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Page 1: Chronic conditions policies: oral health, a felt absence

ORIG INAL ART ICLE

Chronic conditions policies: oral health, a felt absence

Gerson Luis Schwab1, Simone Tetu Moys�es2, Beatriz Helena Sottile Franc�a2,Renata Iani Werneck2, Erica Frank3 and Samuel Jorge Moys�es2

1School of Health and Biosciences, Pontifical Catholic University of Paran�a (PUCPR), Curitiba, PR, Brazil; 2Pontifical Catholic University ofParan�a (PUCPR), Curitiba, PR, Brazil; 3School of Population and Public Health of the University of British Columbia (UBC), Vancouver,BC, Canada.

The global health scenario shows an epidemic of non-communicable diseases that lead to long-term chronic conditions,some of which are incurable. Many infectious diseases, owing to their development and length, also generate chronicconditions. Similarly, non-morbid states, such as pregnancy, and some life cycles such as adolescence and ageing, followthe same logic. Among all these chronic conditions there is a significant interrelationship with oral health, both in paral-lel events and common risk factors. This article presents cross-sectional qualitative research into World Health Organisa-tion recommended health policies to address chronic conditions. Several documents published by the organisation wereanalysed to verify the presence of references to oral health in relation to chronic conditions, particularly cardiovasculardiseases and diabetes as these most frequently have oral manifestations. The analysis showed no significant references tooral health or its indicators within the published texts. The study recognises the value of the work developed by theWorld Health Organisation, as well as its worldwide leadership role in the development of health policies for chronicconditions. This article proposes a coalition of dentistry organisations that could, in a more forceful and collective way,advocate for a greater presence of oral health in drafting policies addressing chronic conditions.

Key words: Non-communicable diseases, chronic conditions, oral health, dental caries, periodontal disease

INTRODUCTION

In May 2010, the United Nations (UN) GeneralAssembly adopted a resolution on prevention andcontrol of non-communicable diseases (NCDs) callingfor:• A high-level NCDs meeting of the General Assem-

bly in September 2011 to discuss NCDs at a high-level plenary meeting, scheduled for September2010, for a review of the Millennium DevelopmentGoals (MDG)

• A Secretary-General’s report on the global status ofNCDs in preparation for the September 2011 meet-ing.That resolution marked a special moment in

addressing NCDs at the global level, which begannearly 20 years ago with the Global Burden of Dis-ease Project (GBDP). Commissioned in 1991 by theWorld Bank, the GBDP provided the first standar-dised, data-driven evidence of the impact of NCDsnot only in high-income countries but also in low andmiddle-income countries. Since then, GBDP updateshave made clearer the toll of NCDs worldwide.

Approximately 60% of the world’s mortality, or35 million deaths in 2005, resulted from NCDs (car-diovascular diseases, cancer, chronic obstructive pul-monary diseases and diabetes), including key riskfactors such as tobacco and alcohol use, unhealthydiets (high in sugars, salt, and trans fats) and insuffi-cient physical activity. While the proximate causes ofthese diseases are individual lifestyle behaviours medi-ated by socio-environmental factors, the globalisationof alcohol, food processing and tobacco marketing, aswell as industrialisation and urbanisation, have con-tributed to the increase of NCDs, demandingimproved global collective action in response1.That United Nations (UN) resolution was the second

such resolution in the entire history of the WorldHealth Organisation (WHO). A decade ago, at a simi-lar meeting on human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), the Glo-bal Fund for HIV/AIDS, Tuberculosis and Malaria wascreated, this being a revolutionary new global healthfunding mechanism. Non-communicable diseasesremain neglected despite their social parallels withHIV. As with HIV there have been misconceptions.

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doi: 10.1111/idj.12066

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Although NCDs have been thought of as diseases of thewealthy, this is not correct. Another common fallacy isthat NCDs stem from a moral failure in that weaknessof will leads to obesity or sedentary lifestyles. In manyparts of the world people face major barriers to makinghealthy choices and face powerful pressures toadopt unhealthy ones. The MDGs did not include non-communicable diseases even though they account for60% of global deaths. Most of the morbidity and mor-tality caused by chronic diseases are preventable.Because non-communicable diseases are not part of thegoals, development agencies fail to prioritise them;health ministers in turn do not seek support for preven-tion and control because of the lack of available fund-ing. As a result, little research can be done on how toprevent and treat these conditions, and this allows theargument that there is weak evidence for intervention.Currently, more than half of the world’s populationlives in urban settings. Slums need corner food storesthat sell fresh produce, not just packaged junk at cheapprices and a long shelf-life. Margaret Chan, WHO’sDirector-General, stated that ‘Today, many of thethreats to health that contribute to NCDs come fromcorporations that are big, rich and powerful, driven bycommercial interests, and far less friendly to health’2.Non-communicable diseases are a low global health

