The mouth is a barometer of social inequities — it reflects the injustices in our society. As George Cuvier, an 18th century naturalist said: “Show me your teeth, and I will tell you who you are”. To me, as a dentist, the mouth is like a microscope that reveals more than just tooth decay. It exposes us to a world where people lack access to water, health, quality education and live on low income.
So, when the FDI World Dental Federation unveils a “Be Proud of Your Mouth” campaign for World Oral Health Day (WOHD) 2021 celebrated on March 20, it needs to go beyond encouraging individuals to adopt good oral health routines such as brushing and flossing. It also needs to urge countries, leaders, policymakers and communities to tackle the social inequities that affect the mouth. It starts from addressing the social determinants of oral health.
Research by the World Health Organization shows that the social conditions in which people live have a great influence on their health and has linked increases in oral health diseases to social determinants such as education, income, food, race, and geographical location.
As a rural dentist working with vulnerable and underserved communities in Nigeria, I’ve had first-hand experience working with children at risk of oral health diseases, such as dental caries, Noma, and dental fluorosis. Most of them brush their teeth daily, but they lack access to clean water, nutritious food, and dental care facilities. Their teeth pay the price.
Studies show that 70% of the Nigerian population have a form of periodontal disease and untreated cavities. This is a whopping 140 million people, more than the entire population of the United Kingdom and France combined.
In the heavily populated northwest part of Nigeria, NOMA, a face disfiguring disease often caused by malnutrition, is one of the most prevalent oral health diseases. Between 2011 and 2017, The Nigerian Centre for Disease Control recorded over 37,646 cases. This is a public health crisis for a disease with 90% mortality rate.
Yet, only 15.5 % of the people living in rural parts of Nigeria have access to a dental facility. There is a lack of dental workforce which is an essential component of oral health access for vulnerable and underserved populations. In 2018, only about 850 out of the 4,358 registered dentists in Nigeria work in rural areas.
One patient, a young girl I worked with, had two of her teeth removed due to a defect caused by a vitamin deficiency. She comes from a village with no access to clean water and her family lives on less than US $1 per day. To complicate matters, the nearest dental facility was a two hour walk from where she lived. This is more than the experience of one girl; it is the experience of many living in communities saddled with social inequities.
What then is the way forward for a country like Nigeria? Clearly, there is a need for innovations, commitment of resources, and full engagement to improve oral health.
The Nigerian dental health system is badly underfunded by the government, which is currently just 0.41% of the country’s health budget. Service delivery is left largely to private markets; with health insurance not covering essential oral healthcare services. This needs to change.
We need the government to allocate more resources to building and equipping dental clinics in rural areas with community support to then train community health workers and dental technicians to take over many where there is no dentist available.
Task shifting, an act of assigning tasks to non-specialists who have received the necessary training in communities where there is shortage of specialists, has been a major success in healthcare for countries like Rwanda and Mozambique. Nigeria can learn from these countries.
Mobile dental clinics are another innovative way to provide oral health services to vulnerable and underserved communities, reaching patients who live far from conventional clinics. This may not totally eradicate the problem of access but it is a start.
Educators and dental professionals should work together to develop an oral health curriculum for primary schools that is both competent yet culturally sensitive to raise awareness on oral health at an early age. They also need to ensure that we have food policies that guarantee healthy food in schools.
Some may say it’s cheaper and better for resource-strapped countries like Nigeria to improve oral health by emphasizing personal responsibility for brushing, while the government focuses on more life-threatening diseases like COVID-19, HIV, cancer, Lassa fever, and tuberculosis.
Even though oral diseases are not usually seen as life-threatening, they are strongly associated with mortality. A recent study shows that people who suffer from poor oral health have a higher risk of cancer, heart diseases and complications from COVID-19. Poor oral health is a major factor that exacerbates these diseases.
I am not saying addressing oral health inequities is an easy task. However, these inequities shape people’s choices and decisions. Brushing and flossing alone is not enough to have a healthy mouth. By tackling inequity we can raise a generation of people who are proud of their mouths and productive in society.