​Received: 31 December 2022 | Revised: 5 January 2023 | Accepted: 17 January 2023
DOI: 10.1111/odi.14516
EDITORIAL
WHO's global oral health status report 2022: Actions,
discussion and implementation
​The Global Oral Health Status Report (GOHSR) directed towards the
promotion and achievement of the universal health coverage (UHC)
for oral health by the year 2030 was published by the World Health
Organization (WHO) in November 2022. The report reviews the
latest evidence-­based data on the status of oral health worldwide
in terms of oral disease burden, risk factors, distributions of dental
practitioners, health benefits package and the national health re-
sponse for oral health crises (World Health Organization, 2022). The
first of its kind report aims to foster discussion and implementation
of the policy reforms on a national and international level amongst
the 194 member states. Most importantly, the report presents the
first-­ever country-­wise oral health profile with critical data on the
oral health situation in each of the WHO member state.
1 | K E Y FI N D I N G S O F TH E G O H S R :
A R E N E W E D C A LL FO R AC TI O N
The WHO estimates that globally close to 3.5 billion people (ap-
proximately 50% of population) suffer from one or the other form
of oral disease (Figure 1). In fact, the global burden of oral diseases
exceeds the combined global burden of the next five most preva-
lent non-­communicable diseases by almost a billion cases. Amongst
the leading cause of oral health diseases, the report identifies un-
treated dental caries (both deciduous and permanent teeth), severe
periodontal disease, edentulism and cancer of lip and oral cavity as
the leading causes of oral disease burden (Table 1). Congenital mal-
formations especially, undifferentiated orofacial clefts (estimated
4.6 million cases globally), noma (no surveillance data available) and
traumatic dental injury (estimated 1 billion cases globally) are the
other identified oral diseases with a significant impact on the health
and well-­being of populations.
Geographically, South-­East Asian and Western Pacific countries
have the highest caseloads of oral diseases, attributable mostly due
to the presence of densely populated countries in these regions.
Shockingly, global caseload of oral disease even managed to surpass
the estimated population growth rate (50% and 45% increase, re-
spectively) between 1990 and 2019, indicating that the current mea-
sures and policies to curb the spread of oral diseases have explicitly
failed.
Economically, global burden of the oral diseases has amounted
to an annual expenditure of about US$ 387 billion in direct costs
and another US$ 323 billion in indirect costs (Table 2). Direct costs
Oral Diseases. 2023;00:1–7. wileyonlinelibrary.com/journal/odi© 2023 Wiley Periodicals LLC.
include both public and private expenditure done in outpatient
dental care and offices of dentists whilst indirect costs include pro-
ductivity losses due to the above identified leading causes of oral
disease burden. In terms of indirect costs, edentulism has the high-
est global burden costing about US$ 167 billion followed by severe
periodontal disease costing US$ 82 billion. Caries of the permanent
and deciduous teeth incurred indirect costs amounting to almost
US$ 22 billion and US$ 1.55 billion globally, respectively.
During the COVID-­19 pandemic, the oral health index also suf-
fered a colossal backslash with little to no importance given to the
oral diseases, resulting in a toll on the overall health status of the
countries. But the pandemic aside, what explains such huge burden
of oral diseases? The report explores three different root causes for
this situation. Firstly, the social determinants of oral health were
found to be in common to those of other non-­communicable dis-
eases. The political, socio-­economic, familial and historical circum-
stances largely determine the behaviours that people adopt and the
opportunities and choices available to them. Inequitable wealth and
manpower distribution and increasing racial polarization and mar-
ginalization in the society are adding fuel to the fire.
Secondly, the ever-­growing power and sophistication of targeted
commercial advertisements have led to an uneven balance. On one
hand, companies have promoted detrimental habits (smoking, alco-
holism) whilst on the other hand, fluoridation and use of fluoridated
products have promoted beneficial habits. The report overviews the
global status and the urgent need to educate and implement vari-
ous other fluoridation techniques for safe oral health for adults and
children—­not on the preventive treatment protocol but on the avail-
ability of affordable fluoridated toothpaste in over 78 countries.
The final factor is the negligent attitude of the policy planners
and insurance companies towards the inclusion of oral health care
under the umbrella of the universal health care. In today's world,
most of the dental practices are private and/or run by private enter-
prises that not only drive the cost of services but also monopolies
on the current situation by creating disparities in workforce access
and distribution. Furthermore, lack of funding in oral health research
and instrumentalization of proper surveillance tools remain equally
contributing factors.
The WHO estimates that presently there are just under 4 mil-
lion oral care providers globally (3,984,325), comprising about 2.5
million (2,465,296) dentists, 1.2 million (1,242,053) dental assistants
and therapists and nearly 300,000 (276,976) prosthetists/techni-
cians. However, these estimates are grossly underestimated. Since
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2 EDITO​RIA​L