priority despite their economic and human burden oncountries. The prioritisation of NCDs for UN institu-tional support can raise its visibility as a critical healthand development challenge. Global initiatives on NCDsare fragmented. Although WHO has provided technicalleadership on NCDs, it lacks the political authority andgovernance to motivate concerted action by the widerange of global stakeholders. Multisectoral collabora-tion is mandatory, although the private sector role inaddressing NCDs is also absolutely critical. Partnersmust be selected cautiously, avoiding any suggestion ofpolicy influence not based on evidence and ethical stan-dards. Multisectoral collaboration should also be takeninto consideration in private sector initiatives1.Deaths from NCDs are only a small fraction of the

problem given that these diseases also inflict a majortoll on quality of life and healthy and happy ageing.The growth in the incidence and mortality of NCDs isprojected to disproportionately affect poor and disad-vantaged populations, thereby contributing to the ever-widening health gaps between and within countries3.A formal meeting of UN member states to conclude

work on the comprehensive global monitoring frame-work, including indicators and a set of voluntary globaltargets for the prevention and control of non-communi-cable diseases, took place in Geneva on 5–7 November2012. The session was attended by representatives from119 member states, one regional economic integrationorganisation, one intergovernmental organisation and17 non-governmental organisations (NGOs)4.

This meeting restated that cancer, diabetes and heartdiseases are no longer diseases of the wealthy, they nowhamper the people and the economies of the poorestpeople even more than infectious diseases. This repre-sents a public health emergency in slow motion. NCDsare a major cause of poverty, a barrier to economicdevelopment and a neglected global emergency, whichdemand joint efforts to be overcome. In May 2009, theNCD Alliance was launched by the InternationalDiabetes Federation, World Heart Federation andUnion for International Cancer Control to representthe millions dying and affected by NCDs across boththe developing and developed world, and prevent fur-ther spread of the NCD epidemics. In February 2010,the NCD Alliance was joined by the InternationalUnion against Tuberculosis and Lung Disease as a fullpartner. The NCD Alliance will drive forward fiveareas of work for presentation to the UN Summit by:leading a civil society movement for NCDs; producingevidence-based arguments to support the NCDs cause;acting as the global voice of its members and peoplewith NCDs; creating a 2020 Roadmap for NCDs andsharing innovative solutions and best practice onNCDs; working with like-minded NGOs, governmentsand businesses to take forward NCD Alliance key ‘asks’for and from the UN Summit5.In recent decades several national and international

guidelines have been produced on the management ofchronic conditions, although they are too complexfor application in primary care, especially in low-resource settings. The Global Status Report on Non-Communicable Diseases 2010 (http://www.who.int/nmh/publications/ncd_report2010/en/) highlights theneed for countries to integrate NCD prevention andmanagement into primary health care even in low-resource settings. The WHO has identified an essen-tial package of cost-effective interventions with highimpact, feasible for application in resource-poor set-tings6.At the end of the 2011 Conference, 193 member

states signed the Political Declaration on Preventionand Control of NCDs, which included Article 19 stat-ing ‘that renal, oral and eye diseases pose a majorhealth burden for many countries and that these dis-eases share common risk factors and can benefit fromcommon responses to non-communicable diseases’.The President of Tanzania, H.E. Jakaya Kikwete,highlighted the importance of oral health in the con-text of the four main types of NCDs by hosting aside-event at the high-level UN meeting, called ‘Putt-ing Teeth into NCDs’. At this meeting, many authori-ties advocated on the need to increase efforts tostrengthen the prevention and control of oral diseases,which are often neglected despite their tremendousimpact in most countries. They made persuasive casesfor the inclusion of oral health in the decisions of the

