口腔指南共识汇总

Global oral

health status

report

Towards universal

health coverage for

oral health by 2030

Global oral health status report: towards universal health coverage for oral health by 2030

ISBN 978-92-4-006148-4 (electronic version)

ISBN 978-92-4-006149-1 (print version)

© World Health Organization 2022

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Design and layout: Julie Pudlowski Consulting

Front cover photograph: Julie Pudlowski

Global oral health

status report

Towards universal health coverage

for oral health by 2030

©Julie Pudlowski

Contents

Foreword

v

Acknowledgements

vii

List of abbreviations

x

Introduction

1

1. Oral diseases are global public health problems

5

1.1 Oral diseases – an increasing global burden

7

1.2 Oral diseases – common determinants and risk factors

15

1.3 Oral diseases – individual and population impacts along the life course

19

1.4 Oral diseases – global inequalities in the burden

22

1.5 Oral diseases – inequalities in access to oral health services

23

1.6 Oral diseases – global expenditures and economic impact of oral diseases

26

2. The burden of the main oral diseases

29

2.1 Dental caries

30

2.2 Severe periodontal disease

37

2.3 Edentulism

41

2.4 Oral cancer

45

2.5 Other oral conditions of public health relevance

52

3. Challenges and opportunities towards oral health for all

59

3.1 Health service and models of oral health care

60

3.2 Global oral health workforce

62

3.3 Fluorides for oral health

66

3.4 Oral health information and research challenges

70

3.5 Issues of public health relevance in oral health care

73

3.6 Reorientation on primary oral health care and UHC

79

4. A road map towards UHC for oral health

83

5. References

87

iii

©Julie Pudlowski

Foreword

Oral diseases are among the most common noncommunicable diseases worldwide, affecting an estimated

3.5 billion people. The burden is increasing, particularly in low- and middle-income countries.

Good oral health is essential for eating, breathing and speaking, and contributes to overall health, well-being

and confidence in interacting with others. But oral health is challenged by a range of diseases and conditions,

and stark and persistent inequalities in the burden of disease and access to oral health care. Disadvantaged

and marginalized people are more likely to be at risk of oral diseases and their negative consequences.

The good news is that many oral diseases can be prevented and treated. Cost-effective preventive and clinical

interventions are available, together with approaches to tackle risks common to all noncommunicable

diseases, with the potential to be effective in a range of contexts, including low- and middle-income countries.

Oral health has long been neglected in the global health agenda. Our biggest challenge now is ensuring that

all people, wherever they live and whatever their income, have the knowledge and tools needed to look

after their teeth and mouths, and access to prevention and care when they need it. For this to happen, all

countries need sufficient staff trained in oral health, and oral health services must be included in national

health coverage packages, either free of charge or at a price that people can afford.

The adoption by WHO Member States of a historic resolution on oral health at the World Health Assembly in

2021 was an important step forward. The development and adoption of a comprehensive Global Strategy on

Oral Health, with a bold vision for universal coverage of oral health services by 2030 was another milestone. The

Global Oral Health Action Plan to be discussed in 2023 will include a monitoring framework, with clear targets

to be achieved by 2030. These policies will provide us with a clear path towards ensuring oral health for all.

This WHO Global oral health status report provides a comprehensive picture of the oral disease burden, the

resources available for oral health, and the challenges ahead.

The report also includes country profiles, and will serve as a baseline for tracking progress. Integrating oral

health promotion and care into primary health care and UHC benefit packages will be key to success. WHO

is committed to providing guidance and support to countries to help make this happen.

I am confident that this report will contribute to continued and increased efforts to improve oral health

globally, so that no one is left behind with preventable and treatable oral diseases.

Dr Tedros Adhanom Ghebreyesus

Director-General, World Health Organization

v

©WHO

©WHO

The World Health Organization (WHO) is grateful for the contributions that many individuals and organizations

have made over several years to the development of this report.

The WHO Global oral health status report was produced by the Department of Noncommunicable Diseases,

Universal Health Coverage/Communicable and Noncommunicable Diseases (UCN) division of the World

Health Organization (WHO), Geneva, Switzerland (WHO HQ), under the initial general guidance of Douglas

Bettcher, Director, Prevention of Noncommunicable Diseases Department, and later of Bente Mikkelsen,

Director, Department of Noncommunicable Diseases and Slim Slama, Unit Head, Noncommunicable Diseases

Management-Screening, Diagnosis and Treatment, Department of Noncommunicable Diseases, and under the

lead of Benoit Varenne, Dental Officer, Oral Health Programme, Department of Noncommunicable Diseases.

Steering committee

Faten Ben Abdelaziz (WHO HQ); Habib Benzian (WHO Collaborating Centre, New York University, New

York City, United States of America); Dongbo Fu (WHO HQ); Yuriko Harada (WHO HQ); Jason Ligot (WHO

HQ); Stefan Listl (Radboud University, Nijmegen, the Netherlands); Wagner Marcenes (Global Burden of

Disease Oral Health Collaborators Group, King’s College, London, United Kingdom of Great Britain and

Northern Ireland); Yuka Makino (WHO Regional Office for Africa, Brazzaville, Congo); Poul Erik Petersen

(WHO Collaborating Centre, University of Copenhagen, Denmark); Nicole Rendell (WHO HQ); Leanne Riley

(WHO HQ); Benoit Varenne (WHO HQ); Akihito Watabe (WHO HQ); and Richard Watt (WHO Collaborating

Centre, University College, London, United Kingdom).

Editorial committee

Habib Benzian (WHO Collaborating Centre, New York University, New York City, United States); Yuka Makino

(WHO Regional Office for Africa, Brazzaville, Congo); Nicole Stauf (London School of Hygiene and Tropical

Medicine, London, United Kingdom); Benoit Varenne (WHO HQ); and Richard Watt ( London, United Kingdom).

Report development

WHO is very grateful to Habib Benzian and Richard Watt for their editorial leadership and technical writing

skills during the development of the report.

WHO also thanks the following individuals whose dedicated efforts and expertise contributed to the

development of the report: Huda Abdul Ghaffar (WHO Regional Office for the Eastern Mediterranean); Samira

Asma (WHO HQ); Paul Brennan (IARC, Lyon, France); Alison Ruth Brunier, (WHO HQ); Andre Carvalho (IARC,

Lyon, France) Somnath Chatterji (WHO HQ); Khassoum Diallo, (WHO HQ); Gampo Dorji (WHO Regional Office

for South-East Asia); Diana Estevez Fernandez (WHO HQ); Jill Louise Farrington (WHO Regional Office for

Europe); Riitta-maija Hämälainen (WHO Regional Office for the Western Pacific); Hayatee Hasan (WHO HQ);

Acknowledgements

vii

Carolina Hommes (WHO Regional Office for the Americas); Andre Ilbawi (WHO HQ); Ratnasabapathipillai

Kesavan, (WHO Regional Office for South-East Asia); Teena Kuniumen, (WHO HQ); Beatrice Lauby-Secretan

(IARC, Lyon, France) Amit Prasad (WHO HQ); Vinayak Prasad (WHO HQ); Felipe Roitberg (WHO HQ); Stefan

Savin (WHO HQ); Deependra Singh (IARC, Lyon, France); Slim Slama (WHO HQ); Yves Turgeon (WHO HQ);

Menno Van Hilten (WHO HQ); Cherian Varghese (WHO HQ); Khan Wasiq Mehmood (WHO Regional Office

for the Eastern Mediterranean).

External reviewers

Aluísio J D Barros (Universidade Federal de Pelotas, Brazil); Lois K. Cohen (National Institute of Dental and

Craniofacial Research, National Institutes of Health, Washington DC, United States); Stefan Listl (Radboud

University, Nijmegen, the Netherlands); Wagner Marcenes (Global Burden of Disease Oral Health Group,

King’s College, London, United Kingdom); Sudeshni Naidoo (WHO Collaborating Centre for Oral Health,

University of the Western Cape, Bellville, Republic of South Africa); Richard Niederman (WHO Collaborating

Centre, New York University, New York City, United States); Srinath Reddy (Public Health Foundation of India,

Gurugram, India); Viroj Tangcharoensathien (International Health Policy Program, Nonthaburi, Thailand);

and Stéphanie Tubert-Jeannin (Université Clermont Auvergne, France).

Other contributors

WHO is grateful to the following WHO Collaborating Centres, consultants and external experts who

contributed to the development of specific sections of the report, to the implementation of WHO-led global

surveys at different stages of the development of the report, and/or to regional consultations organized:

Jun Aida (Tohoku University, Sendai, Japan); Eduardo Bernabé (Global Burden of Disease Oral Health

Collaborators Group, King’s College, London, United Kingdom); Pascal Bovet (University of Lausanne,

Switzerland); Christian Bradley (Western NSW Local Health District, Dubbo, Australia); Peter Carlsson

(WHO Collaborating Centre, Malmö University, Malmö, Sweden); David Conway (University of Glasgow,

United Kingdom); Sarah Crummey (King’s College, London, United Kingdom); Elisabeth Dimba (University of

Nairobi, Kenya); Duangthip Duangporn (University of Hong Kong, China, Hong Kong Special Administrative

Region (Hong Kong SAR, China); Ritu Duggal (WHO Collaborating Centre, All India Institute of Medical

Sciences, New Delhi, India); Maha El Tantawi (Imam Abdulrahman Bin Faisal University, Dammam, Saudi

Arabia); Denise Faulks (Université Clermont Auvergne, France); Carlos Feldens (Universidade Luterana do

Brasil, São José, Brazil); Jenny Gallagher (King’s College, London, United Kingdom); Nicolas Giraudeau

(Université de Montpellier, France); Athanasios Gkekas (University of York, United Kingdom); Mairead Harding

(University College, Cork, Ireland); Anja Heilmann (University College, London, United Kingdom); Milica

Jevdjevic (Radboud University, Nijmegen, the Netherlands); Newell Johnson (Griffith University, Brisbane,

Australia); Raksanan Karawekpanyawong (WHO Collaborating Centre, Niigata University, Niigata, Japan);

Cristin Kearns (University of California, San Francisco, United States); O.P. Kharbanda (WHO Collaboration

Centre, All India Institute of Medical Sciences, New Delhi, India); Yu Kubota (WHO Collaborating Centre,

Niigata University, Niigata, Japan); Özlem Elmas Lubino (Saint-Genis-Pouilly, France); Lorna Macpherson

(University of Glasgow, United Kingdom); Manu Raj Mathur (Public Health Foundation of India, Gurugram,

India); Grazielle Mattos Savage (King’s College, London, United Kingdom); Afshan Mirza (University College,

London, United Kingdom); Peter Mossey (University of Dundee, United Kingdom); Paula Moynihan (University

viii

of Adelaide, Australia); Margaret Namusisi (Makerere University, Kampala, Uganda); Belinda Nicolau (McGill

University, Montreal, Canada); Kaname Nohno (WHO Collaborating Centre, Niigata University, Niigata, Japan);

Hiroshi Ogawa (WHO Collaborating Centre, Niigata University, Niigata, Japan); Emmanuel Otho (Regional

Center for Oral Health Research, Jos, Nigeria); Prathip Phanthumvanit (Association of Asian Chief Dental

Officers, Thailand); Ave Pöld (International Association of Dental Students, Estonia); Kohei Tamura (WHO

Collaborating Centre, Niigata University, Niigata, Japan); James Taylor (Section of Chief Dental Officers and

Dental Public Health, FDI World Dental Federation, and Public Health Agency of Canada, Ottawa, Canada);

George Tsakos (University College London, United Kingdom); Kasturi Warnakulasuriya (WHO Collaborating

Centre, King’s College, London, United Kingdom); Tao Xu (WHO Collaborating Centre, Peking University,

Beijing, China); Shanshan Zhang (WHO Collaborating Centre, Peking University, Beijing, China); and Shuguo

Zheng (WHO Collaborating Centre, Peking University, Beijing, China).

WHO is grateful to Samira Asma (WHO HQ) for facilitating collaboration with the Institute for Health Metrics

and Evaluation (IHME) at the University of Washington, Seattle, United States, who provided access to data

on oral diseases from the Global Burden of Disease Project (2019). At the IHME, WHO especially thanks Kelly

Bienhoff, Lisa Force, Nick Kassebaum, Rafael Lozano and Meghan Mooney.

