literature review on oral health

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The public health approach to oral health: a literature review.

1. Introduction

Operational definitions, 4. discussion.

• Components in Multipronged Approaches
• Aspects of cost-effectiveness

5. Conclusions

Supplementary materials, author contributions, conflicts of interest.

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Cabrera, M.; Bedi, R.; Lomazzi, M. The Public Health Approach to Oral Health: A Literature Review. Oral 2024 , 4 , 231-242. https://doi.org/10.3390/oral4020019

Cabrera M, Bedi R, Lomazzi M. The Public Health Approach to Oral Health: A Literature Review. Oral . 2024; 4(2):231-242. https://doi.org/10.3390/oral4020019

Cabrera, Mariel, Raman Bedi, and Marta Lomazzi. 2024. "The Public Health Approach to Oral Health: A Literature Review" Oral 4, no. 2: 231-242. https://doi.org/10.3390/oral4020019

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Oral Health and Older Adults: A Narrative Review

Martin s. lipsky.

1 College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT 84095, USA

2 College of Urban and Public Affairs, Portland State University, Portland, OR 97201, USA

Tejasvi Singh

Golnoush zakeri.

3 Division of Public Health, University of Utah, Salt Lake City, UT 84108, USA

Associated Data

Data are contained within the article.

Oral health’s association with general health, morbidity, and mortality in older adults highlights its importance for healthy aging. Poor oral health is not an inevitable consequence of aging, and a proactive, multidisciplinary approach to early recognition and treatment of common pathologies increases the likelihood of maintaining good oral health. Some individuals may not have regular access to a dentist, and opportunities to improve oral health may be lost if health professionals fail to appreciate the importance of oral health on overall well-being and quality of life. The authors of this narrative review examined government websites, the American Dental Association Aging and Dental Health website, and the Healthy People 2030 oral objectives and identified xerostomia, edentulism, caries, periodontitis, and oral cancer as five key topics for the non-dental provider. These conditions are associated with nutritional deficiencies, poorer quality of life, increased risk of disease development and poorer outcomes for cardiovascular disease, diabetes, and other systemic conditions prevalent among older adults. It is important to note that there is a bi-directional dimension to oral health and chronic diseases, underscoring the value of a multidisciplinary approach to maintaining oral health in older adults.

1. Introduction

By 2030, the elderly population will increase so that one in every five residents, or more than 70 million Americans, will be 65 years or older [ 1 ]. As the population ages, so will the burden of chronic disease. Among the most common diseases affecting older adults are chronic diseases of the oral cavity, including dental infections (e.g., caries, periodontitis), tooth loss, mucosal lesions, and oral cancer. These conditions can adversely affect nutrition, self-esteem, quality of life, and general health [ 2 ]. Oral health’s association with general health [ 3 ], morbidity, and mortality in older adults highlights its importance for healthy aging.

Despite its importance, poor oral health remains a common morbidity for older individuals. While improvements in dental treatments, community water fluoridation, and better oral hygiene have improved dentition, age-related changes in physiology, comorbidities, and polypharmacy make older adults more vulnerable to oral diseases [ 4 ]. Issues such as accessibility, cognitive impairment, and disability add to the vulnerability of this demographic. More than 60% of seniors lack dental insurance [ 5 ]. Not surprisingly, a high percentage of older adults have unmet dental needs and do not see a dentist annually [ 6 , 7 ].

Poor oral health is not an inevitable consequence of aging, and early recognition of common pathologies increases the likelihood of maintaining good oral health throughout a lifetime. Some patients who do not visit a dentist will see a non-dental provider, presenting opportunities to improve oral health. Oral diseases and many chronic systemic diseases share common risk factors such as unhealthy diet, tobacco use, and alcohol consumption that can benefit from education outside a dental office. The increasing body of evidence documenting a bi-directional association between oral health and chronic systemic disease indicates the importance of incorporating oral health into chronic disease management strategies. Given the inseparable linkages between oral and systemic health, it is not surprising the American Dental Association recommends a multi-disciplinary approach to oral health. However, gaps in knowledge and awareness of the importance of oral health among health professionals may present barriers to optimizing oral health [ 8 , 9 , 10 , 11 ].

This narrative review sought to review and synthesize the literature into a cohesive summary of the current knowledge related to oral health and older adults to increase awareness of its importance and address gaps in non-dental providers’ knowledge. These aims should help busy non-dental providers seeking up-to-date information about oral health to develop strategies that improve the oral health of their patients.

2. Methodology

To organize and synthesize articles related to the narrative review topic of oral health and the elderly, two authors (MSL, MH) independently reviewed government websites, the American Dental Association Aging and Dental Health website, and the Healthy People 2030 oral objectives. To determine what topics to include in this narrative review, each author (MSL, MH) developed a list of key topics about oral health and older adults. The group then discussed these to achieve consensus agreement about the five most important topics for the non-dental healthcare provider. The five identified topics included xerostomia, edentulism, caries, periodontitis, and oral cancer.

