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Documentary
Oral Health Care Disparities, A Broad Smile Foundations Mission to Stop them Before they Start
By: Renee Benjamini

Abstract

Tooth decay, or dental caries, can begin in early childhood. Though, it consistently affects people of all ages across the world. Tooth decay is caused by bacteria in the oral cavity that can create a biofilm conducive to its growth. The bacteria produces compounds which will continue to eat away at tooth material further into the root until pain and infection begin — unless stopped by treatment. Unfortunately, treatment is often inaccessible. Oral health status is affected by many factors which result in global disparities. A deteriorated oral health status is more common among individuals with risk factors, like a low socio-demographic status. The cost of care for the rampant amount of untreated caries is too high for many low-income countries to cover. Therefore, it falls upon supplemental organizations to close the gap in global oral health care through education and treatment.

Introduction

The lifelong struggle with oral health often begins in early childhood and will continue to progress throughout adulthood. Oral health care is essential to prevent serious issues. When the oral cavity is not cared for properly there are a slew of events that take place ultimately leading to pain, damage, and increased overall health risks. Bacteria present in the oral cavity utilizes the food an individual eats and produces lactic acids. The acid slowly destroys the layers of the teeth causing more advanced issues unless it is identified and treated at the onset.

Tooth Decay

The most prominent dental diseases are tooth decay (also known as dental caries) and gum disease (also known as periodontal disease) — tooth decay is more widespread. The process of tooth decay occurs in a consistent manner. The bacteria, Streptococcus mutans, is present nearly everywhere, consequently within the mouth. As the bacteria proliferates it will form plaques which create a sticky film on the teeth. The biofilm provides a favorable environment for the bacteria. Tooth decay begins as a result of lactic acids on the enamel which are byproducts of the bacteria breaking down sugars found in the foods an individual eats. The lactic acid causes demineralization, or the loss of calcium phosphate, from the enamel. This causes the tooth to soften and eventually collapse — forming a cavity.

 

If a cavity is identified during the early stages — while it is still confined to the enamel — decay can be halted by a filling. However, when left untreated, it will continue to “eat through” the dentin and eventually the pulp (Figure 1). indicates the morphology of a tooth. Once the bacteria has invaded the pulp the pain and infection cannot be treated through a filling. Rather it will require a root canal treatment or often an extraction.1

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Figure 1

Disparities in Oral Health

Health Literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”2 According to a study done, the individuals with lowest oral health literacy were the poor, low levels of education, minorities, and the elderly.3 Numerous studies and meta-analyses have been done to assess the disparities in oral health, their causes, and directives to mitigate them. 

 

There is a strong correlation between low Oral Health Literacy and high risk for oral diseases and their associated problems.4 Unfortunately, individuals with low health literacy are less likely to utilize preventative measures and instead seek emergency care resulting in more expensive and invasive procedures.3 Both on the global and national levels there are inequalities in oral health. 

Within the United States low income is directly correlated with a higher occurrence of untreated caries by factors up to three times those of individuals with higher incomes, across all ages. 17% of children between the ages of 2-5 in low income households suffer from untreated cavities in their primary teeth. This is three times that of children from higher income homes in the United States. The disparities are not solely socioeconomic, level of education similarly plays a factor. Between the ages 20-64, adults with less than a highschool education are nearly 3 times as likely to have untreated cavities as those who attended a college.5 It is apparent that individuals are less likely to seek care due to lack of proper education about oral health care and  lack of access due to affordability. 

Globally the problem is very similar to that in the United States. A study was done to assess the burden, trends, and inequalities of untreated caries in both permanent and primary teeth between the years 1990 to 2019 at many different levels, utilizing analytic methods. Untreated caries were found to be the most widespread health condition in 2019. It was similarly the leading disease in children between 0 and 14 years of age. The issue spans across the world, and was even found to be the most prevalent disease in 5 of the 7 named Global Burden of Disease super-regions.

Through global analysis, the attribution to the burden of untreated caries in permanent teeth by sociodemographic inequality was assessed. The results showed that socioeconomically deprived people showed higher caries prevalence, and more commonly within developed countries. It was found that within the age range of 5 to 9 years, there was the largest percent of untreated caries in permanent teeth attributed to inequality. Additionally, countries with a lower socio-demographic index composed a higher percentage of untreated caries in deciduous teeth. Unfortunately, the study indicated that burden has maintained relative stability for decades.6 According to the WHO oral diseases affect nearly 3.5 billion people globally, and 3 out of 4 are from middle-income countries. 