WHO thanks all those mentioned in the case studies for their collaboration and for sharing their own

experiences and personal insights: Semiyu Adetunji Adeniyi, Voramon Agrasuta, Philippe Aubert, Maria

Corazon Dumlao, Claire Jeantet, Mulikat Okanlawon, Victor Oluwalomola, Mary Otto, Warisa Panichkriangkrai,

Norman Tinanoff, Noel Vallesteros, Shashank Wani, Rahul Wankhede, Sakuji Yanadori and Pascal Zoungrana.

WHO owes a very special thanks to Ricardo Martinez and Lucero Lopez Perez, Octoma Consultants Team,

Mexico, for their expert data analysis and visualizations.

WHO acknowledges with gratitude the funds received from the WHO voluntary contributions of the Borrow

Foundation, United Kingdom, and Hilfsaktion Noma e.V., Germany.

ix

AMR

Antimicrobial resistance

CCS

Country Capacity Survey

CPI

Community Periodontal Index

DALY

disability-adjusted life year

DATs

dental assistants and therapists

DMFT

decayed, missing and filled teeth

DPTs

dental prosthetists/technicians

GBD

Global Burden of Disease

GSHS

Global School-based Student Health Survey

HPV

human papillomavirus

HTA

health technology assessment

IARC

International Agency for Research on Cancer

IHME

Institute of Health Metrics and Evaluation

ILO

International Labour Organization

IPC

infection prevention and control

ITU

International Telecommunication Union

mHealth

mobile health

NCD

noncommunicable disease

NGO

nongovernmental organization

NHWA

National Health Workforce Account

OFC

orofacial clefts

PHC

primary health care

SDGs

Sustainable Development Goals

SSB

sugar-sweetened beverage

UHC

universal health coverage

UN

United Nations

UNICEF

United Nations Children’s Fund

WB

World Bank

WHO

World Health Organization

WHO EML/c

WHO model list of essential medicines for adults and children

List of abbreviations

x

Fig. 1

Ranking of most prevalent conditions per WB country income level

8

Fig. 2

Comparison of estimated global case numbers for selected NCDs

9

Fig. 3

Estimated case numbers and prevalence of the major oral diseases combined per WB

country income group (excluding lip/oral cavity cancer)

9

Fig. 4

Estimated case numbers and prevalence of the major oral diseases combined per

WHO region (excluding lip/oral cavity cancer)

10

Fig. 5

Estimated case numbers of the major oral diseases combined between 1990 and 2019

per WB country income group (excluding lip/oral cavity cancer)

11

Fig. 6

Estimated population change between 1990 and 2019 by WB country income group

12

Fig. 7

Comparison of estimated global DALYs for selected NCDs

13

Fig. 8

Social and commercial determinants of oral diseases

15

Fig. 9

Common risk factors for NCDs and oral health

17

Fig. 10

Prevalence rates of four major oral diseases over the life course

19

Fig. 11

Selected impacts of oral diseases

21

Fig. 12

Comparison of edentulism by educational attainment in different populations

(in percentage of edentulous population)

23

Fig. 13

Per capita direct dental expenditure in US$ per WB country income group (2019)

27

Fig. 14

Total direct dental expenditure in US$ per WB country income group (2019)

27

Fig. 15

Per capita dental expenditures in US$ per country (2019)

28

Fig. 16

Estimated prevalence of dental caries of deciduous teeth per country

31

Fig. 17

Estimated cases and prevalence of caries of deciduous teeth per WB country

income group

32

Fig. 18

Estimated cases and prevalence of caries of deciduous teeth per WHO region

33

Fig. 19

Estimated cases and prevalence of caries of permanent teeth per WB income group

34

List of figures

xi

Fig. 20

Estimated prevalence of caries of permanent teeth per country

35

Fig. 21

Estimated cases and prevalence of caries of permanent teeth per WHO region

38

Fig. 22

Estimated cases and prevalence of severe periodontal disease per WB country

income group

38

Fig. 23

Estimated prevalence of severe periodontal disease per country

39

Fig. 24

Estimated cases and prevalence of severe periodontal disease per WHO region

39

Fig. 25

Estimated cases and prevalence of edentulism per WB country income group

42

Fig. 26

Estimated cases and prevalence of edentulism per WHO region

43

Fig. 27

Estimated prevalence of edentulism

44

Fig. 28

Incidence and mortality rates of lip and oral cavity cancer per WB country income group

46

Fig. 29

Incidence and mortality rates of lip and oral cavity cancer per WHO region

46

Fig. 30

Estimated incidence rates of lip and oral cavity cancer

47

Fig. 31

Estimated mortality rates of lip and oral cavity cancer

47

Fig. 32

Estimated numbers of new cases and percentage share of total cases of lip and oral

cavity cancer per WB country income group (2020)

51

Fig. 33

Estimated numbers of new cases and percentage share of total cases of lip and oral

cavity cancer per WHO region (2020)

51

Fig. 34

Estimated cases and prevalence of OFCs by WB Income group

52

Fig. 35

Estimated cases and prevalence of OFCs by WHO region

53

Fig. 36

Workforce for oral health – dentist density

64

Fig. 37

Uses of oral health information

71

Fig. 38

Conceptual model of the primary oral health care pyramid

80

Fig . 39

The primary oral health care operational framework

82

xii

Table 1.

Percentage change in estimated prevalence, case numbers and DALYs of the major oral

diseases (except lip and oral cavity cancer) and change in population by WB country

income group

11

Table 2.

Estimated prevalence and cases of caries of deciduous teeth in 2019 and the percentage

change from 1990 to 2019 per WB country income group

31

Table 3.

Estimated prevalence and case numbers of caries of deciduous teeth in 2019

and their percentage change from 1990 to 2019 per WHO region

32

Table 4.

Estimated prevalence and cases of caries of permanent teeth in 2019

and the percentage change of prevalence, cases and population from 1990 to 2019

per WB country income group

34

Table 5.

Estimated prevalence and cases of caries of permanent teeth in 2019 and the percentage

change of prevalence, cases and population from 1990 to 2019 per WHO region

35

Table 6.

Estimated prevalence and cases of severe periodontal disease in 2019 and the

percentage change of prevalence, cases and population from 1990 to 2019 per WB

country income group

38

Table 7.

Estimated prevalence and cases of severe periodontal disease in 2019

and the percentage change of prevalence, cases and population from 1990 to 2019

per WHO region

40

Table 8.

Estimated prevalence and cases of edentulism in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per WB country income group

42

Table 9.

Estimated prevalence and case numbers of edentulism in 2019 and the percentage

change of prevalence, cases and population from 1990 to 2019 per WHO region

43

Table 10.

Estimated prevalence, case numbers and DALYs of OFCs and their percentage changes

from 1990 to 2019 per WB country income group

53

Table 11.

Estimated prevalence, case numbers and DALYs of OFCs and their percentage changes

from 1990 to 2019 per WHO region

54

Table 12.

Global oral health workforce by WB country income group

64

Table 13.

Global oral health workforce by WHO region

66

List of tables

xiii

Box 1.

Oral diseases – a large group of diseases and conditions

6

Box 2.

Data sources for the burden of oral diseases and other information

7

Box 3.

Understanding and interpreting the oral disease burden

12

Box 4.

What is a disability-adjusted life year?

14

Box 5.

Health expenditure definitions

26

Box 6.

What is dental caries and how is it measured?

30

Box 7.

What is severe periodontal disease?

38

Box 8.

Definition of oral cancer

45

Box 9.

Betel quid: a dangerous yet popular carcinogen

49

Box 10.

IARC handbook Vol. 19 - on oral cancer prevention

49

Box 11.

The Regional Noma Control Programme in the WHO African Region

57

Box 12.

Results from the 2021 Global WHO surveys assessing country capacity for oral health

62

Box 13.

Who is part of the oral health workforce?

63

Box 14.

Affordability of essential medicines: the case of fluoride toothpaste in 78 countries

67

Box 15.

Self-care and maintaining oral health

69

Box 16.

Fluoride-containing products on the WHO model list of essential medicines

70

Box 17.

Minamata Convention on Mercury measures to phase down the use of dental amalgam

74

List of boxes

xiv

Case study 1.

Promoting oral health as essential to healthy ageing (Japan)

20

Case study 2.

The challenge of oral health care for people living with disabilities (France)

24

Case study 3.

Reforming access to oral health care to address disparities (United States)

25

Case Study 4.

Two betel nut consumers and their battles with oral cancer (India)

50

Case Study 5.

Supporting survivors of noma (Nigeria)

56

Case Study 6.

Delivering oral health care to rural communities (Burkina Faso)

65

Case Study 7.

Making good oral health part of the daily school routine (Philippines)

68

Case Study 8.

Oral health benefits and school oral health as part of UHC (Thailand)

81

List of case studies

xv

©Julie Pudlowski

Introduction

The WHO defines oral health as the state of the mouth, teeth and orofacial structures that enables

individuals to perform essential functions, such as eating, breathing and speaking, and encompasses

psychosocial dimensions, such as self-confidence, well-being and the ability to socialize and work

without pain, discomfort and embarrassment. Oral health varies over the life course from early life to

old age, is integral to general health and supports individuals in participating in society and achieving

their potential (1).

Untreated oral diseases affect almost half of the world’s population. Global case numbers have increased

by 1 billion over the last 30 years – a clear indication that many people do not have access to appropriate

oral health care, which includes prevention, risk protection and restorative and rehabilitative services.

The consequences of untreated oral diseases – including physical symptoms, functional limitations

and detrimental impacts on emotional, mental and social well-being – are severe and debilitating. For

those able to obtain treatment, the costs are often high and can lead to significant economic burden.

Oral health plays a major role in well-being and self-esteem, while oral diseases heavily affect quality of

life, productivity and ability to work as well as social participation.

Stark and persistent socioeconomic inequalities in oral diseases exist with a higher disease burden found

in disadvantaged and marginalized population groups. At the same time, public and private expenditures

for oral health care are reaching almost US$ 390 billion globally, with a very unequal distribution among

regions and countries. Despite these challenges, oral diseases are largely preventable with population-

based public health measures.

Concerned about the lack of attention to oral diseases, the World Health Assembly adopted in May

2021 a historic resolution (WHA74.5) recognizing that oral health should be firmly embedded within the

noncommunicable disease (NCD) agenda and that oral health care interventions should be included in

universal health coverage (UHC) programmes (2). The World Health Assembly delegates asked WHO to

develop a draft global strategy for tackling oral diseases that was adopted during the seventy-fifth session

of the WHA in May 2022,to develop by 2023 an action plan including a monitoring framework for tracking

progress with clear measurable targets to be achieved by 2030; to develop “best buy” interventions

on oral health; and to explore the inclusion of noma in the road map for neglected tropical diseases

2021–2030. This WHO Global oral health status report is part of WHO’s series of data reports and is an

important milestone in the larger process of mobilizing political action and resources for oral health.

1

The report has three broad aims:

1. outline the global public health importance and impact of oral diseases over the life course;

2. contribute to the process of implementing the World Health Assembly 74.5 resolution on oral health at

global, regional and country levels by providing baseline information; and

3. encourage commitment and action from governments, United Nations (UN) organizations and nonstate

actors such as nongovernmental organizations (NGOs), academic institutions, philanthropic foundations,

private-sector entities and other stakeholders to address oral diseases in the context of global health agendas.

To achieve these aims, the report will:

• highlight the global burden of oral disease and inequalities using the latest available data from the Global

Burden of Disease (GBD) project and the International Agency for Research on Cancer (IARC);

• emphasize social and commercial determinants and common risk factors that oral diseases and other

NCDs share as a foundation for concerted action;

• highlight challenges and opportunities for oral health within the wider global health context requiring

engagement of stakeholders to accelerate progress towards universal coverage for oral health; and

• provide country oral health profiles based on key health and oral health indicators for monitoring and

evaluation covering all WHO Member States.

The report is not a textbook on oral health and disease and does not aim to cover all topics comprehensively.

Instead, the report reviews the most recent global data on major oral diseases and comes to a clear

conclusion: the status of global oral health is alarming and requires urgent action by all stakeholders on

global, regional, national and local levels. The target audiences are policy leaders and decision-makers;

planners and managers in health, public health and oral health at different levels; oral health stakeholders,

such as oral health professionals, academics and researchers; and other nonstate actors, populations,

communities and anyone affected by or interested in oral diseases. Moreover, the report is not a guidance

document proposing concise policy recommendations but rather is intended to provide fundamental

data and a basis to initiate discussion and generate commitment towards changing the current situation

of neglect. As such, the report is part of a set of tools and processes in the wider context of strengthening

oral health awareness and action, together with the 2021 World Health Assembly resolution on oral health

(WHA74.5), the WHO Global Strategy on Oral Health (WHA75/10 Add. 1) and others.