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UN heads of state regarding national strategies toaddress NCD burdens7.Dental caries is the most common chronic disease

in the world, affecting more than 90% of the world’spopulation. All other mouth diseases, including oralcancer, periodontal disease, craniofacial trauma anddisorders, and Noma (a deadly disfiguring disease ofchildren in sub-Saharan Africa), have significantimpacts on general health, wellbeing and productivitythroughout life. Safe and affordable oral care is oftennot available for large parts of the population in low-and middle-income countries. In addition, there arealso high-income societies where millions live withoutaccess to oral health-care7.Both NCDs and oral diseases share common risk

factors and are linked in reciprocal ways. The mouthcan be a mirror for systemic diseases that manifestthemselves there; similarly, oral diseases can have animpact on systemic conditions. Policies that addressrisk factors for oral illnesses, such as the intake ofsugars, tobacco and alcohol, address the very samerisk factors associated with cardiovascular diseases,cancer, chronic respiratory diseases and diabetes.Other factors, such as lack of clean water and sanita-tion, poor education, low socio-economic status andpoor housing, are determinants of general health andoral health alike. In 2011 the WHO regional officefor Africa convened 17 francophone chief dental offi-cers in Ouidah, Benin, and produced a consensusstatement conveying the importance of integratingoral health into NCD programmes addressing tobaccocontrol, healthy diet and fluoride. Oral health staff atthe Pan American Health Organisation, the WHOregional body responsible for the Americas, are work-ing to integrate language and metrics into the regionaltargets and indicators as the global monitoring frame-work evolves. The World Dental Federation (FDI),representing the dental profession worldwide, hasreleased support material that will assist national den-tal associations in their advocacy with national gov-ernments to incorporate oral health into their nationalNCD strategies7.The common risk factor approach addresses risk fac-

tors common to many chronic conditions, includingoral health, within the context of the wider social envi-ronment. As causes are common to a number of otherchronic diseases, adopting a collaborative approach ismore rational than one that is disease specific. Theimmediate causes of major dental diseases, caries andperiodontal disease are diet, plaque and smoking. Oralmucosal lesions, oral cancer, temporomandibular jointdysfunction and pain are related to tobacco, alcoholand stress, trauma to teeth and other injuries. As thesecauses are common to a number of other chronic dis-eases such as heart disease, cancer, diabetes andstrokes, it is rational to use a common risk factor

approach that can be implemented in a variety of ways.Oral diseases are the most common of the chronicdiseases and are important public health problemsbecause of their prevalence and their impact on individ-uals and society, as well as the cost of their treatment.Chronic diseases such as obesity, diabetes and cariesare increasing in developing countries, with the implica-tion that quality of life related to oral health, as well asgeneral quality of life, may deteriorate8–10.In the interconnected treatment of oral health and

chronic diseases there is evidence about how fewerhospitalisations of diabetic patients could be achievedthrough periodontal therapy, and further studies areanalysing other chronic diseases and conditions suchas heart attacks, strokes and pregnancy with pretermbirth. Periodontal treatment has been associated witha significant decrease in hospital admissions, physicianvisits and overall cost of medical care in diabetics.Referring to this approach, a study showed averagesavings of US$1,814 per patient in a single year and a33% decrease in hospital admissions11.Based on these facts, our research intended to iden-

tify how much oral health is considered in the elabo-ration of public health policies aimed at improvingcare for chronic conditions, especially those related tocardiovascular diseases and diabetes.

METHOD

This research used a cross-sectional qualitativeapproach. Data were collected between 5 December2012 and 10 December 2012 from the ‘media centre’section of the WHO website (http://www.who.int),searching with the expression ‘non-communicable dis-eases’. This resulted in 12,000 publications beingfound. This was reduced to 45 publications by filter-ing in the advanced search mode and asking for ‘Findresults with all of the words, 100 results, LanguageEnglish, File Format.pdf, Occurrences in the title ofthe page, Domain who.int, Sort by date’. These docu-ments were reports, conference abstracts, plans ofaction, manuals and guidelines. All of these are storedin public and open Internet archives. Two wereunavailable. The analysis of the remaining 43 docu-ments occurred from 12 October 2012 to 15 Decem-ber 2012, using the Windows 7 ‘find’ tool to identifythe following keywords: oral health, dental caries,periodontal disease.