not all countries have made available the latest statistics, along
with differences in the definitions and accreditations and inclusion
of non-­practising professionals and ‘quackery professionals’ makes
modelling extremely unreliable. Interestingly, only 1.4% of the total
number of dentists work in low-­income countries whilst more than
80% of all dentists worldwide work in either high-­ or upper-­middle-­
income countries (World Health Organization, 2022). WHO's
European and American regional countries reported the highest
dentist-­population ratio (5.67 and 5.64 per 10,000, respectively)
whilst the African region reported 17× lower dentist-­population
ratio of just 0.33 per 10,000.
Oral and dental diseases are not only about the facio-­maxillary
region but an individual's overall health. The prevalence of oral
diseases equally across the spectrum of different age groups have
also led to other adverse health effects including body-­image is-
sues, sleeplessness, social isolation, pain, discomfort, fear, anxiety
and functional limitations. Severe periodontal disease has been
strongly linked to the promotion of diabetes mellitus and cardiovas-
cular events, and to a lesser extent, to cerebrovascular disease and
chronic obstructive pulmonary disease. Challenges posed by the in-
creased use of antibiotics and subsequent antimicrobial resistance
(AMR) are aptly highlighted in the report. As stated in the report,
WHO's Global Action Plan plays a vital role in spreading awareness
about AMR and controlling the active infection rates in a timely
manner and reaching an international census of the desired moni-
toring structure.
The core structure of the pyramid of oral health care is alarming
to the extent that there is a fundamental structure of the disease
burden but not a significant reform in terms of a gold standard that
member states can work upon within the skeleton of the workforce
in each country. The four primary oral healthcare frameworks that
should be implemented include—­(1) political priority, commitment
and leadership; (2) governance and policy frameworks; (3) funding
and resource allocation; and (4) engagement of communities and
other stakeholders. The focus to use the already existing resources
and allocating new resources to be utilized by the member states
to achieve a common goal is essential. WHO further promotes the
use of advancements in digital health (telehealth, video-­supported
health) in dental medicine. Finally, the report staunchly advocates
for the inclusion of oral health care in either the BBP (basic benefits
package) or the UHC benefits package.
Are these key findings essential and possible to implement at this
stage? Owing to the status of oral health today and the alarming re-
quirement, urgent discussion and implementation are the hour's talk.
2 | D I S CU S S I O N & I M PLE M E NTATI O N O F
TH E K E Y FI N D I N G S
Clearly, despite the collective efforts by the local governments, in-
tergovernmental bodies, the UN's programs, youth associations, pa-
tient group associations, academia, research institutions and various

F I G U R E 1 Country-­wise cumulative prevalence of top five leading causes of oral diseases (global burden of disease; 2019). India and
China had the highest caseloads (632 million and 599 million, respectively) whilst Nauru and Tuvalu had the lowest caseloads (5181 and
4382, respectively). Data accessed from Institute of Health Metrics and Evaluation Global Burden of Disease Database (IHME GBDx;
available from https://vizhub.healt​hdata.org/gbd-­resul​t s/; accessed 28th December 2022).
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EDITO​RIA​L 3

TA B L E 1 Top five countries with the highest prevalence of the leading causes of oral disease burden in 2019 (for all ages and both sexes
combined).