Section 1 of the report highlights oral diseases as largely preventable global public health problems, focusing

on their combined burden, shared risk factors and determinants as well as their impacts on individuals,

populations, health systems and economies globally.

Section 2 details the latest data on burden and trends for the five main oral diseases and conditions –

untreated caries of deciduous and permanent teeth, severe periodontal disease, edentulism and cancer

of the lip and oral cavity – as well as other conditions of public health relevance.

Section 3 analyses some of the key challenges and opportunities related to health systems: challenges

for the oral health workforce, challenges related to oral health information and persisting issues of public

health relevance, including a renewed focus on primary oral health care.

2

Global oral health status report: Towards universal health coverage for oral health by 2030

Section 4 situates the report as part of a global process towards improving oral health and connects oral

health improvement to general development and progress towards agreed-upon international goals.

The report is complemented by country oral health profiles with key health and oral health information for

each WHO Member State. It will be made available as a separate online resource. Information on the data

sources used, indicator definitions and the details of references used are also provided.

The report presents the latest available data and information using different sources with the best possible

global coverage. However, limitations of oral health data and information must be acknowledged and

emphasized. For many aspects of oral epidemiology, surveillance, health system analysis, economic data

and others, the scope and depth of information available are neither as comprehensive nor as reliable as

for other NCDs. This is largely because of inadequate attention to and awareness of oral diseases combined

with a lack of resources, guiding policies and health system investments as well as insufficient political

prioritization. Despite these limitations, many aspects highlighted in the report will be new and previously

unknown to many readers.

It is equally important that the report uses metrics and data that align with global health metrics (such as

disability-adjusted life years) rather than specific oral health indicators that require specialist knowledge

to be understood. Oral health specialists may miss such indicators in the report’s text, yet integration will

be greatly facilitated when using a unified global public health language to describe burden and challenges.

As a status report, this document is part of WHO’s series of data reports and hence presents a snapshot

of the current situation (editorial closure March 2022). Some of the information presented will be useful

in the context of the future monitoring framework aiming to track the implementation of the Global Oral

Health Action Plan (2023-2030). By highlighting data and information gaps, the report may also serve as

an incentive to strengthen and improve surveillance and information systems for oral health, one of the

strategic objectives of the WHO Global Strategy on Oral Health.

©WHO/Malin Bring

3

Introduction

©Julie Pudlowski

Oral diseases

are global public

health problems

1

Oral diseases are a major public health problem for countries and populations worldwide, although they

often are not publicly recognized as such. Globally, these diseases affect almost 3.5 billion people, with

three out of four people affected living in middle-income countries. Oral diseases are a group of distinct

disease entities with their own aetiology and burden as well as different options for prevention, care

and rehabilitation. The oral diseases and conditions (herein referred to collectively as oral diseases)

representing the highest burdens include untreated caries of deciduous (primary) and permanent teeth,

severe periodontal disease, edentulism (total tooth loss) and cancer of the lip and oral cavity.

Each of these diseases is a significant public health problem on a global, regional and national level,

compromising the health of individuals and populations. With their unparalleled burden, stark inequalities

and risk factors shared with other NCDs, oral diseases have a major impact on health, well-being, health

care systems and economies, adding to the increasing burden of NCDs. Most oral diseases are preventable

through self-care or with simple, evidence-based and cost-effective population-wide measures including

action on the wider social, economic and political determinants of health, making it possible to reduce

the disease burden significantly and limit negative impacts.

This section highlights the combined challenges from the main oral diseases. The specific global burden,

key features and risk factors of each of the five major oral diseases as well as selected other diseases and

conditions of public health relevance are further detailed in Section 2 of this report.

Box 1. Oral diseases – a large group of diseases and conditions

Apart from the five main diseases (caries of

deciduous and permanent teeth, severe periodontal

disease, edentulism and lip and oral cavity cancer),

many other diseases and conditions are relevant

for oral health. These include oral manifestations

of systemic diseases (metabolic, allergic and

immunologic diseases, including HIV infection);

oral mucosa diseases; erosion and tooth wear; oral

impacts of substance abuse; noma; congenital

malformations of teeth and the enamel; viral, fungal

and bacterial infections; trauma (including physical

and chemical injuries) of the teeth, jawbones and

adjacent maxillofacial structures; cysts and tumours

of odontogenic origin; salivary gland diseases; and

disturbances in the development and growth of oral

structures (3). These diseases and conditions are not

comprehensively covered in the global estimations

of disease burden from the Institute of Health Metrics

and Evaluation (IHME) GBD project (4). This report

relies on the latest available GBD data from 2019. The

latest available cancer data from 2020 were provided

by the IARC (5).

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Global oral health status report: Towards universal health coverage for oral health by 2030

Box 2. Data sources for the burden of oral diseases and other information

This report uses the latest available data from

sources with a wide coverage of countries. Data on

caries (deciduous and permanent teeth), severe

periodontal disease and edentulism are provided by

the IHME GBD Model for Oral Disorders (4). The Model

reports estimated disease burden (prevalence, case

numbers and other metrics) for all WHO Member

States based on rigorously selected data from 130

countries. As of the time of this report’s publication,

the GBD Model provided data for 1990–2019 – the

most comprehensive dataset on the burden of oral

diseases using the standard GBD metrics. Other

databases available using different metrics more

specific to oral health, such as the decayed, missing

and filled teeth (DMFT) index, the Community

Periodontal Index (CPI) and others, are not regularly

updated and do not provide comparable coverage

of countries. The GBD Model calculates estimations

for all 194 WHO Member States using a complex

modelling approach. For a detailed description of

the methodology see Kassebaum et al. 2017 and GBD

2017 Oral Disorders Collaborators 2020 (4, 6).

The IARC, a specialized WHO organization, provided

the data on lip and oral cavity cancer using their

latest available dataset from the Global Cancer

Observatory (2020) (5). Their estimations of

incidence, case numbers and other metrics for all

cancers, including lip and oral cavity cancer, are the

most comprehensive and are widely used.

Data and other information extracted from relevant

scientific publications and databases are referenced

where used, complementing the two main data

sources. Specific challenges to surveillance and

data analysis for oral health decision-making are

described in Section 3.4.

1.1 Oral diseases:

an increasing global burden

About 3.5 billion people worldwide were affected by

oral diseases in 2019, making them the most widespread

conditions among the more than 300 diseases and

conditions that affect humanity (4). Oral diseases have

remained the most dominant conditions globally since

1990, the first year of oral disease data available from

the GBD dataset (see Fig. 1). Among the major oral

diseases, untreated caries of permanent teeth is the

most prevalent with around 2 billion cases, severe

periodontal disease follows with around 1 billion cases,

then untreated caries of deciduous teeth with about 510

million cases and edentulism with 350 million cases (all

in 2019). The combined estimated number of cases of

oral diseases globally is about 1 billion higher than cases

of all five main NCDs (mental disorders, cardiovascular

disease, diabetes mellitus, chronic respiratory diseases

and cancers) combined (see Fig. 2) (4).

©Julie Pudlowski

7

1.Oral diseases are global public health problems

Fig. 1 Ranking of most prevalent conditions per WB country income level

Note. Data are for all ages and both sexes from GBD 2019 (4).

8

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 2 Comparison of estimated global case numbers for selected NCDs

Note. Data are for all ages and both sexes from GBD 2019; oral diseases do not include lip and oral cavity cancer (4). A standard method has been

applied to incorporate the latest UN population estimates.

Three quarters of people affected by oral diseases live in lower- and upper-middle income countries,

followed by 16% in high-income countries and 9% in low-income countries. Oral diseases have a high

global average prevalence of 45%, which is very similar across World Bank (WB) country income groups

and WHO regions (see Figs. 3 and 4). Both the South-East Asia Region and Western Pacific Region have

the highest case numbers among the WHO regions as they include countries with large population sizes.

The other four WHO regions have similar yet still high case numbers (see Fig. 4). This share of disease

burden among countries is also mirrored in the respective proportions of disability-adjusted life years

(DALYs) for oral conditions combined.

Fig. 3 Estimated case numbers and prevalence of the major oral diseases combined per WB country income

group (excluding lip/oral cavity cancer)

Note. Data are from GBD 2019 (4).

9

1.Oral diseases are global public health problems

Fig. 4 Estimated case numbers and prevalence of the major oral diseases combined per WHO region

(excluding lip/oral cavity cancer)

Note. Data are from GBD 2019 (4).

Between 1990 and 2019, estimated case numbers of oral diseases grew by more than 1 billion – a 50%

increase, higher than the population increase of about 45% during the same period (see Figs. 5 and 6) (7).

During the same period, case numbers in low-income countries more than doubled (114%), and they

increased by 70% in lower-middle income countries and by 33% and 23% in upper-middle and high-

income countries, respectively, outpacing the demographic growth in those countries. Similar trends

are observed for DALYs resulting from oral diseases, with a global average increase of 75% (see Table 1).

The highest increase was observed in low-income countries (123%), followed by lower-middle income

countries (98%), upper-middle income countries (78%) and high-income countries (37%). Details and

challenges of the DALY concept in the context of oral diseases are highlighted in Box 3.

©WHO/Tom Vierus

10

Global oral health status report: Towards universal health coverage for oral health by 2030

Table 1. Percentage change in estimated prevalence, case numbers and DALYs of the major oral diseases (except

lip and oral cavity cancer) and change in population by WB country income group

WB

country

income

group

Percentage

change in

prevalence rates

(1990–2019)

Percentage

change in

case numbers

(1990–2019)

Percentage

change in

DALYs

(1990–2019)

Percentage

change in

population

(1990–2019)

Low income

0.1%

114.0%

123.0%

118.0%

Lower-middle

income

2.6%

70.0%

98.3%

63.2%

Upper-middle

income

5.4%

33.0%

78.1%

28.0%

High income

2.2%

22.7%

37.0%

20.6%

Global

3.2%

49.3%

75.0%

44.8%

Note. Data are from GBD 1990–2019 and UN DESA 2019 (4, 7).

Fig. 5 Estimated case numbers of the major oral diseases combined between 1990 and 2019 per WB country

income group (excluding lip/oral cavity cancer)

Note. Data are from GBD 2019 (4).

11

1.Oral diseases are global public health problems

Fig. 6 Estimated population change between 1990 and 2019 by WB country income group

Note. Data are from UN DESA 2019 (7).

Box 3. Understanding and interpreting the oral disease burden

Understanding and interpreting the burden of oral

disease can be challenging. Using different indicators

and metrics can lead to different conclusions and

narratives, particularly for dental caries.

The GBD model used in this report provides data on

prevalence, case numbers and DALYs for oral diseases.

When considering changes of the time, these indicators

are best interpreted together with demographic

information. Table 1 therefore lists the percentage

changes between 1990 and 2019 of estimated prevalence

rates, case numbers and DALYs of the major oral diseases

together with percentage changes in population.

Selected tables in Section 2 also include information

on changes in population size. Data provided may differ

from published GBD data because a standard method

has been applied to incorporate the latest UN population

estimates instead of GBD population estimates.

The global population grew by 45% between 1990

and 2019 (7). At the same time, the estimated age-

standardized global prevalence of oral diseases

increased by 3.2%, resulting in a 50% increase in

estimated case numbers, which represents about 1

billion additional cases (see Figs. 5 and 6) (4).

The quite similar prevalence rates of oral diseases

across country income level groups or WHO regions (see

Figs. 3 and 4) may be surprising, given that population

and health system profiles across countries vary

markedly. A possible reason lies in the definition of

“case” and “prevalence” used by the GBD model, which

focuses only on the presence or absence of a disease

and does not consider its severity.

Estimated DALYs increased by 75%, likely reflecting a

disproportionate increase in cases of severe periodontal

disease, which has higher DALYs than dental caries,

although caries still has the highest case numbers of all

oral diseases. Fig. 7 shows estimated DALYs for selected

NCDs, highlighting the comparably low number of DALYs

for oral diseases despite their high case numbers and

prevalence. WHO and IHME are planning a review of the

methodology for calculating DALYs for oral conditions to

reflect their burden in a more realistic way (see also Box

4 on DALYs).

12

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 7 Comparison of estimated global DALYs for selected NCDs

Note. Data are for all ages and both sexes from GBD 2019, oral diseases do not include lip and oral cavity cancer (4, 7). A standard method has been

applied to incorporate the latest UN population estimates.

