications. Space precludes detailed analysis, but it is probably fair to say that the economies of few if any of the nations most affected are likely to support the control of oral diseases through conventional, one-on-one patient care provided by dentists and dental specialists (Robert and Sheiham, 2002). We do not intend to detract from the essential and effective role that those highly trained dental health professionals can play in the oral care of people and nations able to afford their services (Greenberg, 2007). However, attention must surely be drawn to the immediate and long-term global needs for adequate oral disease surveillance and prevention approaches, and for the development of models for the cost-effective delivery of care (Hobdell et al., 2003). Clearly, In this regard, oral and dental disease takes its place among the major global health crises of both acute and chronic types. We do not seek here to propose specific solutions to this huge challenge. Instead, we hope to draw the attention of the dental research and professional communities to the severity and nature of the problem.
REFERENCES
Edelstein BL (2006). The dental caries pandemic and disparities problem. BMC Oral Health 6(Suppl 1):S2 doi:10.1186/1472-6831-6-S1-S2.[Medline]
Greenberg MS (2007). Globalization of diagnostic dental specialties. Oral Surg Oral Med Oral Pathol Oral Epidemiol 104:1–2.
Greenspan D (2007). Oral health is global health [speech]. J Dent Res 86:485.
Hobdell M, Petersen PE, Clarkson J, Johnson N (2003). Global goals for oral health 2020. Int Dent J 53:285–288.[Medline]
Mignogna MD, Fedele S (2006). The neglected global burden of chronic oral diseases. J Dent Res 85:390–391.
Petersen PE (2005). Sociobehavioural risk factors in dental caries—international perspectives. Community Dent Oral Epidemiol 33:274–279.[ISI][Medline]
Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C (2005). The global burden of oral diseases and risks to oral health. WHO Bulletin 83:661–669.
Robert Y, Sheiham A (2002). The burden of restorative dental treatment for children in Third World countries. Int Dent J 52:1–9.[ISI][Medline]
Trivedy CR, Craig G, Warnakulasuriya S (2002). The oral health consequences of chewing areca nut. Addict Biol 7:115–125.[ISI][Medline]
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