A narrative review search strategy was used to locate relevant literature on current knowledge related to oral health and older adults. For this review, the authors (MSL, MH, GZ, TS) searched PubMed from 2003 to 2023 using the MeSH terms “xerostomia,” “tooth loss,” “caries, root,” “caries, dental,” “periodontal disease,” “dental disease,” “oral cancer” and “frail older adults.” Google Scholar was also searched from 2003 to 2023 using these terms: oral health, periodontal disease, caries, dental disease, edentulism, tooth loss, xerostomia, and older adults, where the first 10 pages of results returned by the search engine were examined. Retrieved articles were reviewed by the study team for topic relevance. The bibliographies of identified manuscripts were also reviewed for additional articles of relevance and other data sources potentially relevant to this review. When appropriate, governmental websites such as the Centers for Disease Control and Prevention and the National Institutes of Health were used as statistical and epidemiologic data sources. The authors (MSL, MH, GZ, TS) considered all types of peer-reviewed and full-length studies in English, which included randomized controlled trials (n = 5), clinical trials (n = 5), observational studies (n = 56), retrospective studies (n = 15), meta-analyses (n = 1), systematic review articles (n = 4), and other types of reviews (n = 41). For the guiding principles of this review, we used a critical appraisal tool called SANRA (Scale for the Assessment of Narrative Review Articles) to control for the quality of the review process regarding findings in this manuscript [ 12 ]. SANRA covers the following topics: (1) explanation of the review’s importance/relevance, (2) statement of the aims of the review, (3) description of the literature search, (4) targeted referencing, (5) solid logic or scientific reasoning, and (6) adequate presentation of relevant and appropriate endpoint data, also with conclusions.

The value of a narrative literature review is that it can provide an overview of a content area or subject. While this type of review typically employs a non-systematic review strategy, it still plays a vital role by providing readers with up-to-date knowledge about a specific topic [ 13 ]. For healthcare professionals, a narrative review can efficiently summarize large amounts of information about a patient care topic issue into just a few pages [ 14 ].

3. Xerostomia

Xerostomia is the sensation of oral dryness characterized by a reduction in salivary flow and alterations in saliva composition [ 15 ]. While the subjective complaint of dry mouth and xerostomia are sometimes used interchangeably, true xerostomia is the consequence of acute or chronic salivary gland hypofunction with inadequate salivary secretion. Typically, patients complain of oral dryness when the salivary secretion is reduced by >50%. However, the sensation of dry mouth can also occur despite the normal secretory function of the salivary glands [ 16 ], a condition known as pseudo-xerostomia or false xerostomia [ 17 ]. Causes of this subjective symptom include changes in the composition of saliva [ 16 ], mouth breathing, atypical oral and facial symptoms, burning mouth syndrome, oral dysesthesia, and mental, psychological, and psychiatric disorders. In over half of false xerostomia cases, a 50% decrease in the amount of oral fluids was observed [ 18 ].

Various age-related factors, including changes in salivary gland structure and function, medication use, systemic diseases, and psychosocial aspects, contribute to xerostomia in older individuals [ 19 ]. As many as one in two older adults in a primary care setting experience some degree of dry mouth, with a higher prevalence among females [ 19 , 20 ]. Medication plays a pivotal role in the increased prevalence as older adults are more likely to be prescribed multiple medications, many of which can induce xerostomia as a side effect [ 21 ].

The diagnosis of xerostomia is primarily based on history and physical examination. Findings may include a lack of pooled saliva, sticky mucous membranes, reddened mucosa, and a loss of tongue fissuring and papilla. If necessary, sialometry is a diagnostic tool that can objectively measure salivary flow rates and assess salivary gland function [ 19 ].

The most frequently reported cause of xerostomia is xerostomic drugs [ 22 ]. These medications induce xerostomia by directly suppressing the production of acetylcholine or blocking either muscarinic or adrenergic receptors [ 23 ]. Other causes of xerostomia include head and neck radiation, which can damage salivary glands, Sjogren’s syndrome, and autoimmune diseases, such as SLE, which affect salivary gland function [ 24 , 25 ].

While often thought of as merely a nuisance, xerostomia exerts a substantial impact on affected individuals, influencing not only their oral health but also their social and emotional life. A dry mouth can lead to difficulties speaking, chewing, and swallowing, diminishing a person’s overall quality of life [ 19 ]. It also increases the susceptibility to dental caries, periodontal disease, halitosis, and candidiasis. Psychosocial factors, including emotional stress and anxiety, can exacerbate the sensation of dry mouth in elderly individuals and compound the impact of xerostomia [ 26 ]. Xerostomia also contributes to altered oral sensation among cancer patients, which can adversely affect their relationship with food, quality of life, and overall health outcome [ 27 ].

Treatment objectives for xerostomia can generally be categorized into three primary areas: increasing oral moisture and salivary flow, addressing the underlying systemic condition, and preventing tooth decay [ 28 ]. Xerostomia associated with systemic diseases requires optimizing care for the underlying cause, educating patients about hydration, and avoiding triggers like tobacco, coffee, alcohol, and hard-to-chew foods [ 29 ]. Promoting optimal oral hygiene and dental care minimizes dental complications associated with reduced salivary flow.

Strategies to improve oral moisture include increasing fluid intake, saliva substitutes, xylitol gum, sucking on mints or candy, and adjusting or discontinuing xerogenic medications [ 21 ]. Saliva substitutes come in several forms, including sprays, lozenges, and gels, that may be used before meals and as needed. Unfortunately, they can be expensive and are variably effective with a limited duration of action. Since medications often affect salivary gland function, reviewing a patient’s medication list and discontinuing or switching to a drug with less effect on saliva flow should be considered. Anticholinergic and antidepressant drugs are among the most common offending agents, but more than 500 drugs can affect salivary gland function [ 30 ]. Table 1 outlines drug classes associated with dry mouth and examples of offending agents from each class.