Traditional oral health measurements, such as the frequently used DMFT index or the CPI, document

aspects of disease severity, usually for specific age groups. In the absence of comprehensive, comparable

data with global coverage, this report uses only the metrics of the GBD model (see also Boxes 1 and 2).

The dramatic increases in global case numbers since 1990 present a huge burden to health systems. It

appears that measures to prevent and control oral diseases have not been successful. The result is an

all-time high in case numbers, representing billions of people with unmet needs across all countries.

This challenges health care systems everywhere, but particularly in low- and middle-income countries.

©WHO/ Yoshi Shimizu

13

1.Oral diseases are global public health problems

Box 4. What is a disability-adjusted life year?

The DALY was developed in the context of the GBD

project to provide a summary measure of population

morbidity and account for mortality and nonfatal

health consequences. DALY is the unit of analysis for

measuring the relative magnitude of losses of healthy

life associated with different causes of disease and

injury (8, 9).

One DALY represents the loss of the equivalent of

one year of full health. DALYs accumulate when

individuals die prematurely or when they live with

the health consequences of chronic diseases, injuries

or risk factors. For a particular cause of disease or

injury, DALYs are computed as the sum of years of life

lost (YLLs), which capture premature mortality and

health losses, and years lived with disability (YLDs),

which capture lost healthy life due to living in states

worse than perfect health (8, 9).

Applying the DALY concept to oral diseases allows

for comparison with other disease groups. However,

the approach also has limitations: the methodology

emphasizes diseases with high mortality, which is

not the case for the most prevalent oral diseases.

Despite high case numbers and global prevalence,

DALY values for oral diseases (except lip and oral

cavity cancer) are comparatively low. Moreover,

the underlying epidemiologic data sources for

oral diseases are often incomplete and not recent,

requiring advanced estimation techniques with

considerable uncertainties. WHO and IHME are

planning to review the methodology for calculating

DALYs for oral conditions to reflect their burden in a

more accurate way.

Birth

Early

death

Expected

life years

YLL

YLD

Healthy

life

DALY

Disability Adjusted Life Year

is a measure of overall disease burden,

expressed as the cumulative number of years

lost due to ill-health, disability or early death

=

YLD

Years

lived with

disability

YLL

Years

of life

lost

+

Source: Adapted from Public Health England, 2015.

14

Global oral health status report: Towards universal health coverage for oral health by 2030

1.2 Common determinants and risk factors of oral diseases

Oral diseases share determinants and risk factors with other NCDs. The WHO Commission on Social

Determinants of Health drew attention to the importance of the wider socioeconomic, political and

environmental drivers of health: the circumstances in which people are born, grow, live, work and age

(10). These circumstances largely determine the behaviours that people adopt and the opportunities

and choices available to them. This framework has been modified to incorporate the underlying causes

of oral diseases, the shared risk factors between oral conditions and other NCDs, and the commercial

determinants of oral health (11, 12).

1.2.1 Social and political determinants of oral health

The underlying causes of oral health inequalities are often complex and related to country-specific historical,

economic, cultural, social or political factors. The conditions in which people are born, grow, live, work

and age and the structural drivers of those conditions – the inequitable distribution of power, money and

resources in society – are the underlying social determinants of oral health inequalities (13–15). More recently,

aspects of discrimination among racial and ethnic groups or indigenous minority populations have gained

attention as symptoms of inequality in power and agency influencing health and oral health (16, 17). The

conditions and choices available to individuals and their families are therefore largely determined by their

social circumstances – the conditions of daily life (Fig. 8; modified from Peres et al, 2019) (88).

Fig. 8 Social and commercial determinants of oral diseases

15

1.Oral diseases are global public health problems

1.2.2 Commercial determinants of oral health

Commercial determinants of health are the corporate-sector activities that affect people’s health positively

or negatively. Corporations, often with transnational or global reach, are promoting products that are

detrimental to population health, particularly in the areas of NCDs and oral health. The global tobacco

and alcohol industries are prime examples that increasingly target emerging economies in low- and

middle-income countries or particularly vulnerable population groups (18, 19).

Global food and drinks industries, including those producing foods high in sugar and sugar-sweetened

beverages (SSBs), use similar strategies and are lobbying governments and public opinion to delay,

modify or hinder public policies that protect public health, such as controls on advertising to children,

the introduction of health taxes, or limiting the retail size of SSBs. These industries are also keen on

engaging with public health, education and other sectors to give themselves a socially responsible image

including for example sponsorship of school activities and sporting events. Some are also engaging with

health and oral health research and professional organizations, thereby potentially biasing science and

public communication. With sophisticated marketing, promotion and sales approaches these industries

seek to influence consumer behaviour and create an environment where their products are universally

available, affordable, accessible and appealing – a powerful and potent threat to population oral health.

The role of sugar consumption, tobacco use and alcohol use as risk factors of oral disease render oral

health sector particularly susceptible to such detrimental commercial influences (20, 21).

The role and impact of global and local corporations related to unhealthy commodities should be

distinguished from those that are related to the production and marketing of products for personal

oral hygiene and self-care. The widespread commercial promotion of fluoride toothpaste and other

personal oral hygiene products has an overall positive impact on oral health by expanding access to

and daily use of these products, even though pricing and other factors also contribute to inequalities

in affordability. When the complex product portfolio of large holding companies or global corporations

includes products with positive and negative health benefits, public-private cooperation and support

becomes challenging.

1.2.3 The common risk factor approach

The common risk factor approach recognizes that noncommunicable diseases and conditions, including

oral diseases, share a set of key modifiable risk factors (11). For example, tobacco use is a major risk factor

for a range of conditions, such as cardiovascular diseases, respiratory diseases and many cancers, but

also for severe periodontal disease and lip and oral cavity cancer. The common risk factor approach is

the basis for linking action on oral disease prevention with the wider NCD agenda. This can be seen most

notably in relation to the integrated action on improving poor diets, tackling tobacco use and reducing

harmful alcohol consumption.

16

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 9 Common risk factors for NCDs and oral health

diseases

risk factors

Oral

diseases

Cardiovascular

diseases

Cancers

Diabetes

Chronic

respiratory

diseases

Mental and

neurological

conditions

All forms of

tobacco use

Environmental

pollution

Physical

inactivity

Harmful

alcohol use

Unhealthy

diets

1.2.4 Common risk factors of public health importance

High sugar intake, all forms of tobacco and harmful alcohol use are major public health challenges for

a wide range of NCDs. They are also the key modifiable risk factors for oral diseases (more specific risk

factor aspects for selected oral diseases are addressed in Section 2).

Sugar consumption is the main cause of dental caries, showing a clear dose–effect relationship. The

evidence for the role of sugar in the aetiology of dental caries played a crucial role in the WHO Sugars

Guideline recommending less than 10% of daily total energy intake from free sugars as well as the

conditional recommendation to reduce intake even further to 5% of total energy (22, 23). The consumption

of free sugars, defined as “all monosaccharides and disaccharides added to foods and beverages by the

manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit

juice concentrates” is increasingly recognized as a public health concern (24). Sugar is cheap and almost

universally available across the globe. In high- and middle-income countries, sugar consumption far

exceeds WHO recommendations, and in many low-income countries, consumption is steadily rising.

More recently, the very high level of free sugars found in commercial foods for infants and young children

has become a cause for concern, resulting in the promulgation of numerous guidelines from WHO (21).

Despite overall reductions, 22.3% of the global population were estimated to use some forms of tobacco

(2020). Among populations aged 15 years and older, the proportion of men using tobacco amounted

to 36.7% while that of women equaled to 7.8%. The prevalence rate of current tobacco use for males

was more than four times the rate for females. The age-specific rates peak at age group 45–54 for men

17

1.Oral diseases are global public health problems

and 55–64 for women (25). Cancers, heart disease, stroke, chronic lung diseases and many other NCDs,

including oral diseases, are caused by tobacco use. The burden of tobacco use disproportionally falls on

the poor and disadvantaged and is therefore a major cause of health inequality. All forms of tobacco use

are major risk factors for lip and oral cavity cancer (see Section 2.4) (26). More than 350 million people

globally are estimated to use smokeless tobacco, a cultural habit that is particularly popular in South

Asia and some Pacific Island countries (27). Tobacco use remains one of the leading global causes of

preventable deaths and is associated with more than 8 million death in 2019 (28).

An estimated 1.3 billion people aged over 15 years consume alcohol at harmful levels (above non-drinker

equivalence, 2020), with the highest rates found across Europe, the Americas and the Western Pacific

region (29, 30). In 2019, total alcohol per capita consumption was 5.8 litres of pure alcohol, with higher

consumption among men with 9.2 compared to women with 2.5 litres (31). The harmful use of alcohol

is a causal factor in more than 200 disease and injury conditions, including injuries, digestive diseases,

cardiovascular diseases and many other NCDs as well as oral diseases, mainly lip and oral cavity cancer

(see Section 2.4) (32). Moreover, harmful alcohol consumption is associated with a variety of family, social,

and economic problems and mental and behavioural disorders. Globally, the harmful use of alcohol

causes an estimated 3 million deaths per year, representing 5.3% of all deaths. Of the global burden of

disease and injury, 5.1% is attributable to alcohol, as measured in DALYs.

©Julie Pudlowski

©WHO/ Yoshi Shimizu

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Global oral health status report: Towards universal health coverage for oral health by 2030

1.3 Individual and population impacts of oral diseases along the life course

Oral diseases affect individuals and populations across the entire life course (see Fig. 10) (33, 34). The

main oral diseases impair different age groups in specific ways (6). Deciduous teeth are prone to caries

as soon as they erupt, with a peak of prevalence around the age of 6. Similarly, prevalence of caries in

permanent teeth typically shows steep increases after eruption and reaches the highest levels in late

adolescence and early adulthood before remaining stable for the rest of the lifetime. Severe periodontal

disease is a disease of middle age, reaching highest prevalence rates around 60 years. Edentulism (total

tooth loss) steadily increases with a peak in older age groups.

Fig. 10 Prevalence rates of four major oral diseases over the life course

Note. Data are from GBD 2019 (4).

All oral diseases are chronic, progressive and cumulative in nature. Toothache, which accompanies

many of the major oral diseases, is a common individual experience and is consistently rated among

the most intense of pains. Combined with a high prevalence, impacts from oral diseases are often

experienced on a repeated basis, resulting in physical, social and mental consequences. This includes

impacts on self-confidence and self-esteem, often leading to reduced social interaction, isolation or

even stigmatization. Severe untreated oral diseases may negatively affect employment opportunities

and reduce productivity (see Fig.11).

19

1.Oral diseases are global public health problems

Negative impacts from untreated caries are common among children and adolescents, frequently causing

acute infection, dental pain and discomfort (35). Untreated caries affect a child’s ability to eat, speak,

learn and sleep. Severe untreated caries in children affect nutrition, growth and weight gain. Toothache

can also affect school attendance, leading to poorer educational performance (36, 37). In many high-

income countries, the extraction of carious teeth under general anaesthesia is the main reason for

hospitalization of young children. All of these negative impacts of oral diseases disproportionally affect

people from more disadvantaged backgrounds (38).

Case study 1.

Promoting oral health as essential

to healthy ageing (Japan)

In 1987, a survey in Japan found that people at age 80

had only about five natural teeth on average, causing

malnutrition and poor health in the elderly. Two years

later, based on new data on oral functionality, Japan’s

Ministry of Health and Welfare and Japan Dental

Association launched the 8020 Campaign (39). The goal

was to ensure that people still had 20 of their teeth at

age of 80 so that they could maintain nutritional and

social well-being. The campaign adopted a lifelong

approach to preventing tooth loss by engaging

multiple sectors and carrying out initiatives that

targeted all generations.

At 93 years old, Sakuji Yanadori from Niigata City,

Japan, still has 30 natural teeth, dispelling the myth

that “losing teeth is a normal part of getting older.” His

explanation for his healthy mouth does not reveal any

secrets. He practices good oral hygiene, does not miss

his regular dental visits and avoids sugar.

Maintaining natural teeth with adequate functionality

allows Yanadori to enjoy well-balanced meals that he

shares with his family. His diet consists of a variety

of meat, fish and vegetables that helps him keep his

body in optimum condition, allowing him to remain

socially connected as well. Today, Yanadori can still

be found playing piano or the game Go at the local

community club.