Total cases with 95% confidence Countries with highest Oral No. of cases per % share of global
Oral disease interval (global; 2019) disease caseload country (2019) caseload

Caries of permanent Estimate—­2,029,495,070 India 366,858,183 18.1%

teeth Upper—­2,348,141,439 China 330,136,487 16.3%
Lower—­1,737,975,382
United States of America 75,034,853 3.7%
Indonesia 69,024,654 3.4%
Pakistan 52,232,325 2.6%
Severe periodontal Estimate—­1,086,825,543 India 221,084,427 20.3%
disease Upper—­1,379,710,922 China 209,627,097 19.3%
Lower—­810,684,261
United States of America 42,149,181 3.9%
Indonesia 38,105,664 3.5%
Pakistan 32,999,906 3.0%
Caries of deciduous Estimate—­520,065,521 India 98,199,025 18.9%
teeth Upper—­639,369,160 China 67,172,112 12.9%
Lower—­4 05,848,491
Pakistan 24,968,276 4.8%
Nigeria 21,082,438 4.1%
Indonesia 18,343,127 3.5%
Edentulism Estimate—­351,808,988 China 64,187,526 18.2%
Upper—­450,669,731 India 34,905,533 9.9%
Lower—­274,129,977
United States of America 24,995,120 7.1%
Brazil 21,880,208 6.2%
Russian Federation 15,849,308 4.5%
Lip and oral cavity Estimate—­1,401,286 India 327,648 23.4%
cancer Upper—­1,723,916 China 177,782 12.7%
Lower—­1,128,231
United States of America 170,538 12.2%
Pakistan 92,840 6.6%
Spain 36,953 2.6%

Note: Data accessed from Institute of Health Metrics and Evaluation Global Burden of Disease Database (IHME GBDx; Available from https://vizhub.
healt​hdata.org/gbd-­resul​t s/; Accessed 05th January 2023).

other institutions, there is still much to be done in the prevention,
early diagnosis and successful treatment of oral health diseases
globally. In this regard, the WHO has recently published the draft
Global Oral Health Action Plan (2023-­2030) on January 11, 2023
that aims to foster discussion and implementation of the key findings
highlighted in the GOHSR (available at https://www.who.int/publi​
catio​ns/m/item/draft​-­globa​l-­oral-­healt​h-­actio​n-­plan-­(2023-­2030);
accessed 29th January 2023).
Primary prevention remains the number one tool in oral health,
as most oral conditions are preventable (Bourgeois & Llodra, 2014;
Kwan et al., 2005). The global trend in healthcare in general is that
the GDP (gross domestic product) of a society is positively correlated
with the amount of money spent on the healthcare systems (World
Health Organization. Health expenditure, 2022). This presents a
great problem for lower income countries trying to implement pri-
mary prevention strategies in their healthcare programs as almost all
the health expenditures of a country originate from its own budget.
This trend is especially exemplified in dental practices—­the rich-
est societies have access to the best preventative measures and
services and are more geared towards the more lucrative, cosmetic
dental medicine, meanwhile poor income countries do not have ac-
cess to enough dental professionals and cannot get even the most
basic dental health coverage (Hayashi et al., 2014). This makes im-
plementing these strategies easier said than done. Apart from inad-
equate resources, other obstacles may include poor prior planning
of such programs and the support of key stakeholders in the society
(Molete et al., 2020). However, at the same time, it provides oppor-
tunities for creation and implementation of innovative solutions, as
highlighted by the GOHSR report (Table 3).
A good portion of the strategies towards oral health promotion
are centred around limiting the exposure to harmful factors such
as alcohol, tobacco and sugar-­rich food and beverage consumption
(Table 4). Many countries have successfully reduced tobacco product
consumption by creating attractive graphic campaigns that counter-
acted the highly effective marketing tricks of the multi-­billion to-
bacco companies. Compulsory labelling on the tobacco products has
proved to be very instrumental in public education and awareness.
Campaigns that included more emotional and more personal stories
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4 EDITO​RIA​L

TA B L E 2 Top five countries with highest direct and indirect annual expenditure related to the leading five oral diseases in 2019.