Classes and characteristics of drugs.

ACH = acetylcholine; NSAIDs = nonsteroidal anti-inflammatory drugs.

Two FDA-approved drugs that stimulate salivary flow are cevimeline and pilocarpine [ 31 , 32 ]. Both work on muscarinic receptors to stimulate salivation but require some residual salivary gland function to work and need up to a three-month trial to determine their efficacy [ 33 ]. Side effects include sweating, nausea, and rhinitis. Topical physostigmine is an alternative option that may have fewer side effects [ 34 ]. While pharmaceutical interventions can provide relief, it is essential to include their use as part of a comprehensive approach.

Adjunct aids also play a pivotal role in managing the adverse consequences of xerostomia. These may include implementing a low-sugar diet to reduce the risk of dental caries [ 32 ], appropriate fluoride supplementation and fluoride mouthwash to strengthen enamel. Antimicrobial mouthwashes can aid in maintaining oral hygiene and preventing infections in individuals with compromised salivary function [ 35 ]. Table 2 summarizes the management of xerostomia.

Management of xerostomia.

4. Edentulism

Edentulism, or the complete loss of natural teeth, is a significant concern for overall well-being. Edentulism can be the result of congenital, iatrogenic, or traumatic causes, but dental caries and periodontal diseases are the main causative factors of teeth loss in the elderly [ 36 ]. Edentulism often represents the final stage of untreated caries or periodontal disease [ 37 ]. Although the prevalence of complete tooth loss has declined due to improved oral health care and access to dental services, edentulism remains a major problem for older adults. About one in six older adults (17%) in the US have lost all their teeth. Among older adults who are current smokers, 43% had lost all of their teeth, which is more than three times the prevalence among those who never smoked (12%) [ 38 ]. Women are also more susceptible to edentulism [ 39 ]. In contrast to the declining rates of tooth loss seen in developed countries, some note an opposite trend in developing nations [ 40 , 41 ].

Studies link several behavioral risk factors, such as tobacco use, consumption of alcoholic beverages, and a poor diet, to edentulism [ 42 ]. Additionally, systemic conditions such as diabetes, cardiovascular disease, hypertension, and endocrine disorders can contribute to tooth loss in the elderly [ 43 ]. Socioeconomic factors, including low income, no dental insurance, minimal education, and limited access to dental care, are also associated with an increased prevalence of edentulism [ 44 , 45 ].

Addressing edentulism is important because of its harmful effects on oral and general health. Oral consequences include mandibular bone loss, impaired masticatory function, an unhealthy diet, social disability, and poor quality of life. Denture use is associated with denture stomatitis, an inflammatory condition of the palatal mucosa resulting in redness, swelling, and tenderness [ 46 ]. It occurs more commonly when dentures are not properly fitted, are not removed nightly, or when dentures are not cleaned properly. Wearing dentures alters the oral microbiome, and about 90% of dental stomatitis is due to an overgrowth of candida [ 47 ]. Good denture hygiene is the most important aspect of treatment and includes removing dentures at night, properly cleaning and disinfecting dentures, and storing them overnight in an antiseptic solution. Often, a topical antifungal agent and antimicrobial mouthwash such as chlorhexidine are prescribed [ 46 ]. Cases that fail to respond to the usual treatments suggest the possibility of systemic diseases, such as type 2 diabetes mellitus, that compromise the ability to fight infection [ 48 ].

Edentulous individuals are also at risk for nutritional compromise. For every five teeth lost, a person is 1.42 times more likely to have a decreased intake of vital nutrients and is also at greater risk for obesity [ 49 ]. Other comorbid conditions associated with edentulism include cardiovascular disease, rheumatoid arthritis, pulmonary diseases (including chronic obstructive pulmonary disease), and cancer. Not surprisingly, a reduced number of natural teeth that are not restored increases the risk of mortality [ 49 ].

Managing edentulism requires a comprehensive approach. Removable dentures, implant-supported fixed prostheses, and implant-supported dentures are among the available treatment options [ 50 ]. Individualized treatment plans tailored to each patient’s unique needs and preferences are crucial in achieving successful outcomes and improving their quality of life [ 51 ]. Regular tissue check-ups are essential to ensure the health and stability of oral prostheses and prevent complications [ 52 ]. Moreover, ongoing patient education is paramount since it empowers elderly individuals to maintain good oral hygiene practices [ 53 ].

Caries is a very prevalent oral health problem [ 54 ]. Commonly known as tooth decay or cavities, caries is a dental condition characterized by the demineralization of the tooth structure due to the action of cariogenic bacteria metabolizing sugars to produce acid [ 55 ]. This acid attacks and damages the tooth surface, leading to caries formation [ 55 ]. Key factors contributing to caries development include the presence of cariogenic bacteria, consumption of sugary drinks, high-carbohydrate diets, and inadequate oral hygiene practices [ 56 ]. Due to age-related salivary and immune function changes, multiple co-morbidities, and medication-induced xerostomia, caries are the most frequent dental pathology encountered among the elderly [ 57 ]. Gingival recession, which is common as individuals age, makes root caries more common among older adults.