A national survey in 2016 showed that the 8020

Campaign had been successful in reaching its goals,

with half of the 80-year-old population maintaining

more than 20 of their natural teeth. The campaign

continues to adopt a holistic approach to oral

health, ensuring that the future elderly population

has sufficient teeth and oral function to maintain

good health and quality of life (40).

Poor oral health among older people can negatively affect daily activities and thereby contribute to

overall frailty. Oral diseases result in specific challenges related to pain, impaired chewing and eating

ability, or even nutritional deficiencies. Frail older people living in long-term care facilities often have

especially high oral health needs that may complicate existing comorbidities. As longevity increases,

©Hiroshi Ogawa

20

Global oral health status report: Towards universal health coverage for oral health by 2030

quality of life matters even more, and oral health is among the major health aspects related to improved

quality of life (41, 42). It is therefore important for oral health care services and professionals to provide

appropriate services for the needs of older populations. The UN declared the “Decade of Healthy Ageing

(2021–2030).” The accompanying action plan recognizes that oral health is a key indicator of overall

health in older age (43).

Fig. 11 Selected impacts of oral diseases

Impact on educational

attainment

Impact on aesthetics/

reduced self esteem

Social isolation

Pain and discomfort

Fear / anxiety

Time off work/school

to attend clinics

Reduced productivity

of the workforce

Impact on general

health

Impaired growth

in children

Functional

limitations

Treatment costs

(societal and individual)

Sleepless nights

1.3.1 Relation between oral health and general health

Oral health is integral part of general health, sharing common causal pathways and affecting each other

in a bi-directional fashion. In recent decades, many studies have assessed the potential link between

poor oral health and a range of chronic diseases (44). The strongest and most consistent evidence has

shown an association between severe periodontal disease and diabetes mellitus; clinical interventions

to treat severe periodontal disease have shown improvements in diabetes status (45, 46). Evidence also

exists of an association between severe periodontal disease and cardiovascular disease and, to a lesser

extent, cerebrovascular disease and chronic obstructive pulmonary disease (47–49). In addition to severe

periodontal disease, associations have been found of caries and tooth loss with other conditions such

as cognitive decline, certain cancers and pneumonia. These associations are underpinned by shared

biological (infection, inflammation, microbiome and immune responses), behavioural and wider social

risk factors. It is important, however, to recognize that the nature of associations between poor oral

health and other chronic diseases is not necessarily causal and is often weak compared to other key

risk factors. More high-quality research is needed to understand fully the potential shared pathways

between oral diseases, poor oral health and other general diseases and conditions, the coexistence of

multiple health conditions, as well as the impact of oral health interventions on general health (50).

21

1.Oral diseases are global public health problems

1.4 Global inequalities in the burden of oral diseases

The burden of oral diseases is not uniformly distributed across populations. Instead, all oral diseases

are socially patterned and show strong social gradients, disproportionally affecting the most vulnerable

and disadvantaged population groups within and across societies, and over the life course. People

who are on low incomes, people living with disabilities, older people living alone or in care homes,

people who are refugees, in prison or living in remote and rural communities, children and people

from minority and/or other socially marginalized groups generally carry a higher burden, similar to

other NCDs. These differences in oral health status are not inevitable and do not occur by chance;

inequities are caused by a complex array of interconnecting factors, many of which are largely beyond

individuals’ direct control.

Oral health inequalities are defined as differences in oral health status that are avoidable and deemed

to be unfair, unacceptable and unjust. Addressing oral health inequalities is a matter of social justice,

ethical public health policy and professional practice.

Different types of oral health inequalities exist. It is important to distinguish inequalities in oral health

status from inequalities in access and use of oral health services. Both aspects are important but are

caused by different factors and therefore require different policy solutions.

Many studies from high-, middle- and low-income countries have shown the direct and proportional

association between different measures of socioeconomic status (income, education and social class)

and the prevalence and severity of oral diseases across the life course, from early childhood to older

age. The association between socioeconomic status and oral diseases is not limited to the differences

between the rich and the poor in society. As is the case with most chronic diseases, oral diseases are

socially patterned across the entire social spectrum in a consistent stepwise fashion – the social gradient

in oral health. This has important policy implications because a traditional approach of targeting only

high-risk groups fails to address the social gradient in oral health.

Inequalities in oral health status also exist across different population groups. Across the life course,

oral diseases and conditions disproportionally affect the poor and vulnerable members of societies,

often including those who are on low incomes, people living with disabilities, older people living alone

or in care homes, people who are refugees, in prison or living in remote and rural communities, and

people from minority and/or other socially marginalized groups.

The burden of severe tooth loss and edentulism provides a stark example of significant inequalities in

oral health status (see Fig. 12) (51–53). Those with lower socioeconomic status, with lower education

levels or who are affected by other disadvantages have on average fewer teeth than population

groups with higher socioeconomic and educational indicators. The resulting impacts on speaking,

eating, social interaction and self-esteem can be significant and further contribute to disadvantage

and inequality. The negative aesthetic and social impacts of visibly missing teeth greatly reduce

prospects of finding a job (54).

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Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 12 Comparison of edentulism by educational attainment in different populations (in percentage of

edentulous population)

Note. Data for Australia, Canada, Chile, New Zealand and the United States are for adults aged 25+ years; education categories: lowest, secondary,

postsecondary and university (from Elani et al., 2017). Data for Colombia are for adults aged 45+ years; education categories: primary or less,

secondary, technical and university (from Guarnizo-Herreño et al., 2018) (51, 52).

1.5 Inequalities in access to oral health services

Access to oral health services is highly variable both within and among

countries. Oral health care is largely a demand-led service rather

than the result of a rigorous planning process and therefore can be

poorly aligned with the oral health needs of the local population. In

many situations, the classic inverse care law applies: provision of oral

health services is inversely related to the oral health needs of the

population (57). Across the world, oral health care is predominantly

provided by private practitioners. Both, private and public oral

health care services, often only cover a small proportion of the

population (see Section 3.1). Inequalities in dental attendance also

exist throughout the life course (58). In high- and middle-income

countries, oral health services are often poorly distributed or

inaccessible to vulnerable or disadvantaged groups in society. In

stark contrast, there is often an overconcentration of oral health

services in affluent urban neighbourhoods where disease levels

are generally lower than in poorer, underserved areas. In many low-

income countries, the situation is far worse. In these settings, oral

health professionals tend to be concentrated largely in urban areas,

inaccessible to much of the population who live in rural locations.

In these circumstances, people often spend considerable time and

cost for travel to seek professional oral health care (12).

©Julie Pudlowski

23

1.Oral diseases are global public health problems

Philippe Aubert, 42 years old from France, lives

with athetotic cerebral palsy (CP). This condition,

characterized by involuntary movements, is

present from birth and affects muscle function. The

uncontrolled movements prevent Aubert from walking,

talking or using his arms.

“Due to pronounced bruxism (habitual teeth grinding),

I had almost ground down all my teeth. I had serious

difficulties in chewing and eating,” Aubert explains,

referring to his dental problems caused by the

symptoms of cerebral palsy (55). “My teeth were

a real problem for a long time, considering all the

difficulties I went through to get them treated.” Aubert

explains that dental appointments had been very

challenging since childhood because medical staff had

little knowledge of his special needs and the dental

equipment and settings were inappropriate.

“I can testify that, as far as the experience of disabled

people in dental offices is concerned, many simple

details including the texture of the seats, transfer to

the dental chair, the light, the noise of the dental drill,

and even the typical smell of a dental clinic could easily

trigger spasticity, anxiety or other symptoms for a

patient with CP,” Aubert says.

Some experiences during Aubert’s dental visits made

him feel unsafe and more reluctant to go to another

appointment. “Once I almost choked on a dental x-ray

film that was put in my mouth and nearly destroyed

the dental chair on which I was being examined,

because of the involuntary movements triggered by

the procedure,” he explains.

Aubert strongly believes that the most important

aspect of successful treatment of people with special

needs is the attitude and skill of the health care team.

“Lack of knowledge and training of medical and dental

personnel regarding different types of disabilities

needs to be addressed,” he says, highlighting the

need for organized and effective training of medical

personnel.

Case study 2.

The challenge of oral health care for people living

with disabilities (France)

“I am well aware of the practical challenges of listening

to the individual needs of disabled patients, but a

reliable and respectful relationship is required for the

care of these patients and can only be established by

taking time to hear them out and understand their

needs,” says Aubert, calling for a caring approach to

build a trusting relationship with each patient.

After years of hospital visits, which usually ended in

tooth extraction, Aubert found help through a non-

profit organization, Handident (https://www.handident.

com/), where he was warmly welcomed and treated for

his dental problems. “I had to go to the extreme of full

mouth rehabilitation so that I could claim, and finally

appreciate, my mouth and teeth,” Aubert says with

gratitude to the dentists who treated him with kindness.

He refers to them as the people who changed his life.

After publishing his book Rage to exist, Aubert became a

public figure with a mission to highlight the experience

of people with disabilities (56). His words are “spoken”

via a speech synthesizer that is controlled by his gaze,

but his emotions are clearly conveyed by his smile.

“I have not spoken since birth! My mouth and teeth

helped me to eat, not to communicate. Today, my mouth

plays an essential role in my communication and my

aesthetic,” says Aubert referring to his bright smile as a

real asset that has become part of his identity.

©Philippe Aubert

24

Global oral health status report: Towards universal health coverage for oral health by 2030

In February 2007, 12-year-old Deamonte Driver died

in Maryland after complications from an avoidable

dental infection. “Twelve-year-old Deamonte Driver

died of a toothache Sunday. A routine, $80 tooth

extraction might have saved him. If his mother had

been insured. If his family had not lost its Medicaid.

If Medicaid dentists weren’t so hard to find. If his

mother hadn’t been focused on getting a dentist for

his brother, who had six rotted teeth,” wrote Mary

Otto on the Metro page of the Washington Post on

28 February 2007 (59).

Deamonte’s death brought to light the long-standing

issue of access to oral health care for Maryland’s

poor children. Reports at that time showed that 71%

of children on Medicaid in Maryland (ages 0–20) had

received no dental services during the previous year,

and more than 11 000 of these children had not seen

a dentist in 4 years. As a result, more than 30% of

Maryland’s elementary school children had untreated

caries. Because of poor Medicaid reimbursement

rates, only 12% of Maryland dentists were full

participants in the program.

Otto’s article in the Washington Post sparked global

media attention, which then led to a collaboration

among oral health advocates, civil society

organizations, policy-makers and legislators to

prioritize the oral health agenda.

“The oral health reforms first is about a tragedy

of a child that rants and improvements to oral

health surveillance and infrastructure statewide.

As a result of numerous oral health policy reforms

and initiatives, utilization rates of oral health care

increased as did the number of dentists participating

in the state Medicaid programme, making Maryland a

role model for other states (60).

Case study 3.

Reforming access to oral health care to address

disparities (United States)

“The story of Deamonte Driver continues to be

told, not just in Maryland but around the country.

It has become part of an ongoing movement to

improve access to oral health services to Americans

of all ages who might otherwise go without care,”

Otto says. She highlights the difficulties that

economically disadvantaged people are facing and

the need to integrate oral health into overall health

care in her book Teeth (2017) (61).

Since Deamonte’s death, access to dental services for

all has been identified as an important component of

comprehensive health care for children. In 2009, the

reauthorization of the Children’s Health Insurance

Program (CHIP) required states to provide dental

coverage to enrolled children and gave states the

option to provide dental benefits to certain children

who did not qualify for full CHIP coverage. In 2010,

the health reform bill known as the Affordable Care

Act required that starting in 2014, all insurance

plans to be offered through new health insurance

exchanges had to include oral health care for children

and prohibited insurers from charging out-of-pocket

expenses for preventive paediatric oral health

services (62).

© WHO/Johannah Jorgensen

25

1.Oral diseases are global public health problems

1.6 Global expenditures and economic impact of oral diseases

Expenditures for oral health care are highly unequal globally as well as across regions and countries. With

a generally high burden of untreated oral disease for all populations and countries, the differences in

spending indicate great differences in availability of and priority for oral health care. However, the level

of national expenditures is not necessarily correlated to better or worse oral health status. In addition,

there are significant challenges in availability, scope, quality and comparability of economic data at

national, regional and international levels (63–65).

1.6.1 The cost of oral health care

The total direct expenditure for oral diseases among 194 countries amounted to US$ 387 billion or a

global average of about US$ 50 per capita in 2019. This represents about 4.8% of global direct health

expenditures. At the same time, productivity losses from oral diseases were estimated at about US$ 42

per capita, totalling to around US$ 323 billion globally (66).