RESULTS AND DISCUSSION

In the 43 publications analysed, ‘oral health’ appearsseven times, ‘dental caries’ four times and ‘periodontaldisease’ does not appear. The inexpressive presence of‘oral health’ could be attributed to a broad approachto health with no compartmentalisation. What

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became of the most prevalent oral chronic conditions:‘dental caries’ and ‘periodontal disease’? The NCDsissue has become globalised beyond the capacity ofany single country or organisation and multisectoralcollaboration should be taken into consideration. Pri-vate sector initiatives such as the Global Alliance onChronic Diseases, formed in June 2009 to mobiliseresources for NCDs research in developing countries,have demonstrated efficacy1.Misunderstanding of non-communicable diseases,

with people facing barriers to making healthy choicesand facing powerful pressures to adopt unhealthyones leads to similar causality in oral health. Similarto the HIV meeting, the UN high-level meeting onnon-communicable diseases is a battleground, pittingpublic interests against powerful private ones. How-ever, unlike the HIV activism of the past, the voicesof people affected by NCDs are mostly quiet. Whetheror not the UN meeting encourages the emergence of aglobal social movement for change will shape thefuture of our health for years to come2.The inclusion of oral health in the Political Declara-

tion issued by the UN heads of state and sponsoredby WHO is a collaborative effort of many players andorganisations. Many of the same, and other partici-pants will support national planning, implementationand evaluation of integrated NCD strategies. Theseefforts involve clinicians and their representatives,dental educators, researchers, public sector adminis-trators, policy-makers and industrial leaders, as wellas NGOs working with disadvantaged populationsnationally and globally7.It is well established that partnerships and collabo-

rations are essential to success in the internationalfight against non-communicable diseases. Therefore,the American Cancer Society, the American DiabetesAssociation and the American Heart Association havejoined forces to support the UN effort. This work isbeing conducted under the banner of the PreventiveHealth Partnership, a joint initiative founded in 2004to work together to reduce the burden of cancer, dia-betes mellitus, cardiovascular disease and strokes. Theinternational goal is to raise awareness about the bur-den of NCDs globally by providing key policy andmedia stakeholders with technical assistance to informpolicy discussions, along with resources that highlightthe global burden of NCDs and the need for coordi-nated interventions3.A global monitoring framework, including 25 indi-

cators and a set of voluntary global targets for theprevention and control of non-communicable diseases,were integrated to develop a draft WHO global actionplan for the prevention and control of non-communi-cable diseases. This plan, covering the period 2013–2020 was submitted to the 66th World Health Assem-bly, through the Executive Board, and approved.

Among the 25 indicators there are none related tooral health4.A coordinated and resourced programme of work

by civil society in the lead up to and immediately afterthe UN summit will be essential to its success. Thefour leading NCD federations – International DiabetesFederation (IDF), World Heart Federation (WHF),Union for International Cancer Control (UICC) andThe International Union Against Tuberculosis andLung Disease (The Union) – have coordinated the glo-bal civil society response through the creation of anNCD Alliance that has worked alongside NGOs, theWHO, health professionals, academia, the private sec-tor and other stakeholders to form a powerful andunited voice5.The WHO guideline objectives stated that the pri-

mary goal is to improve the quality of care and out-comes in people mainly in low-resource settings. Thisguideline provides a basis for the development of sim-ple algorithms for NCD management with essentialmedicines and technology available in first-contacthealth services in low-resource settings. It recom-mends a set of basic interventions to integrate NCDmanagement into primary health care. The recommen-dations are limited to patients with certain chronicconditions, as the more complex management of otherconditions requires more specialised care. The targetusers are health-care professionals responsible fordeveloping NCD treatment protocols, which will beused by health-care staff in primary care units in low-resource settings. A guideline development group wascreated and included external experts and WHO staff.In one specific case it resulted in a 72-page guidelinefor cancer, heart disease and stroke, diabetes, andchronic respiratory disease. Surprisingly, there is nomention of oral health, dental caries, periodontal dis-ease or dentists6.Since 2000 there has been evidence that further

improvements in oral health and a reduction in oralhealth inequalities will only be secured through theadoption of oral health promotion policies basedupon the common risk factor approach. Individuallyfocused oral health education interventions are inef-fective, wasteful of limited resources and may increaseinequalities. The same applies to policies on NCDs,which must address risk factors common to manychronic conditions within their context. The potentialbenefits of such an approach are far greater than iso-lated interventions. To be effective in this style ofworking oral health professionals need to develop arange of networking and communication skills toenable them to work collaboratively with other agen-cies and professionals8,9.In October 2012, the FDI called upon its member

national dental associations to contact their ministerof health and chief dental officer: the goal was to