The relationship between systemic diseases and caries is significant, with several medical conditions, such as diabetes and polypharmacy, associated with dental caries. Xerostomia greatly increases the risk of caries [ 58 ]. Maintaining oral health is particularly crucial for geriatric populations, as more adults are retaining their natural teeth, emphasizing the importance of preventive measures [ 59 ].

Management of dental caries includes both preventive and treatment strategies. Preventive measures are essential for mitigating caries risk and include regular semi-annual dental visits, professional cleanings, and fluoride use [ 60 ]. Proper at-home oral hygiene practices play a pivotal role in reducing the prevalence of caries, particularly among the elderly population. Educating individuals about dietary choices, the importance of regular dental visits, and the correct use of fluoride products can empower them to take proactive steps to preserve their oral health [ 61 ].

Fluoride remains a cornerstone in caries prevention, with daily fluoride concentration recommendations proving highly effective in remineralizing teeth. For older populations, especially those in institutionalized settings, nursing homes, or home-bound adults, the use of higher fluoride toothpaste and fluoride varnish concentrations is recommended over conventional toothpaste [ 61 ]. Daily use of a 0.2% NaF mouthwash also reduces caries risk [ 62 ].

Research supports the use of fluoride toothpaste (5000 ppm) twice daily and monthly fluoride varnish application as effective strategies for reducing caries risk [ 63 ]. Additionally, for individuals with root caries, the application of 5% NaF four times a year and yearly application of silver diamine fluoride have been proposed as beneficial interventions [ 64 ]. While fluoride is well-accepted as a tool for reducing caries, a systematic review highlights the need for further research on the best strategies for fluoride use in caries prevention among older adults [ 60 ]. Some additional products, such as chlorhexidine, xylitol, and casein phosphopeptide-amorphous calcium phosphate, also reduce cariogenic bacteria, but to date, studies do not provide conclusive evidence of their benefit in arresting caries development or tooth remineralization.

Dental caries merit treatment to control pain and to prevent tooth loss, which adversely affects aesthetics, chewing efficiency, speech, and social interaction. Untreated caries may also progress to irreversible pulpitis, tooth loss, and abscess formation, which can spread to surrounding tissues. Symptoms include thermal sensitivity and mild-to-severe pain. Overall, about one in five individuals over age 65 have dental decay that needs treatment [ 65 ]. As people live and retain their teeth longer, it is likely there will be an increase in untreated caries in this growing demographic [ 66 ].

Traditional treatment involves surgical intervention and restoration [ 67 ]. Advanced dental caries may necessitate root canal treatment or extraction. Optimizing treatment should be individualized and incorporate factors such as overall health, decisional capacity, cognition, physical disability, and personal preference. Silver diamine fluoride (SDF) application can arrest cavities and is emerging as a cost-effective nonsurgical option for older individuals with medical, physical, or mental issues that make restoration challenging or for those who have difficulties affording dental care [ 68 , 69 , 70 ]. While safe and effective, a disadvantage is that SDF turns the decayed area permanently black.

6. Periodontitis

Periodontal disease encompasses gingivitis and periodontitis and is characterized by bacterial infection leading to gingival inflammation, tooth loss, bone resorption, and gingival recession [ 66 ]. Gingivitis is the earliest stage of periodontal disease and is used to describe inflammation between the gingival line and tooth. Gingivitis can often be reversed with improved oral hygiene [ 71 , 72 , 73 , 74 ]. Periodontitis occurs when the microbially induced, host-mediated inflammation progresses into a chronic, destructive, irreversible disease state that damages the tooth attachment and the supporting bone [ 75 ]. Tooth loss and edentulism represent the final stages of untreated periodontitis [ 75 ].

Epidemiological studies note the greater loss of attachment with increasing age, and by age 65, about 70% of individuals have periodontitis [ 76 , 77 ]. Some evidence suggests that age-related changes in the immune system, cellular senescence and “inflammaging”, and impaired wound healing play key roles in the pathogenesis of periodontal disease [ 76 ]. The risk factors for periodontitis in older adults are like those in younger age groups and include inadequate brushing and flossing, being poorer, less educated, non-insured and cigarette smoking [ 75 ].

Among the aging population, systemic diseases have been identified as accelerators of periodontal disease progression. Diabetes mellitus, respiratory diseases, cardiovascular disease, stroke, osteoporosis, arthritis, and Alzheimer’s disease have all been linked to an increased risk of periodontal disease [ 66 , 78 ]. Evidence also suggests there is a bi-directional link between periodontitis and systemic disease, with associations established for periodontitis and an increased risk for several chronic diseases, including cardiovascular diseases [ 79 ], diabetes, rheumatoid arthritis, cancer, and chronic obstructive pulmonary disease [ 80 , 81 ].

Tobacco use is the most important modifiable risk factor, and smoking cessation reduces the risk of periodontitis and tooth loss [ 82 ]. Moreover, over half of adults 65 years and older report taking four or more prescription drugs to manage chronic conditions, and some drugs, including those for cardiovascular diseases and diabetes, cause xerostomia, which can exacerbate periodontal issues [ 83 , 84 ].

Gingival swelling, redness, and bleeding when brushing or flossing suggest periodontal disease [ 76 ]. A dentist establishes the diagnosis of periodontal disease by using a probe to assess bleeding and by measuring the depth of the periodontal pocket or gap between the gingival and the tooth and how far down it is until the gingival attaches to the tooth [ 85 ]. Probing depths greater than 3 mm indicate periodontal disease, and these pockets serve as a breeding ground for bacterial pathogens. Studies demonstrate that high levels of specific bacteria, including Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Fusobacterium nucleatum, are detected when periodontal disease is present [ 86 ]. In addition to the clinical exam, radiographs are indicated for individuals with clinical evidence of periodontal destruction to assess alveolar bone loss.