Box 5. Health expenditure definitions

Direct dental expenditure includes public and private

treatment costs for oral health care (without the costs of

care for lip and oral cavity cancer). Such costs comprise

workforce, facility and service costs covered by public

and private financial sources, including patient out-

of-pocket expenditures. Travel costs are excluded.

Data detailing the share of prevention or specific

interventions as part of direct dental expenditures are

not available (63, 67).

Productivity losses are calculated using the methodology

of the WHO Commission on Macroeconomics and Health

whereby GDP per capita values are multiplied by oral-

disease-specific estimates of DALYs (68). Further details

are provided in Section A.2.

The inequalities of oral health expenditures are

striking, and differences among countries are

very notable. The average per capita expenditure

in low-income countries is US$ 0.52, whereas

high-income countries spend an average of US$

260 per capita – 500 times more. The ratio of

total amounts spent on oral health care is even

worse: all low-income countries together spend

800 times less than all high-income countries

together (see Figs. 13 and 14). The single highest

total amount is spent in the United States with

US$ 134 billion, followed by China with US$ 61

billion; both combined represent a 51% share of

all direct costs globally.

The pattern of unequal spending among the countries reveals four major groups (Fig. 15):

• Group 1:

- 99 countries (about half of WHO Member States) spend very little on oral health care

- 50 countries (about one quarter of countries, among them 34 from the WHO African Region) spend

less than US$ 1 per person per year.

- 50 countries (about one quarter of countries) spend between US$ 1 and US$ 10 per person per year.

• Group 2:

- 49 countries (about one quarter of WHO Member States) spend between US$ 11 and US$ 50 per person

per year.

26

Global oral health status report: Towards universal health coverage for oral health by 2030

• Group 3:

- 31 countries (16% of WHO Member States) spend between US$ 51 and US$ 300 per person per year.

• Group 4:

- 12 countries (6% of countries) spend more than US$ 300 per person per year.

The combined direct dental expenditures of the 13 highest-spending countries equal about US$ 340

billion. This is an 88% share of the global direct expenditure, yet these countries only represent 22.5%

(2.5 billion people) of the world’s population. People in these highest-spending countries benefit from

an average of US$ 136 per capita annual expenditure. The remaining 13% of global direct expenditure

(US$ 47 billion) is shared among 181 countries with 5.3 billion people; their average per capita annual

expenditure is 15 times lower, reaching only US$ 9 per capita each year (66).

Fig. 13 Per capita direct dental expenditure in US$ per WB country income group (2019)

Fig. 14 Total direct dental expenditure in US$ per WB country income group (2019)

27

1.Oral diseases are global public health problems

In terms of WHO regions, the lowest total and per capita direct expenditure was reported from

the South-East Asian Region, with a total expenditure of US$ 0.76 billion and US$ 0.52 per capita

expenditure. The Region of the Americas shows the highest amounts, with US$ 157 billion total and

US$ 155 per capita annual expenditure.

Out-of-pocket costs can be major barriers to accessing oral health care. With private practitioners

predominantly providing services, which often are only partially or not at all covered by government

programmes and/or insurance, patients accessing oral health services must either pay the entire cost

of care or need to cover substantial copayments. Paying for necessary oral health care is one of the

leading reasons for catastrophic health expenditures, resulting in an increased risk of impoverishment

and economic hardship (69, 70). A survey by the WHO European Region Office (2019) showed that

among all households with catastrophic health expenditures, dental expenditures ranked third after

medicines and inpatient care (71). The same survey reported that access to general health care is

much more equitable than access to oral health care. On average, out-of-pocket expenditure for

oral health care within the 28 countries of the European Union was more than 60% of the treatment

costs, and in some Member States, it was close to 100% due to complete exclusion of oral health

care from health coverage.

Fig. 15 Per capita dental expenditures in US$ per country (2019)

Per capita dental

expenditures in US$

Less than $1

$1 to $10

$11 to $50

$51 to $300

More than $300

Data not available

Not applicable

Data Source: Jevdjevic & Listl 2022. Economic impacts of oral diseases in 2019. Map Production: WHO NCD/MND unit. Map Creation

Date: 30 August 2022. Note: N = 194 countries.

28

Global oral health status report: Towards universal health coverage for oral health by 2030

©Julie Pudlowski

The burden

of the main

oral diseases

2

2.1 Dental caries

2.1.1 The burden of untreated dental caries

More than one third of the world’s population lives with untreated dental caries. The disease, also

known as tooth decay or simply cavities, is the most widespread NCD and a major public health problem

for populations and governments worldwide. Untreated dental caries in permanent teeth is the most

prevalent condition among all diseases, affecting more than 2 billion people worldwide. In deciduous

teeth, untreated caries is the single most common chronic childhood disease, affecting 514 million

children worldwide (4, 6, 72).

2.1.2 Prevalence and case numbers of untreated caries of deciduous teeth

The estimated global average prevalence of caries of deciduous teeth is 43%, and 134 of 194 (69% of

countries) WHO Member States have prevalence figures of more than 40% (see Fig. 16).

Prevalence ranges from 46% in upper-middle-income countries to 38% in high-income countries. Case

numbers are highest in lower-middle-income countries (244 million cases) and lowest in high-income

countries (45 million cases; see Table 2 and Fig. 17). Overall, more than three quarters of cases of untreated

caries in deciduous teeth are found in middle-income countries where health systems and resources to

address the burden are often inadequate.

Box 6. What is dental caries and how is it measured?

Dental caries is defined as a gradual loss and

breakdown (decay) of tooth hard tissues (enamel

and dentine) that results when free sugars contained

in food or drink are converted by bacteria into acids

that destroy the tooth over time. Free sugars are all

sugars added to foods by the manufacturer, cook

or consumer, plus sugars that are naturally present

in honey, syrups and fruit juices (22, 73). Caries can

lead to cavities, which are permanently damaged

areas in the hard surface of the teeth (“holes” or

“cavities”) (74).

Dental caries can be measured like all diseases

with prevalence and incidence. In addition, WHO

recommended the use of the DMFT index, which

reports cumulative caries experience over time (75).

Other indicators and caries assessment systems

exist, and new indicator frameworks are now being

considered. The GBD project uses its standard

metrics, such as estimated prevalence, case numbers

and DALYs, in the context of dental caries (72, 76).

Dental caries affects all age groups, starting with the

eruption of the first teeth (deciduous teeth/primary

dentition) and increasing in prevalence until late

adulthood, then remaining at high levels until older

age. The onset of the disease in children younger

than 6 years is early childhood caries, which at times

progresses quickly to complete destruction of the

primary dentition. Children with early childhood

caries have a much higher risk of continued disease

burden in their later life (77–79).

30

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 16. Estimated prevalence of dental caries of deciduous teeth per country

Estimated

prevalence of untreated

caries of deciduous teeth

in children 1-9 years, 2019

18.7% - 33.4%

33.4% - 41.4%

41.4% - 45.8%

45.8% - 53.2%

Data not available

Not applicable

Data source: Global Burden of Disease Collaborative Network. GBD 2019. Seattle: IHME; 2020. Map Production: WHO NCD/MND unit.

Map Creation Date: 30 August 2022. Note. N = 194 countries; data are for children aged 1–9 years, both sexes, from GBD 2019 (4).

Table 2. Estimated prevalence and cases of caries of deciduous teeth in 2019 and the percentage change from

1990 to 2019 per WB country income group

WB income

group

Prevalence

(2019)

Cases

(2019)

Percentage change

prevalence

(1990–2019)

Percentage change

cases

(1990–2019)

Low income

40.00%

73 733 740

-3.31%

87.49%

Lower-middle

Income

42.92%

244 114 139

-2.51%

17.37%

Upper-middle

Income

45.61%

151 481 711

-1.84%

-21.22%

High income

38.30%

44 907 180

-3.88%

-11.94%

Global

42.71%

513 829 451

-3.33%

5.56%

Note. Data are for children aged 1–9 years, both sexes, from GBD 2019 and UN DESA 2019 (4, 7).

31

2. The burden of the main oral diseases

Fig. 17 Estimated cases and prevalence of caries of deciduous teeth per WB country income group

Note. Data are for children aged 1–9 years, both sexes, from GBD 2019 (4).

Among WHO regions, the highest prevalence is estimated for the Western Pacific Region (46%) and the

lowest for the African Region (39%). Case numbers are highest in the South-East Asia Region, with an

estimated 135 million cases, and lowest in the European Region, with an estimated 41 million cases (see

Table 3 and Fig. 18).

Table 3. Estimated prevalence and case numbers of caries of deciduous teeth in 2019 and their percentage

change from 1990 to 2019 per WHO region

WHO region

Prevalence

(2019)

Cases

(2019)

Percentage change

prevalence

(1990–2019)

Percentage change

cases

(1990–2019)

African Region

38.61%

111 024 979

-3.40%

87.19%

Eastern Mediterranean

Region

45.10%

66 378 695

0.60%

44.35%

European Region

39.64%

40 853 621

-7.22%

-22.10%

Region of the Americas

43.21%

57 459 634

-2.21%

-2.29%

South-East Asia Region

43.77%

135 260 519

-1.96%

-3.25%

Western Pacific Region

46.20%

102 138 618

-0.20%

-22.75%

Global

42.71%

513 829 451

-3.33%

5.56%

Note. Data are for children aged 1–9 years, both sexes, from GBD 2019 and UN DESA 2019 (4, 7).

32

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 18. Estimated cases and prevalence of caries of deciduous teeth per WHO region

Note. Data are for children aged 1–9 years, both sexes, from GBD 2019 (4).

2.1.3 Caries of deciduous teeth – trends 1990–2019

Between 1990 and 2019, the global average prevalence of caries of deciduous teeth decreased slightly

by 3% (with the largest decreases in high-income countries). Estimated global average case numbers

increased by 6%. However, this figure masks significant increases in case numbers, with an increase

(87%) that almost doubled in low-income countries as well as a 17% increase in lower-middle-income

countries. Case numbers decreased by 21% in upper-middle-income countries and by 12% in high-

income countries (see Table 2).

A decrease in estimated prevalence is reported for all WHO regions (with the largest decrease in

the European Region at 7%), yet the other decreases are modest. Only the Eastern Mediterranean

Region showed a slight increase in prevalence. Estimated changes in case numbers with the highest

increases were reported for the African Region (87%) and the Eastern Mediterranean Region (44%),

while all other regions showed decreases (with the largest decrease in the Western Pacific Region at

23%; see Table 3).

2.1.4 Prevalence and case numbers of caries of permanent teeth

The estimated global average prevalence of caries of permanent teeth is 29%, and case numbers

reach more than 2 billion cases. Prevalence differences between country income groups are minor.

The highest case numbers are estimated for lower-middle-income countries (816 million) and upper-

middle income countries (690 million). Middle-income countries thus report 75% of cases of untreated

caries in permanent teeth (see Table 4 and Figs. 19 and 20).

33

2. The burden of the main oral diseases

Table 4. Estimated prevalence and cases of caries of permanent teeth in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per WB country income group

WB income

group

Prevalence

(2019)

Cases

(2019)

Percentage

change prevalence

(1990–2019)

Percentage

change cases

(1990–2019)

Percentage

change population

(1990–2019) a

Low

income

30.61%

180 950 660

-0.43%

120.55%

117.98%

Lower-middle

income

28.89%

815 650 762

-0.69%

73.57%

63.25%

Upper-middle

income

27.75%

689 898 365

-4.15%

26.23%

27.97%

High

income

29.30%

331 635 645

-4.64%

16.66%

20.63%

Global

28.70%

2 019 706 083

-2.59%

46.07%

44.79%

Note. Data are for ages greater than 5 years, both sexes, from GBD 2019 and UN DESA 2019 (4, 7).

a Population numbers are for total population across all age groups.

Fig. 19. Estimated cases and prevalence of caries of permanent teeth per WB income group

Note. Data are for ages greater than 5 years, both sexes, from GBD 2019 (4).

34

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 20. Estimated prevalence of caries of permanent teeth per country

Estimated

prevalence of untreated

caries of permanent teeth

in people 5 years+, 2019

23.3% - 30.6%

30.6% - 35.6%

35.6% - 40.6%

40.6% - 55.7%

Data not available

Not applicable

Data source: Global Burden of Disease Collaborative Network. GBD 2019. Seattle: IHME; 2020. Map Production: WHO NCD/MND unit.

Map Creation Date: 30 August 2022. Note. N = 194 countries; data are age standardized, for ages greater than 5 years, both sexes, from GBD 2019 (4).