Expenditure per Per capita

Global Country with highest country (in US$, % share of global expenditure per
Type of expenditure expenditure expenditure billion) expenditure country (in US$)

Direct expenditure 387.093 billion United States of America 133.51 34.5% 405.46
US$ China 61.55 15.9% 43.96
Germany 30.88 8.0% 372.15
Japan 28.73 7.4% 227.70
Italy 19.12 4.9% 316.82
Indirect expenditure 322.686 billion United States of America 78.47 24.3% 238.46
US$ China 45.71 14.2% 31.19
Japan 23.66 7.3% 187.53
Germany 19.40 6.0% 232.24
France 11.99 3.7% 184.16

Note: Data accessed from Heidelberg University Open Research Data Translational Health Economics (Available from https://heidata.uni-­heidelberg.
de/dataset.xhtml?persistentId=doi:10.11588/data/JGJKK0; accessed 5th January 2023).

TA B L E 3 Major challenges and potential solutions for achieving better oral health and oral care, as highlighted in the GOHSR report.

Challenges Towards Better Oral Health & Care Potential solutions

Use of dental amalgam as a filling material
High carbon footprint and environmental
degradation arising from dental practices
Inclusion of oral healthcare in universal
healthcare pyramid
Implementation of at least two of the nine measures of the Minamata Convention on Mercury,
2013 including:
• Primary prevention of dental caries
• National policy on reducing amalgam use
• Promotion of mercury-­free alternatives
• Promotion of research and development
• Education of dental students to avoid use
• Remove insurance cover on amalgam-­fillings
• Encouraging insurance cover on alternatives
• Restrict use of amalgam to encapsulated form
• Adoption of best environmental practices
Steps needs to be taken to make dental practice sustainable including reducing the impact of
three largest contributing factors:
• Patient and staff travel (65% contribution)
• Products and procurement of materials (19% contribution)
• Direct energy utilization (15% contribution)
Implementation of effective stock management, recycling or replacing disposable plastic
materials with reusable alternatives. Computer use, economical printing, e-­health, digital
health, digital x-­ray can reduce the footprint considerably.
A five-­stage pyramid model should be adopted (from bottom to top):
• Fundamental prevention through self-­c are and management of risk factors
• Community oral health programmes, such as water fluoridation schemes
• Essential oral health care as the entry level to the formal health care system
• Advanced oral care provided by a dentist
• Specialized oral health care for complex and advanced disease management
The basic principle should be that the need and demand are highest at the lower levels and
decrease at the higher levels. Cost of services should have an inverse relation.

have also been shown to be effective. India's inclusion of smoking
advertisements before the projection of movies at cinema houses
and inclusion of ‘Tobacco smoking is injurious to health’ tagline in
scenes where actors are smoking are prime examples. Furthermore,
the quantity of advertisements to which the smoker is exposed is
crucial in determining the success rate of such campaigns (Durkin
et al., 2009).
One of the most neglected factors when it comes to maintaining
good oral health and oral disease prevention is the mental well-­being
of the individuals in a community or population. Tobacco and alcohol
consumption are often used as a mean to relieve anxiety and depres-
sion in people from all sections of the society (Fluharty et al., 2017;
Keyes et al., 2012; Stubbs et al., 2017). These harmful behaviours are
introduced to individuals from a very early age—­whether by media
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EDITO​RIA​L 5

TA B L E 4 WHO recommended ‘Best buys’ policy options and cost-­effective interventions for prevention and control for non-­
communicable diseases including oral diseases (only a selection is presented here).

Primary objective Policy interventions

Reduce tobacco use • Implement WHO's Framework Convention on Tobacco Control (WHO FCTC)
• Reduce affordability of tobacco products by increasing taxes
• Implement smoke-­free environments in all indoor workplaces, public places and public transport
• Effective health warnings and mass media campaigns
• Ban all forms of tobacco advertising, promotion and sponsorship
Reduce alcohol use • Implement the WHO's global strategy to reduce harmful use of alcohol
• Regulating commercial and public availability of alcohol
• Restricting or banning alcohol advertising and promotions
• Using pricing policies such as excise tax increases on alcoholic beverages
Encourage healthy eating habits • Implement the WHO Global Strategy on Diet, Physical Activity and Health
• Increase consumption of fruit and vegetables
• Implement public awareness programmes on diet and physical activity
• Manage food taxes and subsidies to promote healthy diet