Restorative considerations, such as indirect restorations, crowns, bridges, partial dentures, and implants, potentially increase plaque accumulation and caries risk, necessitating extra measures in these patients to mitigate bacterial growth in the periodontium [ 87 ]. This is particularly relevant to older adults who require frequent dental restorations to maintain oral function and aesthetics.

Prevention strategies for periodontal disease involve controlling co-morbidities and, when necessary, restorative treatments to maintain oral health [ 76 ]. Dentists should assess and stage the degree of periodontitis and incorporate the medical history when formulating treatment plans. Chlorhexidine mouthwash, a broad-spectrum oral antimicrobial rinse, helps limit plaque formation, although its long-term use may lead to tooth staining [ 88 ]. Chlorhexidine has both a bactericidal action and a prolonged bacteriostatic action due to absorption into the enamel. Chlorhexidine also comes in a wafer form that can be directly inserted into the periodontal pocket. Electric toothbrushes, interdental brushes, water flossers, and oral rinses are also recommended to reduce the microbial burden in the oral cavity [ 89 ].

Regular dental check-ups every six months to assess hygiene and home care techniques, monitor probing depths, and detect bone loss are essential in the management of periodontal disease [ 84 ]. Additionally, comprehensive health check-ups can help identify and address underlying systemic conditions that may contribute to gingival disease. It is crucial to recognize that periodontal disease can have a significant impact on both life expectancy and quality of life if not promptly assessed and managed in older individuals.

7. Oral Cancer

Oral cancer (OC) is the most common form of head and neck cancer and includes cancers of the lips, tongue, palate, oropharynx, tonsils, and other oral structures. The most common type is squamous cell carcinoma. OC is a disease of older adults with an average age of 64 years at the time of diagnosis. Each year, there are over 54,000 new cases and 11,000 deaths from oral cancer [ 90 ].

The non-dental provider’s role consists primarily of prevention and early diagnosis. About three out of four cases occur in individuals with one or more risk factors, and counseling patients about these risks offers an opportunity for primary prevention [ 91 ]. Tobacco use is the strongest risk factor, and smoking tobacco and smokeless tobacco products both increase the risk of OC [ 92 ]. Alcohol, particularly heavy drinking, also increases the risk of oral cancer. Smoking and alcohol act synergistically, and individuals who both smoke and drink increase their OC risk by as much as 30 times more than nonsmokers and drinkers [ 93 ].

OC is also associated with the human papillomavirus (HPV) [ 94 ]. While the HPV vaccine protects against several types of HPV linked to oral cancer, the vaccine first became available in 2006 [ 94 ]. Since cancer takes years to develop, a significant decline in OC from HPV vaccination may not become evident until the 2040s [ 95 ]. While not a common practice in the US, chewing betel nut is endemic in large parts of Asia and increases the risk of OC.

Early diagnosis improves outcomes. The principal means for an early diagnosis is a physical examination that consists of systematic inspection and palpation. The 5-year survival rate for an early-stage OC is over 80%, but only about a quarter of cases are diagnosed at an early stage [ 96 ]. Once the cancer spreads to the surrounding tissues or the regional lymph nodes, the 5-year survival rate declines, and for individuals presenting with distant metastases, the 5-year survival falls to 40% [ 97 ]. An awareness of the common presenting symptoms, such as a non-healing lesion, red or white patches, and hoarseness, is key to making an early diagnosis. A thorough visual inspection of the entire oral cavity, digital palpation, and lymph node assessment detects most OCs [ 98 ]. Removing precancerous lesions, such as leukoplakia or erythroplakia, reduces the incidence and mortality of OCs. Leukoplakia are white patches that do not wipe off and cannot be characterized clinically or pathologically. Erythroplakia is the red counterpart to leukoplakia and refers to a red patch of tissue without an obvious cause. When scraped, erythroplakia tends to bleed easily. Squamous cell carcinomas are usually present as a non-healing ulcer or mass. Consequently, suspicious lesions, growths and non-healing ulcerations merit referral for evaluation and biopsy. Lesions that appear benign and relate to a reversible condition, such as local irritation or infection, can be treated and reassessed in 10 to 14 days [ 99 ]. Failure to improve after 2 to 3 weeks indicates the need for additional testing [ 99 ].

8. Implications

The American Dental Association advocates a multidisciplinary approach to maintaining oral health in older adults. Individuals who visit a primary care provider may not have a dentist, creating opportunities for other health professionals to improve oral health through education and appropriate referrals. Early recognition of dental disease and referral increases the likelihood of individuals retaining their natural teeth, which can impact nutrition, self-esteem, and overall health. A multidisciplinary approach recognizes a growing body of evidence linking oral health with several chronic diseases that are prevalent among older adults, including diabetes, cardiovascular diseases, rheumatoid arthritis, Alzheimer’s disease, and Parkinson’s disease [ 3 , 100 ]. These systemic diseases and their related medications place older adults at greater risk for oral health conditions, such as periodontal disease, dental caries, and even oral precancerous and cancerous lesions. Often overlooked is that there is a bi-directional dimension to oral health and chronic disease. Studies demonstrate that addressing oral pathology can improve blood pressure and blood sugar [ 101 , 102 ]. Medications can adversely affect oral health, and involving pharmacists along with dentists and primary care providers can help develop comprehensive care plans tailored to the unique needs of each patient [ 103 ].