Reducing Disparities

 

A study was done with the purpose of assessing the effectiveness of childhood education on oral health knowledge. Since oral health literacy is correlated with oral health status, oral health education is a step towards an effective preventative system. India was chosen as the population of interest as a majority of the population is poor and do not have access to sufficient oral health care.7 In the study, 200 school-going children between 12-16 years answered a questionnaire about oral hygiene and proper care. Then, the students were given an in-depth course for the purpose of education. Afterwards, they were tested again. The new test scores, when compared to those before the intervention, indicated that there was a 60.4% increase in oral health care knowledge. For example, only around 50% of the participants knew that brushing twice daily was essential for maintenance and caries prevention, and only 27% knew the importance of routine dental check-ups.

 

The studies showed that there was a general lack of knowledge of oral hygiene. However, through effective education the children may be able to prevent diseases and perhaps see the signs to identify them before their oral health passes the point of restoration. In this study, prior to implementation of education the students got most questions wrong. After implementation, barely any students got the answers wrong, indicating that the students were well educated on oral health after the seminar. The conclusion is a call to action for proper oral health education beginning in childhood in order to diminish the struggle of high-risk individuals.

In Amsterdam, the Netherlands, a group of researchers constructed a study that helps better understand families and professionals' perceptions of the inequality in oral health care and its causes. As of 2020, nearly 29% of children in Amsterdam did not visit the dentist. The researchers strongly believe that implementing oral health intervention programs  will help reduce the inequality. This study is intended to lead to the development of an effective intervention program. In order to do so, professionals from a variety of dental and non-dental fields working in disadvantaged neighborhoods in Amsterdam, the Netherlands were interviewed regarding the oral health inequality and its primary causes. Since these individuals are involved in the lives of vulnerable families more directly, their insights were requested for this study. Some of the most commonly suggested causes were: unhealthy diet, children’s non-compliance, and low oral health literacy in parents. With these results, it was suggested that the most crucial change is to implement a family-centered education program. It is equally important that family, teachers, community, as well as dental professionals, and non-dental professionals create a pro-oral health care environment. Increasing child and parent oral health knowledge in proper dental practices should be utilized as a preventative measure.9  

The American Dental Association specifically notes that Early Childhood Caries are a serious, but preventable, disease that affects much of the population — specifically at-risk communities. Their primary method suggested to prevent early onset of a lifelong oral health struggle is through educating parents and expecting parents on oral health care and the importance of establishing a Dental Home before the age of one. Additionally, they assert that caries detection, classification, and prevention/risk management methods can reduce the patient’s likelihood of more advanced diseases.10 

Daily brushing and flossing is effective at preventing the accumulation of plaques in the most common areas.1 Consequently, brushing and flossing prevents caries. A study over a 28 day period was done that evaluated whether brushing daily (compared to brushing less often) led to decreased plaque build-up. The study showed that brushing more frequently resulted in less plaque, calculus, and even reduced the severity of pre-existing gingivitis.11 Additionally, fluoride can help the tooth resist the loss of calcium phosphate. Fluoride is often supplemented through toothpaste, tap water, rinse, or it can be professionally applied. Fluoride is effective because it is able to replace hydroxyapatite, found in tooth enamel, with fluorapatite — a harder compound.1 

Some researchers have identified a flaw in modern dentistry. Namely that there is too much focus on treatment and technology, rather than utilizing the knowledge about prevention. For example, there are identifiable risk factors like diet, socioeconomic status, education, environment, and even biological factors that increase the risk of dental caries in an individual. Given these risk factors, the first step should be prevention by mitigating them so that the caries are less likely to form at all.12 Global education about oral health care preventative methods is essential in decreasing the burden of disease of untreated dental caries.6 Though, it must be partnered with access to proper care and items like toothbrushes, floss, and fluoride. 

Obstacle to Oral Health Equality

 

While the path to equality appears clear, providing education and care for the entire population may be an insurmountable obstacle. An analysis of the costs necessary to treat existing and future caries in the child population alone in developing countries was done. The calculations were executed using the WHO dental databases and spreadsheet calculations of costs. The results concluded that since 90% of dental caries are untreated in Third World Countries, the cost of treatment would be between $1,618 and $3,513 per 1,000 children between the ages of 6 - 18 years of age. This is found to be more than the resources allocated towards oral health care plans in 15 to 29 low-income countries. As such, it is not within the financial abilities of low-income countries to treat the dental caries in children.13 While an option may be to redesign the finances of these countries, oral health care is often neglected as a priority leaving much of the population in consistent pain. Hence, it is essential to stop it before it starts. Caries prevention must be a priority if the cost of treatment is too high. Since fewer people would suffer from oral health diseases, investing in caries prevention systems would be a preferable solution financially to governments and to the general population.

Non-Profit Organizations

 

As concluded by many studies, it is imperative that there is education and access to oral health care provided to all. Specifically, in low-income homes and those with lower levels of education. This will allow a decrease in the frequency of emergent dental issues and oral health pain among neglected communities. In order to implement this, numerous organizations have been founded. Some provide treatment by sending out dentists and supplies and even construct tent clinics. Others provide education through free seminars and even distribute the essentials. 

