Oral Health for All — Realizing the Promise of Science | NEJM - nejm.org

Oral health is paramount to overall health and well-being, yet inequities in oral health continue to pose a major global public health threat. To bolster health throughout the United States, it's essential that we acknowledge the factors driving the unequal burden of oral disease and leverage scientific and technological advances to guide responses. A new National Institutes of Health report,¹ which was compiled by the National Institute of Dental and Craniofacial Research, aims to address these issues and offer solutions.

In 2000, Oral Health in America: A Report of the Surgeon General affirmed the importance of oral health for overall health and captured the attention of researchers, policymakers, practitioners, and the general public. Although the past two decades have seen progress in this area, dental and oral diseases remain problematic for many Americans. According to the Centers for Disease Control and Prevention (CDC), 47% of U.S. adults 30 years of age or older have periodontal disease. Oropharyngeal cancer associated with human papillomavirus (HPV) has become more prevalent than HPV-associated cervical cancer, with men more than five times as likely to be affected as women. Nine out of 10 adults 20 to 64 years of age have had dental caries, a figure that hasn't meaningfully changed during the past 20 years. Caries in permanent teeth still rank among the most common childhood diseases. Untreated carious lesions cause pain and infections in bone and soft tissues, thereby perpetuating the cycle of lost productivity and use of emergency services in lieu of preventive care.

We believe a reform agenda should include strategies for tackling the high costs of, and unequal access to, oral health care. Over the past 20 years, per-person dental care costs have increased by 30% in the United States; in 2018, Americans paid $55 billion in out-of-pocket dental expenses, which constituted more than 25% of all health care out-of-pocket spending. The highest burden of dental and oral disease, nationally and globally, is shouldered by marginalized and chronically underserved populations.²

The Covid-19 pandemic has highlighted the need to reexamine health and well-being through the lens of social and systemic determinants. Groups that have been most affected by SARS-CoV-2 in the United States appear to be the same groups that have disproportionately high rates of oral disease. The oral cavity is a potential locus of SARS-CoV-2 infection and a site of Covid-19 symptoms,³ and altered immune status in people with periodontal disease can make oral tissues more prone to SARS-CoV-2 infection. Such observations support the longstanding argument that the links between the oral cavity and other body systems necessitate better integration of health care delivery practices. Covid-19 has permanently affected care delivery and has exacerbated existing inequities. Moving forward, we will need to forge a path for oral health care that prioritizes overall health, prevention, expanded access, affordability, and equity.

Communities that are disproportionately affected by dental and oral disease often have limited access to health services. Policy changes are needed to integrate oral, medical, and behavioral health care and prevention services in community health centers, schools, assisted-living facilities, primary health care settings, and dental clinics. Access to care has improved for children from low-income families thanks to strengthened collaborations between oral health professionals and pediatricians. Examples of these collaborations include the promotion of dental visits within the first 3 years of life, the execution of well-designed risk-assessment studies for dental diseases, and the use of sealants and fluoride varnishes — expenses that are covered by Medicaid and the Children's Health Insurance Program. Along with broad policy initiatives such as fluoridation of public water supplies, these integrative approaches have the greatest potential for mitigating oral diseases of high public health importance and should be reinforced in health professional curricula and training.⁴

Collaboration among communities, dental professionals, and other clinicians is critical to eliminating inequities that impede access to culturally competent care.⁵ Community leaders are experts in the needs of their populations and must be included in the planning, design, and implementation of oral health care systems. An area in which community engagement is especially important is the intersection of dental care and opioid misuse. For many people, particularly adolescents and young adults undergoing wisdom-tooth extractions, a first exposure to opioids occurs in the context of oral surgery. Although dental practitioners have substantially changed their opioid-prescribing practices during the past 20 years, opioid prescriptions remain common when patients seek care for dental problems in hospital emergency departments. This phenomenon reflects the need for expanded, affordable, and equitable access to routine dental care, particularly in vulnerable communities. Opioid use disorder continues to be a serious public health problem: CDC data indicate that in the 12-month period ending in April 2021, more than 100,000 Americans died from drug overdoses, an increase of nearly 30% from the previous year.

Tobacco and other inhaled and consumable products can cause oral cancer, periodontal disease, and other oral health problems. In addition, the relationship between mental health and oral health warrants further investigation. People with schizophrenia, other psychoses, and bipolar disorder have particularly high rates of gum disease and decay and are three times as likely as people without mental disorders to become edentulous. Preventing and treating oral disease precipitated by mental disorders requires an understanding not only of the oral cavity, but also of overall health and the environmental, psychosocial, and behavioral factors that shape health and well-being.

Over the past 20 years, science has transformed our understanding of the molecular and cellular mechanisms that underlie disease and has sparked clinical applications that improve health and prevent disease. Newly proposed government initiatives are poised to propel "use-driven" research, which aims to solve practical, real-world public health problems. These approaches could lead to interventions to prevent, detect, and treat complex diseases including diabetes, cancer, and Alzheimer's disease. Such innovation could also help mitigate inequities and improve precision in oral health care. Recent scientific and technological advances provide opportunities for tailoring oral health care on the basis of a person's genomic, environmental, and socioeconomic risk factors.

Improved understanding of the oral and gut microbiomes, combined with other "omics," will provide the basis for therapies such as probiotics and mouth rinses that can be used to address disease-associated oral microbial ecosystems and biofilms and create healthier ones. Deep-phenotyping approaches that integrate clinical data, digital biomarkers, imaging, tissue and biospecimen analyses, and advanced analytics could improve prevention and health-promotion efforts, prognostics, and treatment for inherited and acquired dental, oral, and craniofacial diseases.

Research advances cannot stand alone. It's essential that we engage people and communities to address social, economic, and environmental determinants of poor oral health, such as lack of access to healthy food. Concurrently, health care systems should recognize inequities in oral health care and other services and resources in the context of the compounded challenges that affect marginalized populations, including structural and interpersonal racism. To substantially improve oral health throughout the United States, policy changes are needed to reduce or eliminate social, economic, and other systemic inequities. Oral diseases are preventable, and social and other determinants of health need to be considered in prevention and treatment strategies. Policymakers must make oral health care more accessible, affordable, and equitable. It will also be essential to diversify the country's oral health workforce so that clinicians reflect the communities they serve, to address the rising costs of educating and training the next generation of oral health professionals, and to ensure a strong research enterprise dedicated to improving oral health.

This century began with the recognition that oral health is central to overall health. Now, it's critical that we build on this knowledge and the scientific progress we've made to ensure that oral health is fully integrated into this new era of discovery and to harness policy changes and technological advances to disrupt systemic inequities. Only then will we truly improve the health of people, families, and communities.