“Big sugar” and a lack of prevention fuel Australia’s oral health crisis

Oral health has been isolated from traditional healthcare and health policy for too long, despite the major global public health burden of oral diseases, according to a Lancet Series on Oral Health, published in The Lancet.

Failure of the global health community to prioritise the global burden of oral health has led to calls from Lancet Series authors for the radical reform of dental care, tightened regulation of the sugar industry, and greater transparency around conflict of interests in dental research.

Oral diseases, including tooth decay, gum disease and oral cancers, affect almost half of the global population, with untreated dental decay the most common health condition worldwide. Lip and oral cavity cancers are among the top 15 most common cancers in the world.

Professor Marco A Peres, Menzies Health Institute Queensland and School of Dentistry and Oral Health, Griffith University Australia, a co-author of the Lancet Series, said that tooth decay was particularly prevalent among children in Australia: “Tooth decay affects 34% of five-and-six year-old children and 46.2% of nine-and-10-year olds in Australia. In older children with permanent dentition the prevalence is 9.2% among six to eight-year-olds and nearly 40% in 12 to 14-year-olds.”

In addition to lower quality of life, oral diseases have a major economic impact on both individuals and the wider health care system. Australasia has the second-highest per capita expenditure on dental care and productivity losses due to dental problems in the world. Recurrent expenditure on dental services within Australia was reported as high as $9.904 billion in 2015-16.

The Lancet Series on Oral Health was led by University College London.  Researchers brought together 13 academic and clinical experts from 10 countries to better understand why oral diseases have persisted globally over the last three decades, despite scientific advancements in the field, and why prevalence has increased in low- and middle- income countries (LMIC), and among socially disadvantaged and vulnerable people, no matter where they live.

A tipping point for global oral health

“Dentistry is in a state of crisis,” said Professor Richard Watt, Chair and Honorary Consultant in Dental Public Health at UCL and lead author of the Series. “Current dental care and public health responses have been largely inadequate, inequitable, and costly, leaving billions of people without access to even basic oral health care. While this breakdown in the delivery of oral healthcare is not the fault of individual dental clinicians committed to caring for their patients, a fundamentally different approach is required to effectively tackle to the global burden of oral diseases.”

In high-income countries (HIC), dentistry is increasingly technology-focused and trapped in a treatment-over-prevention cycle, failing to tackle the underlying causes of oral diseases. Oral health conditions share many of the same underlying risk factors as non-communicable diseases, such as sugar consumption, tobacco use and harmful alcohol consumption.

In middle-income countries the burden of oral diseases is considerable, but oral care systems are often underdeveloped and unaffordable to the majority. In low-income countries the current situation is most bleak, with even basic dental care unavailable and most disease remaining untreated.

Coverage for oral health care in LMIC is vastly lower than in HIC with median estimations ranging from 35% in low-, 60% in lower-middle, 75% in upper middle, and 82% in high income countries.

Sugar, alcohol and tobacco industries fuel global burden

The burden of oral diseases is on course to rise, as more people are exposed to the main risk factors of oral diseases. Sugar consumption, the underlying cause of tooth decay, is rising rapidly across many LMIC. While sugary drinks consumption is highest in HIC, the growth in sales of sugary drinks in many LMIC is substantial. By 2020, Coca-Cola intend to spend US$12 billion on marketing their products across Africa in contrast to WHO’s total annual budget of $4.4 billion (2017).

Professor Peres said there was debate in Australia regarding the effectiveness and appropriateness of having a ‘sugar tax’: “Many public health, academic and consumer groups support a tax on sugar, but political support is limited and there is a strong lobby against the implementation of a sugar tax led by sugary drinks companies.”

Professor Watt added: “The use of clinical preventive interventions such as topical fluorides to control tooth decay is proven to be highly effective, yet because it is seen as a ‘panacea’, it can lead to many losing sight of the fact that sugar consumption remains the primary cause of disease development. We need tighter regulation and legislation to restrict marketing and influence of the sugar, tobacco and alcohol industries, if we are to tackle the root causes of oral conditions.”

Writing in a linked commentary, Cristin E Kearns of the University of California and Lisa A Bero of the University of Sydney raise additional concerns with the financial links between dental research organisations and the industries responsible for many of these risk factors.

“Emerging evidence of industry influence on research agendas contributes to the plausibility that major food and beverage brands could view financial relationships with dental research organisations as an opportunity to ensure a focus on commercial applications for dental caries interventions—eg, xylitol, oral hygiene instruction, fluoridated toothpaste, and sugar-free chewing gum—while deflecting attention from harm caused by their sugary products.”

Lancet Series authors argue a pressing need exists to develop clearer and more transparent conflict of interest policies and procedures, and to restrict and clarify the influence of the sugar industry on dental research and oral health policy.

Radical reform of dentistry required

Lancet Series authors have called for wholesale reform of the dental care model in five key areas:

1. Close the divide between dental and general healthcare
2. Educate and train the future dental workforce with an emphasis on prevention
3. Tackle oral health inequalities through a focus on inclusivity and accessibility
4. Take a stronger policy approach to address the underlying causes of oral diseases
5. Redefine the oral health research agenda to address gaps in LMIC knowledge

The Australia Government implemented the Child Dental Benefit Schedule (CDBS) in 2014 to provide financial support for basic dental care for nearly 3 million children aged 2 to 17 years. The CDBS has a cap of $1,000 per child over two consecutive years (Australian Government 2018).

“To the best of our knowledge, there is no study evaluating the cost-effectiveness of the CDBS,’’ Professor Peres said. “The implementation of universal dental care coverage has been advocated to reduce socioeconomic inequalities in oral health and should be considered in Australia.”

Dr Jocalyn Clark, an Executive Editor at The Lancet, said: “Dentistry is rarely thought of as a mainstream part of healthcare practice and policy, despite the centrality of the mouth and oral cavity to people’s well-being and identity.

A clear need exists for broader accessibility and integration of dental services into healthcare systems, especially primary care, and for oral health to have more prominence within universal health coverage commitments. Everyone who cares about global health should advocate to end the neglect of oral health.”