FUTURE OFDENTISTRYGlobal Oral Health
DETERMINANTS OF GLOBAL ORAL HEALTH
"Global health" refers to health status, issues, and
concerns that transcend geographic and political
boundaries. The study of global oral health patterns
reveals trends, profiles, and lessons for preventing
disease and promoting health for our own popula-
tion. Within the United States, the distinction
between domestic and international health is losing
its validity and may even be misleading in light of
the rapid rate at which the United States population
is becoming ethnically and racially diverse.
Protecting the public health in the United States is a
national responsibility for health professionals that
might be well served by addressing global determi-
nants of health and disease. By engaging in collab-
orative actions that cross borders, the American
Dental Association (ADA) can understand the fac-
tors associated with global health and develop inno-
vative strategies to improve oral health in the United
States. Failure to engage in global activities, which
enable the United States to prevent disease and ame-
liorate health, could jeopardize the nation's health
and ultimately impact the economy (Institute of
Medicine [IOM], 1997).
In 1974, Marc Lalonde, then Minister of Health
of Canada, set the stage for identifying four deter-
minants of health and disease: human biology,
lifestyle, environment, and organization of health
care. Since then, a number of studies have been con-
ducted to specify factors associated with those four
determinants and global oral health. Two large
World Health Organization (WHO) international
collaborative studies of oral health outcomes (in
which the United States participated) tested several
approaches related to these determinants (Arnljot et
al, 1985; and Chen et al, 1997). At the outset, it
was believed that the availability of dental personnel
was directly associated with oral health outcomes,
but the evidence showed that perceived need for oral
health services was a better predictor of dental visit
utilization and oral health than were availability,
accessibility, or acceptability of dental services.
Only prevention services seemed to be of equal or
greater significance. A second WHO study suggest-
ed that two environmental factors––fluoridation
and the lack of cariogenic food policies––were addi-
tional, powerful determinants of oral health out-
comes and override the effects of delivery of oral
health services. Promotion of oral health clearly
emerges as a possible mechanism to make more salient
for decision-makers the need for either individual
health services and/or community-based prevention,
such as fluoridation and healthy food policies.
Global maps of oral diseases reveal widely differ-
ent patterns of oral health status that are not related
to dental workforce, availability of services, or eco-
nomic development. For example, utilizing data from
the WHO Global Oral Health Database, Barmes
reported in 1999 that for most of the developing
countries represented in the database, the prevalence
of dental caries was low to very low (Barmes, 1999).
Some countries experienced hardly any perceptible
increase over time, some showed increases in urban
areas, others showed large differences between low
rural and high urban areas, and others experienced
caries at levels as high as many of the emerging mar-
ket countries. However, by assessing workforce capac-
ity and service availability, he reported that Latin
American countries form a special group because they
have a high prevalence of caries, a deficit of personnel
and services, and a large number of informally trained
workers who emerged, presumably, in response to a
high disease rate. Global data do not show clear
demarcation on destructive periodontal disease
among population groups.
The prevalence of dentofacial anomalies varies
among populations within and between countries,
and levels of demand for treatment vary by age, gen-
der, culture, and available services. At present, the
prevalence for cleft lip, cleft palate, salivary gland dis-
orders, and oral cancers are not in the database. Basic
methods and procedures for collecting these data are
needed, and the methodology must be refined for
recording dental caries and periodontal diseases.
The important lesson learned from these and
other international comparative studies is that caus-
es and solutions to specific health issues might
evolve from multiple factors and that relying on
only one set of factors may obscure more cost-effec-
tive and beneficial outcomes possible from alternative
approaches. The perceptions of the public concerning
their own needs for services and community-based
preventive services further complicate the assessment
of workforce requirements. Whether the solutions are
food safety policies, more creative financing models,