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ensure that concrete measures to integrate oral healthinto NCD strategies were debated during the WHOconsultations. For its part, the FDI has submitteddetailed comments on the WHO ‘Zero Draft’ docu-ment, which, without strategies and policies to ‘maxi-mise opportunities and efficiencies for mutual benefit’measures for monitoring progress, consigns oralhealth to the realm of good intentions rather thansolid actions. The FDI noted that what is most impor-tant is non-communicable disease policies througheffective prevention and early diagnosis by primaryhealth-care and multi-stakeholder interventions, toreduce the cost of NCDs to the public, governmentsand national health-care systems. In its submission,the FDI pays due regard to current constraints withinthe WHO. It emphasises, nonetheless, that it is essen-tial ‘to recognise the important role of the WHO inthe global health leadership by retaining the OralHealth in the Work Programme proposal and amongthe priorities in the fight against NCDs’12.According to these concepts, Curitiba, in southern

Brazil, has been innovating in dealing with chronicconditions, using a chronic conditions care modeldeveloped for the Unified Health System (SUS). Fam-ily health teams are formed by individuals from differ-ent disciplines such as the family doctor andcommunity nursing staff, the oral health team, socialworker, pharmacist, psychologist, nutritionist, physio-therapist, physical education teachers and communityhealth agents. They work together, interconnected byhealth-care networks, providing health care for a spe-cific community13.The WHO Global Action Plan for Prevention and

Control of Non-communicable Diseases 2013–2020contains specific mention of oral diseases. The planwas adopted by WHO member states on 27 May atthe 66th World Health Assembly (Geneva, May20–28, 2013). The reference to oral diseases reflectsgovernment commitment in the 2011 UN PoliticalDeclaration on NCDs, which recognises that oral dis-eases share risk factors with the four major chronicdiseases: cancer, diabetes, cardiovascular and respira-tory disease, and thus benefits from a commonapproach. However, there are only two mentions oforal diseases in the 55-page document14.

CONCLUSION

The WHO has played an undisputed leadership rolein combating chronic conditions around the worldthrough largely efficient health policies. These actionshave already brought many benefits to millions ofpeople. Partnerships with several organisations in dif-ferent areas seem highly positive. Nevertheless, it isundeniable that oral health has been overlooked inpolicies aimed at combating chronic conditions, par-

ticularly cardiovascular diseases and diabetes wherethere are more interactions and oral manifestations.In addition, oral health associations should establishpartnerships and/or alliances to advocate with theWHO for multisectoral policies geared primarily forthose professionals who work in primary care.Health-care networks should fulfil their role of inter-connecting teams, leveraging what is offered by estab-lished policies developed in consensus with thevarious sectors involved.

Conflict of interest

None declared.

REFERENCES

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9. Watt RG, Sheiham A. Integrating the common risk factorapproach into a social determinants framework. CommunityDent Oral Epidemiol 2012 40: 289–296. doi: 10.1111/j.1600-0528.2012.00680.

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10. World Health Organization (WHO). Oral Health, GeneralHealth and Quality of Life. World Health Organization; 2005.Publication no. 05-024158. Available from: http://www.who.int/bulletin/volumes/83/9/editorial30905html/en/index.html. Accessed11 December 2012.

11. Jeffcoat M. Periodontal Therapy Reduces Hospitalizations andMedical Care Costs in Diabetics. 2012. Available from: http://www.medicalnewstoday.com/releases/243335.php. Accessed 11December 2012.

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13. Mendes EV O Cuidado das Condic�~oes Cronicas na Atenc�~aoPrim�aria �a Sa�ude: O Imperativo da Consolidac�~ao da Estrat�egiada Sa�ude da Familia, 1st ed, p. 324–327. Bras�ılia: Organizac�~aoPan-Americana da Sa�ude, Organizac�~ao Mundial da Sa�ude, Con-selho Nacional de Secret�arios de Sa�ude; 2012.

14. World Health Organization (WHO). Follow-Up to the PoliticalDeclaration of the High-Level Meeting of the General Assemblyon the Prevention and Control of Non-Communicable Diseases.Geneva: World Health Organization (WHO); 2013. Publicationno. WHA66.10. Available from: http://www.fdiworldental.org/media/26435/who_ncd-action-plan_2013-20_a66_wha.pdf.Accessed 6 April 2013.

Correspondence to:Gerson Luis Schwab,

School of Health and Biosciences,Pontifical Catholic University of Paran�a (PUCPR),

Rua Mato Grosso, 80, apto. 403,Curitiba, PR 80620-070, Brazil.Email: [email protected]

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