Table 5. Estimated prevalence and cases of caries of permanent teeth in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per WHO region

WHO region

Prevalence

(2019)

Cases

(2019)

Percentage

change prevalence

(1990–2019)

Percentage

change cases

(1990–2019)

Percentage

change population

(1990–2019) a

African Region

28.50%

262 650 114

-1.66%

119.94%

114.98%

Eastern Mediterranean

Region

32.25%

202 193 940

-0.27%

102.94%

93.08%

European Region

33.63%

293 866 294

-3.91%

6.09%

9.94%

Region of the Americas

28.24%

264 462 149

-0.05%

46.35%

40.70%

South-East Asia Region

28.69%

525 752 700

0.67%

65.26%

52.38%

Western Pacific Region

25.41%

463 936 789

-6.50%

20.37%

24.96%

Global

28.70%

2 019 706 083

-2.59%

46.07%

44.79%

Note. Data are for ages greater than 5 years, both sexes, from GBD 2019 and UN DESA 2019 (4, 7).

a Population numbers are for total population across all age groups.

35

2. The burden of the main oral diseases

Estimated prevalence for WHO regions range from 25% (Western Pacific Region) to 34% (European

Region). Case numbers are highest in the South-East Asia Region (526 million) and Western Pacific Region

(464 million; see Table 5 and Fig. 21).

Fig. 21. Estimated cases and prevalence of caries of permanent teeth per WHO region

Note. Data are for ages greater than 5 years, both sexes, from GBD 2019 (4).

2.1.5 Caries of permanent teeth – trends 1990–2019

Over almost a 30-year period, the number of cases increased by about 640 million cases, despite a

slight decrease in prevalence (-2.6%). This significant increase in caries burden is mainly driven by the

rise in case numbers due to the population growth in low- and lower-middle-income countries, where

prevalence increases of 121% and 74% respectively were reported (see Table 4).

The WHO African Region showed the highest increases (120%), followed by the Eastern Mediterranean

Region with 103%. The lowest increase was estimated for the European Region with a 6% increase.

Between 1990 and 2019, prevalence was estimated to remain stable or decrease slightly in all WHO

regions, with the strongest decrease in the Western Pacific Region (-6%; see Table 5).

2.1.6 Risk factors, determinants and impacts of dental caries

Dental caries is a multifactorial disease, and its development is linked to a complex web of individual,

family and community-related factors that include the social and physical environment, behaviour and

health services as well as commercial determinants, all acting over the life-course time (80, 81).

36

Global oral health status report: Towards universal health coverage for oral health by 2030

However, the consumption of free sugars in food and beverages is the most important risk factor for

dental caries and is one of the common risks for NCDs. High sugar consumption is directly related to

higher caries activity, and restricting intake of sugars decreases incidence and severity of dental caries.

In addition, self-care and personal oral hygiene practices can significantly reduce the development and

slow down the progression of caries. This is the rationale for recommending to brush teeth twice daily

with a fluoride toothpaste to reduce the risk of caries in all age groups.

Untreated caries has many negative impacts in different phases of life. Repeated episodes of pain as well

as chewing and sleeping difficulties reduce quality of life and productivity. Caries is a major cause of

productivity losses at work, leads to missed educational opportunities and contributes to poor academic

performance in school. Severe untreated caries with systemic inflammatory reactions from pulp infections

is also a contributing factor to underweight and stunting in children (36, 82–87).

2.2 Severe periodontal disease

2.2.1 Global burden of severe periodontal disease

Severe periodontal disease (see Box 7 for definition) is widespread, with a global prevalence of about

19% in people aged greater than 15 years, representing more than 1 billion cases worldwide.Prevalence

across country income groups is similar, yet case numbers are highest in lower-middle-income countries

(437 million) and lowest in low-income countries (80 million; see Fig. 22 and Table 6). Prevalence of severe

periodontal disease starts in late adolescence, peaks around 55 years of age and remains high until old age.

Men and women are almost equally affected (88, 89). Fig. 23 provides an overview of prevalence per country.

©WHO

37

2. The burden of the main oral diseases

Box 7. What is severe periodontal disease?

Periodontal disease is a chronic inflammation of the

soft and hard tissues that support and anchor the

teeth. Periodontal diseases include gingivitis (gum

disease), a superficial and reversible inflammation

of the gum resulting in swelling and bleeding. In

the presence of other accelerating factors, such as

tobacco use, systemic diseases or a compromised

immune response, gingivitis may develop into

periodontitis, thereby affecting the deeper gum

tissues and bone. The loss of attachment (“pocket”)

eventually leads to increased mobility and tooth

loss. Only severe periodontal disease, defined as the

presence of a pocket of more than 6 mm depth, is a

condition of public health concern (4, 89).

Fig. 22. Estimated cases and prevalence of severe periodontal disease per WB country income group

Note. Data are age standardized, for ages greater than 15 years, both sexes, from GBD 2019 (4).

Table 6. Estimated prevalence and cases of severe periodontal disease in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per World Bank income group

WB income group

Prevalence

(2019)

Cases

(2019)

Percentage

change prevalence

(1990–2019)

Percentage

change cases

(1990–2019)

Percentage

change population

(1990–2019) a

Low income

19.71%

80 008 079

0.73%

129.75%

117.98%

Lower-middle income

19.80%

436 697 336

17.24%

124.66%

63.25%

Upper-middle income

18.19%

386 443 138

34.98%

96.83%

27.97%

High income

17.65%

176 251 937

18.71%

51.43%

20.63%

Global

18.82%

1 079 927 025

23.96%

99.18%

44.79%

Note. Data are age standardized, for ages greater than 15 years, both sexes, from GBD 2019 and UN DESA 2019 (4, 7).

a Population numbers are for total population across all age groups.

38

Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 23. Estimated prevalence of severe periodontal disease per country

Estimated

prevalence of severe

periodontal disease in

people 15 years+, 2019

2.9% - 10.6%

10.6% - 19.6%

19.6% - 27.3%

27.3% - 36.7%

Data not available

Not applicable

Data source: Global Burden of Disease Collaborative Network. GBD 2019. Seattle: IHME; 2020. Map Production: WHO NCD/MND unit. Map Creation

Date: 30 August 2022. Note. N = 194 countries; data are age standardized, for ages greater than 15 years, both sexes, from GBD 2019 (4).

Among the WHO regions, prevalence ranges in a narrow band between 16% (Western Pacific Region) and

23% (African Region), while the case numbers reflect the demographic share of the respective regions,

with the South-East Asia Region and Western Pacific Region showing the highest case numbers and the

Eastern Mediterranean Region showing the lowest (see Fig. 24 and Table 7).

Fig. 24. Estimated cases and prevalence of severe periodontal disease per WHO region

Note. Data are age standardized, for ages greater than 15 years, both sexes, from GBD 2019 (4).

39

2. The burden of the main oral diseases

Table 7. Estimated prevalence and cases of severe periodontal disease in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per WHO region

WHO region

Prevalence

(2019)

Cases

(2019)

Percentage

change prevalence

(1990–2019)

Percentage

change cases

(1990–2019)

Percentage

change population

(1990–2019) a

African Region

22.80%

144 745 633

2.47%

136.93%

114.98%

Eastern Mediterranean

Region

17.37%

82 864 263

10.42%

149.44%

93.08%

European Region

17.89%

136 209 156

16.13%

34.14%

9.94%

Region of the Americas

18.89%

148 617 765

19.74%

89.37%

40.70%

South-East Asia Region

20.77%

306 964 138

22.66%

125.95%

52.38%

Western Pacific Region

16.28%

258 963 653

39.19%

97.51%

24.96%

Global

18.82%

1 079 927 025

23.96%

99.18%

44.79%

Note. Data are age standardized, for ages greater than 15 years, both sexes, from GBD 2019 and UN DESA 2019.

a Population numbers are for total population across all age groups.

2.2.2 Trends in disease burden 1990–2019

Prevalence and case numbers of severe periodontal disease increased significantly between 1990 and

2019. Estimated case numbers increased by almost 540 million, while estimated prevalence increased

by 24%. Upper-middle-income countries showed the highest increase in prevalence (35%); the group of

low-income countries was estimated to have almost no change in prevalence. Case numbers, however,

increased the most in this country group (130%), as opposed to high-income countries with the smallest

increase in case numbers (51%; see Table 6).

Among the WHO regions, the Western Pacific Region had the highest increase in prevalence between

1990 and 2019, while the highest increase in case numbers was estimated for the Eastern Mediterranean

Region (see Table 7).

Prevalence of severe periodontitis increases with age (see Fig. 10). With the global demographic changes

characterized by larger ageing populations and increasing longevity, an even higher global burden of

severe periodontal disease may be expected in the future.

2.2.3 Severe periodontal disease, inequalities and general health

As for other NCDs, there are significant inequalities among population groups resulting from differences

in exposure to risk factors and wider determinants of health. A greater disease burden is found in

populations with lower socioeconomic status, income or education as well as among those living in rural

areas. The consequences of severe periodontal disease for people affected include difficulties with eating

or speaking, particularly when teeth are loose or already lost. Social interaction, general well-being and

quality of life may also be significantly impaired.

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Global oral health status report: Towards universal health coverage for oral health by 2030

Poor oral hygiene is a major behavioural risk factor for periodontal disease, together with common

NCD risk factors such as tobacco use (90).

Severe periodontal disease is closely interlinked with major NCDs; particularly an association with

unmanaged type 2 diabetes is well documented. Good periodontal health improves glycaemic control;

deterioration of periodontal health may be an early indicator of poorly managed diabetes (44, 91).

2.3 Edentulism

2.3.1 The global burden of severe tooth loss and edentulism

A person is said to suffer from severe tooth loss when fewer than nine teeth are remaining in the mouth,

which includes complete toothlessness, or edentulism (4, 92). Losing teeth is generally the end point of a

lifelong history of oral disease, mainly advanced dental caries and severe periodontal disease, but can also

be due to trauma and other causes, all possibly leading to tooth extraction. It can also be a consequence

of weak oral health care services in resource-poor settings where restorative and prosthetic care are

either not generally available or unaffordable (88).

Losing teeth is often seen as an inevitable result of ageing and is socially accepted in many cultures.

However, losing teeth and living with reduced or absent dentition can be psychologically traumatic, socially

damaging and functionally limiting to the individual affected. Balanced nutrition may become difficult,

especially when partial or full dentures to replace missing teeth are not accessible or affordable (54).

©Julie Pudlowski

41

2. The burden of the main oral diseases

The estimated global average prevalence of complete tooth loss is almost 7%, with more than 350

million cases worldwide (see Table 8). The lowest prevalence is estimated for low-income countries (3%),

followed by lower-middle-income countries (4.5%) and upper-middle-income countries (8%). The highest

prevalence rates of 10.5% are estimated for high-income countries, as well as highest case numbers with

98 million cases (see Fig. 25). The European Region has the highest prevalence among the 6 WHO regions

and, together with the Western Pacific Region, also has the highest numbers of cases (see Table 9 and

Fig. 26). The African Region has the lowest prevalence and case numbers.

Table 8. Estimated prevalence and cases of edentulism in 2019 and the percentage change of prevalence, cases

and population from 1990 to 2019 per WB country income group

WB income group

Prevalence

(2019)

Cases

(2019)

Percentage change

prevalence

(1990–2019)

Percentage change

cases

(1990–2019)

Low

income

3.10%

10 221 945

-4.35%

118.01%

Lower-middle

income

4.56%

87 256 962

2.56%

103.26%

Upper-middle

income

7.89%

153 803 699

30.41%

105.66%

High

income

10.52%

98 065 451

5.63%

39.02%

Global

6.82%

350 060 709

8.02%

81.12%

Note. Data are age standardized, for ages greater than 20 years, both sexes, from GBD 2019 and UN DESA 2019

Fig. 25. Estimated cases and prevalence of edentulism per WB country income group

Note. Data are age standardized, for ages greater than 20 years, both sexes, from GBD 2019 (4).