9. Conclusions

Xerostomia, edentulism, caries, periodontal disease, and oral cancer represent five common oral pathologies among elderly patients. These conditions are associated with nutritional deficiencies, poorer quality of life, increased risk of disease development and poorer outcomes for cardiovascular disease, diabetes, and other systemic conditions prevalent among older adults. Opportunities to improve oral health may be missed by health professionals who may fail to appreciate the importance of oral health on overall well-being and quality of life.

Acknowledgments

The authors thank the Clinical Outcomes Research and Education at Roseman University of Health Sciences College of Dental Medicine and the Analytic Galaxy for the support of this study. They also thank Duane Callahan for reviewing and providing feedback on the manuscript.

Funding Statement

This study has not received any external funding.

Author Contributions

M.S.L.: contributed to study conception, study design, data interpretation, original draft preparation, and review and editing. T.S.: contributed to data collection, original draft preparation, and review and editing. G.Z.: contributed to data collection, original draft preparation, and review and editing. M.H.: contributed to study conception, study design, data interpretation, funding acquisition, original draft preparation, and review and editing. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflicts of interest.

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• Published: 28 July 2023

Oral health equity for rural communities: where are we now and where can we go from here?

• Hannah Theriault 1 &
• Gemma Bridge 2  

British Dental Journal volume  235 ,  pages 99–102 ( 2023 ) Cite this article

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Oral health is embedded in overall health and contributes to physical, social and mental wellbeing. Most diseases are preventable, and yet, oral diseases pose a significant public health problem and an economic burden globally. Poor oral health is a risk factor for certain systemic diseases, such as cardiovascular disease, diabetes and lung pathologies. Rural populations are disproportionately affected by oral disease, with higher levels of periodontal disease, caries and the loss of teeth. These issues are worsened by barriers in access to oral healthcare services and minimal promotion of healthy behaviours in rural communities. Certain interventions, including mobile dental clinics, teledentistry, dental outreach camps and educational initiatives, have been successful in addressing rural challenges. Policies and action plans should be considered by public health officials to reduce the disparities in oral health among rural communities, reduce the overall burden of oral health and promote health equity.

Most oral diseases are preventable, but if left untreated can negatively impact the wellbeing of individuals and have high societal costs.

Rural populations are disproportionately affected by oral disease due to limited access to oral healthcare services and limited support to maintain healthy behaviours.

Interventions, such as mobile dental clinics and teledentistry initiatives, could improve oral health outcomes for rural communities. Policies to strengthen and expand oral health promotion and access to care should be implemented.

You have full access to this article via your institution.

Introduction

Oral health is a key indicator of overall health, contributing to physical, psychological and social wellbeing. 1 Good oral health enables individuals to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex. 1 Globally, oral diseases affect approximately 3.5 billion people, with caries being the most common condition. 2 It is estimated that two billion people suffer from caries of permanent teeth and 520 million children suffer from caries of primary teeth. 2 Poor oral health is a risk factor for certain systemic diseases, such as cardiovascular disease, diabetes and lung pathologies. 3 Poor oral health has an economic impact, with over 34 million school hours and more than $45 billion in productivity lost annually due to dental emergencies in the United States alone, 4 while in the UK, the NHS spends approximately £2.25 billion on dental treatment annually. 5 Moreover, while most oral health conditions are preventable and can greatly improve quality of life when treated in the early stages, the NHS spent around £50.5 million on tooth extractions in children under 19 years old, mostly for tooth decay, in 2015-16. 6

Inequalities in the experience of oral health are present globally; people on low incomes are associated with an increased prevalence of dental disease. 7 , 8 Another important factor that contributes to reduced oral health status is rurality, that is, living in a remote area. It has been posited that worse oral health can be explained, at least in part, by reduced access to healthcare services. 9 , 10 , 11 Despite this, oral health policy fails to include rurality as a concept to consider. Evidence from the UK context indicates that only 1% of policy documents from Wales, and none from England and Northern Ireland, mention rurality as a determinant of poor oral health. 12 This paper aims to describe the current inequalities in oral health among rural populations, highlight the impact on society and discuss possible interventions and policy approaches that could be implemented to address this issue.

Literature review

Rurality and access to oral health care.

Poor oral health is more prevalent among rural populations, with increased levels of periodontal disease and decayed, missing due to caries, and filled teeth (DMFT). 13 , 14 , 15 A smaller percentage (73-75%) of children in rural areas report good oral health and receive preventive dental care than urban children (78%). 16 Data also indicate that people in rural areas have an increased prevalence of partial edentulism (removal of several teeth) compared to those in urban areas (45% compared to 38.4%, respectively). Partial edentulism is even higher (51.3%) in high poverty rural areas. 17 The same phenomenon is observed with full edentulism, with a prevalence of 4.3% in urban cities compared to 8.2% in rural counties and 10.5% in high poverty rural areas. 17

Rurality and reduced oral health status may be explained by three key factors: namely, geography, availability of health care professionals, and rural culture. 9