Note: More detailed interventions and measures are available from the WHO's Global Action Plan for Prevention and Control of Non-­communicable
Diseases 2013–­2020 appendix 3 (available from https://apps.who.int/iris/bitst​ream/handl​e/10665/​94384/​97892​41506​236_eng.pdf?seque​
nce=1&isAll​owed=y; accessed on 5th January 2023).

promotions or through exposure to elders with similar behaviour.
Mental health and well-­being are still seen as a general stigma in
many cultures and a lot of people simply refuse to acknowledge the
existence of their problems. Additionally, many people do not have
access to mental health specialists (Morales et al., 2020), thereby,
directly affecting the efficacy of anti-­smoking and anti-­alcohol cam-
paigns in these countries and indirectly impacting oral health.
Although effective media campaigns have the potential to influ-
ence societal behaviour (Ribeiro et al., 2022; Sharma et al., 2022),
their implementation is once again limited by the financial power of
a country's economy. A possible way to circumvent this issue is on-
line advertisements. Online advertisements do not require as much
financing as traditional printed material such as flyers and pamphlets
(one-­time investments). Online advertisements also have an unprec-
edented superiority in terms of creativity and outreach and can not
only help in correction of detrimental habits but also promote pri-
mary prevention. Yet, their effectiveness would be dependent on
the placement of such advertisements (entertainment vs educa-
tional websites) (Hashemi et al., 2022).
Fluoride and fluoride products are known to prevent the rate of
tooth decay. The daily recommended dosage of fluoride can be ob-
tained through fluoridation of water supplies or the addition of flu-
oride in products such as toothpaste, salt or milk (Horst et al., 2018;
Iheozor-­Ejiofor et al., 2015; Medjedovic et al., 2015; Pollick, 2018).
Low-­income and high-­income societies face different issues in the
implementation of fluoride use, thereby requiring a tailored ap-
proach rather than ‘one-­fits-­all’ approach. Poorer countries and
sometimes even poor regions in the developed countries lack the
sufficient finances to introduce fluoride additives to drinking water
or other products (Goldman et al., 2008). In the USA, children living
in low-­income families but not below poverty line, are more likely
to live in a county with non-­fluoridated water (Sanders et al., 2019).
Water fluoridation may be an indispensable strategy in reduc-
ing rates of tooth decay, as experiences from Brazil tells us (Peres
et al., 2006). Meanwhile in the high-­income societies there is a more
and more widespread backlash against fluoridation. A good example
of this would be Ireland (Powell, 2014).
A persistent and often very difficult problem to solve that gov-
ernments encounter when trying to improve their own dental health-
care system is the lack of a sufficient number of employees such as
dentists, dental technicians etc. In fact, 69% of all dentists globally
providing services to just 27% of the world's population (Gallagher
& Hutchinson, 2018). This occurrence is primarily due to the de-
veloped countries producing more dentists and mass immigration.
What is perhaps most striking is that most of the data that focus on
the decreasing availability of primary dental healthcare are in low
socio-­economic countries. Implementing the actions mentioned in
such countries will be questionable unless proper education about
dental and oral diseases is provided.
3 | CO N C LU S I O N S
All in all, global strategies for improving dental health, although suf-
ficient for most developed countries, might not be so feasible for
countries with lower GDPs, especially from a financial and logistics
aspect. As self-­care and regular dental hygiene are the most effec-
tive factors in preventing dental diseases, the promotion of oral hy-
giene from an early age both by the schooling systems and within the
family might be the best and the least costly strategy for reducing
the global burden of dental diseases.
AU T H O R C O N T R I B U T I O N S
NJ conceptualized the present study whilst NJ, UD and IR were in-
volved in data collection, data verification, formal analysis and meth-
odology. NJ was responsible for visualizations. UD and IR wrote the
initial draft of the manuscript whilst revisions and editing was done
by NJ and SJ. Supervision was led by SJ. Resources and project
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6 EDITO​RIA​L

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