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Global oral health status report: Towards universal health coverage for oral health by 2030

Table 9. Estimated prevalence and case numbers of edentulism in 2019 and the percentage change of

prevalence, cases and population from 1990 to 2019 per WHO region

WHO Region

Prevalence

(2019)

Cases

(2019)

Percentage change

prevalence

(1990–2019)

Percentage change

cases

(1990–2019)

African Region

3.34%

17 369 660

-11.75%

105.84%

Eastern Mediterranean

Region

5.93%

24 454 031

-2.75%

130.89%

European Region

12.42%

88 199 746

8.95%

30.01%

Region of the Americas

10.54%

74 843 184

14.51%

88.25%

South-East Asia Region

4.06%

52 687 418

16.39%

123.36%

Western Pacific Region

6.24%

91 909 753

39.15%

114.86%

Global

6.82%

350 060 709

8.02%

81.12%

Note. Data are age standardized, for ages greater than 20 years, both sexes, from GBD 2019 and UN DESA 2019.

Fig. 26. Estimated cases and prevalence of edentulism per WHO region

Note. Data are age-standardized, for ages greater than 20 years, both sexes, from GBD 2019 (4).

For people older than 60 years the global average prevalence of edentulism is much higher, estimated

at 22.7% – almost one in four persons older than 60 have no teeth left. Rates vary across country income

groups, with low-income countries showing the lowest rate (11.7%) and high-income countries reporting

the highest rate (25.4%). Among the WHO regions, the highest rate is estimated for the European Region

(31.3%) and the lowest for the African Region (12.1%; see Fig. 27).

The burden of DALYs due to tooth loss is estimated at more than 9.5 million (GBD combines severe tooth

loss and edentulism to calculate DALYs).

43

2. The burden of the main oral diseases

Fig. 27. Estimated prevalence of edentulism

Estimated

prevalence of edentulism

in people 60 years+, 2019

5.0% - 16.4%

16.4% - 26.2%

26.2% - 34.1%

34.1% - 50.9%

Data not available

Not applicable

Data source: Global Burden of Disease Collaborative Network. GBD 2019. Seattle: IHME; 2020. Map Production: WHO NCD/MND unit.

Map Creation Date: 30 August 2022. Note. N = 194 countries; data are for ages greater than 60 years, both sexes, from GBD 2019 (4).

2.3.2 Trends in disease burden 1990–2019

The global average prevalence of edentulism increased by 8%

and the estimated global case numbers rose by 81% between

1990 and 2019, representing an additional 157 million cases

(see Table 8). During this time span, only low-income countries

saw a modest decrease in prevalence (-4%), while all other

country income groups had increases, which were highest in

upper-middle-income countries (30%). Case numbers more

than doubled in all country income groups, except in high-

income countries, where case numbers increased by 39%.

Among the WHO regions, the African Region had the largest

decrease in prevalence (-12%), followed by the Eastern

Mediterranean Region (-3%; see Table 9). Prevalence

increased in all other WHO regions, with the most growth in

the Western Pacific Region (39%). Case numbers more than

doubled in all WHO regions, except for the European Region

(30% increase) and the Region of the Americas (88% increase).

The trends measured in DALYs follow similar patterns, with

a global increase of 80% from 1990 to 2019.

©Julie Pudlowski

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Global oral health status report: Towards universal health coverage for oral health by 2030

2.4 Oral cancer

2.4.1 Global and regional burden of lip and

oral cavity cancer

Oral cancers are a disease group with high mortality

and morbidity. The IARC Global Cancer Observatory

(GLOBOCAN) estimated 377 713 new cases and

177 757 deaths from lip and oral cavity cancers

worldwide in 2020(93, 94). The number of estimated

incident cases of lip and oral cavity cancers ranked

16th among all cancers (for both sexes); combined

with cases of oropharyngeal cancers, the rank

increased to the 13th most common cancer

worldwide. The global incidence rate for men (13.1

per 100 000) is more than 2.5 times higher than for

women (5 per 100 000). Mortality rates for men are

more than double compared to women (see Figs. 28

and 29). Lip and oral cavity cancer is the 11th most

common cancer for men (all ages), with a share of

3.5% of all cancers.

Box 8. Definition of oral cancer

The umbrella term oral cancer includes malignant

neoplasms, predominantly squamous cell

carcinomas occurring in the mucosa of the lips and

oral cavity (tongue, upper and lower gums, floor of

the mouth, palate and other parts of the mouth),

corresponding to the International Classification of

Diseases (ICD-10) codes C00–C06. The IARC groups lip

and oral cancers together under the generally used

term oral cancer, yet they are cancers with distinct

epidemiological and clinical profiles (93, 95). Due to

increasing incidence of cancers of the tonsils and

other parts of the oropharynx (ICD-10 C09 and C10)

linked to human papillomavirus (HPV) infections,

they are now also recognized as global public health

problems under the term oropharyngeal cancer. This

report uses oral cancer for lip and oral cavity cancer,

unless otherwise stated.

Prevalence of oral cancer differs significantly by

regions, countries and population groups (see Fig. 30).

Middle- and high-income countries carried almost the

entire burden in terms of case numbers in 2020, with

estimates for lower-middle-income and high-income

countries encompassing more than three quarters of

global estimated cases (5). The WHO South-East Asia

Region shows the highest incidence and mortality of

all WHO regions, with rates almost double the global

average (see Figs. 29, 30 and 31). Oral cancers are the

most common cancer for males in the region, with men

aged 25–39 accounting for more than one quarter of

all cancer cases. Overall, inequalities are significant

with people with low income, socio-economic status

or other disadvantage being more frequently affected.

Treatment availability, outcomes and survival rates are

generally better in high-income countries (96, 97).

©WHO/Ahmad Yusni

45

2. The burden of the main oral diseases

Fig. 28. Incidence and mortality rates of lip and oral cavity cancer per WB country income group

Note. Data are age-standardized, for ages greater than 30 years, from GLOBOCAN 2020 (5).

Fig. 29. Incidence and mortality rates of lip and oral cavity cancer per WHO region

Note. Data are age-standardized, for ages greater than 30 years, from GLOBOCAN 2020 (5).

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Global oral health status report: Towards universal health coverage for oral health by 2030

Fig. 30. Estimated incidence rates of lip and oral cavity cancer

Estimated

incidence rates

of lip and oral

cavity cancer in people

30 years+ per 100 000

population (2020)

0.0 - 3.1

3.1 - 5.4

5.4 - 8.1

8.1 - 11.0

11.0 - 14.6

14.6 - 47.6

Data not available

Not applicable

Data source: Ferlay et al. Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer: Lyon, France; 2020.

Map Production: WHO NCD/MND unit. Map Creation Date: 30 August 2022. Note. N = 176 countries; data are age-standardized, for ages 30–85

years, both sexes, from GLOBOCAN 2020 (5).

Fig. 31. Estimated mortality rates of lip and oral cavity cancer

Estimated

mortality rates

of lip and oral

cavity cancer in people

30 years+ per 100 000

population (2020)

0.0 - 1.1

1.1 - 2.1

2.1 - 3.2

3.2 - 4.9

4.9 - 8.3

8.3 - 18.9

Data not available

Not applicable

Data source: Ferlay et al. Global Cancer Observatory: Cancer Today. International Agency for Research on Cancer: Lyon, France; 2020.

Map Production: WHO NCD/MND unit. Map Creation Date: 30 August 2022. Note. N = 176 countries; data are age-standardized, for ages 30–85 years, both

sexes, from GLOBOCAN 2020 (5).

47

2. The burden of the main oral diseases

The 136 000 new cases and 75 000 deaths occurring in India alone account for 36% of all new cases and

42% of deaths from oral cancers worldwide. The South-East Asia Region has a 52% share of deaths from

oral cancer (97).

Variations of oral cancer are also observed relative to location. The tongue is the most common site of

oral cavity cancers in Europe, the United States and Japan, whereas the buccal and lip mucosa are more

common cancer locations in some regions of Asia. These regional variations in the incidence of oral cavity

cancer subsites relate to the distribution of the main risk factors (such as tobacco and alcohol use in

Western countries and betel quid and tobacco chewing in South and Southeast Asia).

2.4.2 Oral cancer – trends over time

Observed trends in incidence and mortality of oral cancers vary according to geographical location, age

group and sex. Differences largely follow changes in tobacco consumption, thereby reflecting the stage

and degree of the tobacco epidemic of the respective region. Overall, there is a long-term downward trend

in the incidence of oral cancers among men, while it is increasing or stable among women in countries

where the tobacco epidemics reached their peak some time ago. By contrast, and not unexpectedly,

oral cancers have increased in countries with rising tobacco use.

2.4.3 Specific risk factors of oral cancer

The main risk factors for lip, oral cavity and oropharyngeal cancers are tobacco use, alcohol consumption

and betel quid use, which act independently or in combination (see Section 1.2.4). Other risk factors

with lower impact include diet and socioeconomic position (98–100).

Lip and oral cavity cancers are the third most common cancer related to tobacco use, and about one

quarter of oral cancer cases are related to harmful alcohol consumption. Both risk factors combined

substantially increase the risk of oral cavity cancers.

The group of Human Papilloma Viruses (HPV) is a well-recognized cause of about 4.5% of all cancers

worldwide. HPV types 16 and 18 are now the most common cause of oropharyngeal cancers (base of

the tongue, tonsils and back of the throat). Increases in cases have been reported in many countries

where previously low incidence rates were seen, particularly among young male white adults. With

rising prevalence of HPV infection in specific age cohorts, the incidence of oropharyngeal cancer in

men surpassed the incidence of cervical cancer in women in the United Kingdom in 2016. Survival

rates of HPV-positive oropharyngeal cancers are better compared to patients with HPV-negative

cancers. In many countries, public health agencies advocate for gender-neutral HPV vaccination as a

populationwide primary prevention strategy to reduce incidence of HPV-associated cancers in both

males and females (101–103).

Specific risk factors for lip and oral cavity cancers are smokeless tobacco (chewing and snuff) and betel

quid (paan), substances that have long been established as strong carcinogens (104). Chewing betel

quid without tobacco is estimated to increase the risk of oral cavity cancer 2.5-fold; in combination with

tobacco the risk increases 7.74-fold, with a cumulative effect over the life course (105). More research is

needed to assess the impact of e-cigarettes and vaping nicotine products on oral cancer.

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Global oral health status report: Towards universal health coverage for oral health by 2030

Box 9. Betel quid: a dangerous yet popular carcinogen

Betel quid chewing with tobacco is one of the most

common forms of smokeless tobacco and is used by

approximately 600 million individuals worldwide, with

a higher prevalence in South and South-East Asia and

the Pacific islands. The effect of betel quid chewing is

a general stimulation, similar to the effects of tobacco

or caffeine (110).

Betel quid is a mixture of areca nut (nut of a palm tree,

Areca catechu), slaked lime (calcium hydroxide) and betel

leaf (leaf of the piper betel vine), and it can have tobacco

(mainly in South-Central Asia) or not (in East Asia and

Melanesia). All of the ingredients are wrapped inside the

betel leaf and made into a bunch commonly known as a

“quid,” which is then chewed. It stains teeth and tissues

dark red and is spit out after chewing for a few hours.

Box 10. IARC handbook Vol. 19 - on oral cancer prevention

The IARC handbooks of cancer prevention provide

comprehensive reviews and consensus evaluations

of interventions and strategies that aim to reduce

cancer incidence or mortality at the population level.

The process involves a working group of international,

interdisciplinary experts who review the literature and

assess the body of evidence.

The volume 19 of the IARC handbook covers the

topic of oral cancer prevention, both primary and

secondary prevention. In terms of primary prevention,

the handbook evaluates the effectiveness of quitting

exposure to the known risk factors for oral cancer –

tobacco smoking, alcohol consumption, and chewing

of products (including betel quid) that contain

smokeless tobacco, areca nut, or both – in reducing

oral cancer incidence and mortality. In the subsequent

section, the handbook assesses the impact of

interventions aimed at quitting the use of smokeless

tobacco and areca nut products; the impact of policies

pertinent to smokeless tobacco and areca nut control

is also assessed. In terms of secondary prevention, the

effectiveness of screening by clinical oral examination

is evaluated. The handbook also covers other related

topics, such as the global burden of oral cancer and

potentially malignant disorders, their natural history,

risk factors for oral cancer, the prevalence of smokeless

tobacco and areca nut chewing in the different WHO

regions, screening methods and technologies as well

as screening programmes and the determinants of

participation in screening.

Publication of the IARC handbook on oral cancer

prevention, volume 19, is scheduled for the end of

2022. This handbook will help policy-makers develop

evidence-based interventions or recommendations

to reduce oral cancer risk at the population level. See

https://publications.iarc.fr/Book-And-Report-Series/

Iarc-Handbooks-Of-Cancer-Prevention.

©WHO/Yoshi Shimizu

49

2. The burden of the main oral diseases

Oral cancer contrib