Access to health care is affected by distance, isolation, weather and transportation. Rural patients report feeling isolated because of distance. Many people living in rural areas have to travel over 60 minutes to access dental care, 18 which poses additional costs to accessing care and therefore additional barriers for those on low incomes. Such distances can lead to stress for rural patients, their families and caregivers. 9 Pereira da Silva and Souto de Medeiros found that rural adolescents showed a high prevalence of a negative impact of oral health on their quality of life. 19 Weather can also make it difficult to seek care. 20

The quality of oral health care in rural areas is affected by a high turnover of primary care providers and a significant lack of specialists. 9 , 20 Rural dwellers depend almost exclusively on local family physicians and the high rate of turnover was reported as distressing. 9 Furthermore, successful referral and access to specialised care was affected by rural providers' relationships with urban providers. 9 As a result, people living in rural areas have limited access to specialised care, and in turn, are left feeling helpless if they suffer from severe or complex oral disease.

Rural culture, characterised by low health literacy and reticence to seek care, 9 , 21 can further impact on access to and utilisation of healthcare services. Low health literacy can foster unhealthy behaviours, false beliefs and lead to an increased vulnerability to adverse health outcomes. 9 Furthermore, rural dwellers who suffer from chronic diseases may be disadvantaged, as self-management is complex and requires the necessary knowledge and support. 9 Rural culture can imply an obligation to 'make do' with available resources and solve problems independently, which can contribute to the severity of conditions. 9 Those living in rural areas may be unwilling to seek care and experience vulnerability when they decide to. Barriers in accessing care for those living in a rural location can lead to a sense of defencelessness and marginalisation among rural communities, which can affect wellbeing and willingness to seek care. 9

Impact of poor oral health among rural communities on society

Poor oral health issues among rural communities also pose financial burdens on the healthcare system. The economic burden of oral health disease occupies a large share of many countries' healthcare budget. In 2018, the USA reported the total annual costs related to dental care to be $136 billion 22 (US dollar), which is forecast to continue increasing to $272 billion in 2040. 23 This trend is not limited to the USA; dental expenditures in 32 Organisation for Economic Cooperation and Development countries are predicted to increase substantially, ranging from $485 billion to $728 billion in 2040. 23 Increasing expenditure on oral health is observed among low- and middle-income countries as well, with the dental care being a $2 billion industry in India, with an unprecedented year-on-year growth rate of 30%. 24 These trends highlight the need for a shift towards preventive care in order to reduce unnecessary spending.

It is in the best interest of the health system to address oral health inequalities to prevent unnecessary oral emergencies and hospitalisations. 18 Limited access to dental care is a key reason for the high prevalence of untreated oral diseases. 25 As such, it is important to increase access so that oral diseases can be treated as soon as they arise. However, in conjunction with this, it is also important to promote preventive services, as they are typically more cost-effective than restorative services by preventing the incidence of disease in the first instance. 26

Pathway to improving oral health status for rural communities

To improve overall health and wellbeing, it is critical to consider oral health as a central part of overall health and a stepping stone to improving quality of life. Reducing health inequities within and between countries is a goal of health systems worldwide and has been a priority for the public health sector since the World Health Organisation's (WHO's) Ottawa charter for health promotion in 1986. 27 The cost of such inequities can be measured in human terms, such as premature death and disability, as well as in economic terms, such as productivity losses, lost taxes, increased welfare and direct costs to the healthcare system. 28 To reduce these health inequities, oral health must be taken into consideration as a public health priority. The World Health Assembly recently approved a 'resolution on oral health' which recommends a shift from the traditional curative approach towards a preventive approach. 29 This should include a promotion of oral health and includes timely, comprehensive and inclusive care within the primary healthcare system. The resolution affirms that oral health should be firmly embedded within the noncommunicable disease agenda and that interventions should be included in universal health coverage programmes. 29

Policies to improve oral health among rural communities

The global strategy on oral health , which was adopted in May 2022, focuses on six objectives: oral health governance; oral health promotion/prevention; oral health workforce; oral health care integrated in primary health care and universal health coverage; oral health information systems; and oral health research. 30 Oral health being the most common noncommunicable disease in the region, the WHO regional office for South East Asia has published an action plan to reach universal health coverage for oral health. Certain core actions could be applied similarly to address oral health in rural populations. The first being to establish an effective national oral health coordinating entity, which can allow for effective planning, resource management and should include a capacity to work with private sectors. 30 Secondly, to strengthen and expand health-promoting environments through policies and activities that foster environments more conducive to health and empowers populations to improve their own oral health and wellbeing. 30 Furthermore, integrated oral health workforce planning must be ensured, as well as the design and implementation of effective workforce models, which can address shortages and misdistributions of oral health professionals. 30 Finally, the action plan touches on teledentistry and the importance of the promotion of patient-centred digital innovations to lower access thresholds and foster inclusiveness. 30

The WHO has published a global policy recommendation on increasing access to health workers in remote and rural areas. 31 One key factor is education: medical schools play a major role by enrolling students from rural backgrounds and/or establishing schools in remote areas. This should be paired with curricula suitable for rural health needs and students' rotations in rural areas. Secondly, regulatory interventions should be implemented, which create conditions for rural health workers to do more, to make the most of compulsory service requirements, and provide education subsidies, with enforceable agreements of return of service in rural or remote areas. Financial incentives are also recommended, such as hardship allowances and housing grants, to outweigh the opportunity costs associated with working in rural areas. Finally, personal and professional support are critical to ensure rural health worker retention. It is important to pay attention to living conditions for health workers and their families, provide a good and safe working environment, implement appropriate outreach activities to facilitate cooperation between health workers, and support the development of professional networks.