A Broad Smile Foundation

​Many nonprofit organizations have been founded in order to help provide the necessary care across the world where there is improper access, education, and funding. However, in order for those organizations to successfully close the gap in oral health care it requires the assistance of donors and volunteers. A Broad Smile Foundation, one such organization, was founded with the mission to create change across the world through donations, supplies, and missions to provide care and education to communities without access. They do this through many outlets and the help of students and professionals. A Broad Smile Foundation organizes drives at middle and highschools to simultaneously gather oral health care essential items and educate about the importance of oral health hygiene. Additionally, they fundraise for missions in underprivileged communities to cover the costs of care delivered by volunteer dental professionals. They also have begun teaching seminars that guide and educate about oral health care. Prevention through education is an effective method, as concluded by many studies. Individuals who do not have the capability of providing physical dental care, do have the ability to work on the prevention side. Oral health literacy among the entire population is a first step in abolishing the disparities in oral health status.  

 

Conclusion

From the moment a tooth erupts, the risk of disease emerges. Early childhood caries affect so many children. The risks increase depending on many factors including diet, self care, oral hygiene, socioeconomic status, education, ethnicity, race, age, and more.14 Many of the disparities in risk level can be prevented by education and access to care. It is imperative that people unify to provide this care and tame one of the most rampant global diseases.

References

  1. Heng, Christine. “Tooth Decay Is the Most Prevalent Disease.” Federal Practitioner : for the Health Care Professionals of the VA, DoD, and PHS, U.S. National Library of Medicine, Oct. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC6373711/. 

  2. Ratzan, S C, and R M Parker. “National Library of Medicine Current Bibliographies in Medicine: Health Literacy .” Edited by C R Selden and M Zorn, ScienceDirect, National Academies Press (US), 2004. 

  3. Horowitz, Alice M., and Dushanka V. Kleinman. “Oral Health Literacy: A Pathway to Reducing Oral ... - Wiley Online Library.” Wiley Online Library, 20 Mar. 2012, onlinelibrary.wiley.com/doi/10.1111/j.1752-7325.2012.00316.x. 

  4. Baskaradoss, Jagan Kumar. “Relationship between Oral Health Literacy and Oral Health Status - BMC Oral Health.” BioMed Central, BioMed Central, 24 Oct. 2018, doi.org/10.1186/s12903-018-0640-1. 

  5. “Disparities in Oral Health.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 5 Feb. 2021, www.cdc.gov/oralhealth/oral_health_disparities/index.htm. 

  6. Wen, Y.F., et al. Global Burden and Inequality of Dental Caries, 1990 to 2019. 2 Dec. 2021, journals.sagepub.com/doi/10.1177/00220345211056247. 

  7. Singh, Abhinav, et al. “Addressing Oral Health Disparities, Inequity in Access and Workforce Issues in a Developing Country.” International Dental Journal, Elsevier, 7 Dec. 2020, www.sciencedirect.com/science/article/pii/S0020653920336728?via%3Dihub. 

  8. Sinha S;Pisulkar SG;Nimonkar S;Dahihandekar C;Purohit H;Belkhode V; “The Effect of Structured Education Training Program on Oral Health Awareness Among School-Going Children of Central India: A Cross-Sectional Study.” Cureus, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/36017272/. 

  9. Balasooriyan, Awani, et al. “Professionals' Perspectives on How to Address Persistent Oral Health Inequality among Young Children: An Exploratory Multi-Stakeholder Analysis in a Disadvantaged Neighbourhood of Amsterdam, the Netherlands - BMC Oral Health.” BioMed Central, BioMed Central, 14 Nov. 2022, doi.org/10.1186/s12903-022-02510-w. 

  10. “Caries Risk Assessment and Management.” American Dental Association, www.ada.org/resources/research/science-and-research-institute/oral-health-topics/caries-risk-assessment-and-management. 

  11. Harvey, Colin et al. “Effect of Frequency of Brushing Teeth on Plaque and Calculus Accumulation, and Gingivitis in Dogs.” Journal of veterinary dentistry vol. 32,1 (2015): 16-21. doi:10.1177/089875641503200102

  12. Selwitz, Robert H et al. “Dental caries.” Lancet (London, England) vol. 369,9555 (2007): 51-9. doi:10.1016/S0140-6736(07)60031-2

  13. A;, Yee R;Sheiham. “The Burden of Restorative Dental Treatment for Children in Third World Countries.” International Dental Journal, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/11931216/. 

  14. “Oral Health.” World Health Organization, World Health Organization, www.who.int/news-room/fact-sheets/detail/oral-health. 

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