Interventions to improve oral health among rural communities

Given that rurality is a determinant of oral health, several interventions have been developed to improve access to services.

Mobile dental clinics provide an innovative solution to cater to rural populations who do not have access to dental healthcare services in their community. These clinics can provide a variety of dental treatments for a large number of patients, in a controlled environment with a high standard of infection control. 32 Data indicate that mobile dental clinics can decrease missed appointments and directly address transportation problems, seeing as the clinics are transported to areas where transportation is difficult. 32 In addition, costs to set up a mobile clinic are much more moderate compared to a conventional clinic, ranging from US$200,000-300,000, which can allow dental services to be feasible in poor rural areas. 32 Furthermore, a case study in South Africa showed that a school-based mobile dental unit was cost-efficient at 25% allocation of staff time and that a dental therapy-led service could save costs by 9.1%. 33

Teledentistry is another approach to target those geographically disadvantaged by linking rural and remote communities with health providers using electronic health records, telecommunications technology, digital imaging and the internet. 34 Teledentistry can increase accessibility of specialists, as well as decreasing the time and costs associated. 35 A systematic review of the research evidence for the benefits of teledentistry found that it can be cost-saving when compared to a conventional consultation. 36 Teledentistry can be a cost-effective solution to target rural populations who typically do not have oral health services within reach.

Dental camps allow for increased outreach among underserved populations, by setting up alternative sites, such as classrooms, with basic portable equipment. 37 These camps can equally be used as an opportunity to promote healthy behaviours. A case-study of two long-term refugee camps in western Tanzania found that the programme was sustainable and was able to meet the oral needs of the camp population as well as a small segment of the native population. 38 Various treatments were successfully completed with dental extractions being the most common. 38

Education initiatives can improve access to oral health care for rural and remote populations. This approach includes training and education of dental and allied health students, training and education of rural/remote community members, and programmes on oral healthcare services in rural/remote areas. 39 University-based initiatives, which include a defined period of rural placement training for dental students, such as 1-10 weeks, have been successful in the past. 39 Curriculum should include a focus on oral health issues which may be specific to rural and remote areas. 39 Furthermore, rural residents should be supported and encouraged to pursue dentistry and outreach programmes should be promoted. 39

Rural populations are disproportionally affected by oral disease, with a higher prevalence of periodontal disease, caries and edentulism. Prevention and treatment of such conditions is challenging due to limited access to oral healthcare services. However, leaving poor oral health untreated contributes to poor overall health and wellbeing. The burden of oral diseases in rural areas can be reduced through public health interventions which promote healthy behaviours and improve accessibility to preventive care. Such actions are essential to improving health equity, and as such must be a priority of public health officials. Targeted interventions, such as mobile dental clinics, teledentistry and dental camps, are warranted. Policies, such as those suggested by the WHO, are also needed to stimulate change. Policymakers and public health officials should focus on establishing an effective national coordinating entity; strengthening and expanding oral health-promoting environments; ensuring there are integrated oral workforces and designing effective workforce models; and promoting patient-centred digital innovations. Furthermore, there must be a focus on increasing access to health care in rural areas by increasing the size of the health care workforce through enrolment of people with rural backgrounds in medical schools, educational subsidies, and increasing worker retention by promoting good working and living conditions.

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Hannah Theriault

York St John University, York, United Kingdom

Gemma Bridge

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Hannah Theriault was responsible for writing the original draft and Gemma Bridge was responsible for reviewing and editing. Both authors contributed to research.

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Theriault, H., Bridge, G. Oral health equity for rural communities: where are we now and where can we go from here?. Br Dent J 235 , 99–102 (2023). https://doi.org/10.1038/s41415-023-6058-4

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Received : 22 December 2022

Revised : 21 February 2023

Accepted : 28 February 2023

Published : 28 July 2023

Issue Date : 28 July 2023

DOI : https://doi.org/10.1038/s41415-023-6058-4

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Health and oral health literacy: A comprehensive literature review from theory to practice

Affiliations.

• 1 Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.
• 2 Department of Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
• PMID: 39096054
• DOI: 10.1111/ipd.13255

Background: Health literacy (HL) refers to an individual's ability to access, understand, and apply health information to make informed decisions about their health. On the contrary, oral health literacy (OHL) focuses on an individual's ability to understand and utilize oral health information to maintain good oral health.

Aim: This study presents a comprehensive literature review that explores the theoretical foundations and practical applications of HL and OHL.

Design: A comprehensive search was conducted using keywords on the following databases: PubMed, Google Scholar, and Cochrane Database of Systematic Reviews.

Results: The existing literature on various aspects of HL, including the most common used definitions of HL, conceptual frameworks, and consequences of limited health and OHL, was summarized. Additionally, the review discussed the significance of HL and OHL. Also, the relation between parent level of OHL and children's oral health was described. It further highlights modern approaches that have been shown in previous studies to improve the OHL of primary caregivers.

Conclusions: Understanding the significance of HL and OHL is crucial in developing effective interventions that can address disparities and improve oral health outcomes for individuals of all backgrounds.

Keywords: health education; health promotion; literacy; oral health literacy.

© 2024 BSPD, IAPD and John Wiley & Sons Ltd.

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