Global oral health status report Towards universal health coverage for oral health by 2030 Summary of the WHO European Region Abstract This publication describes the status of oral health across the WHO European Region, covering 53 countries across Europe and Central Asia, based on the Global Oral Health Status Report 2022. The summary reviews the prevalence of oral disease across the Region, and identifies the drivers forharm. It highlights regional issues and opportunities in establishing effective oral health provision. It also explores the proportion of countries with national oral health policies and dedicated staff embedded in Ministries of Health focusing on oral health. The aim of this regional summary is to encourage governments and health authorities to increase access to safe, effective and affordable essential oral health care in order to address oral health inequities and improve health for all in the WHO European Region. The recommendations contained in this report complement those in the Global Oral Health Action Plan, and focus on oral health as being integral to Universal health coverage. Key Words: ORAL HEALTH; UNIVERSAL HEALTH COVERAGE; NONCOMMUNICABLE DISEASES; ORAL HEALTH POLICY ISBN: 978-92-890-5898-8 (PDF) ISBN: 978-92-890-6001-1 (Print) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover photograph: ©WHO/Sanne De Wilde/NOOR Global oral health status report Towards universal health coverage for oral health by 2030 Summary of the WHO European Region © W H O / Kh al ed M os ta fa Contents Foreword vii 1. Towards global oral health equity through universal health coverage 1 2. Oral diseases are global and regional health problems 3 Oral diseases present an increasing global and regional burden 4 Oral diseases share risk factors with other NCDs and have impacts along the life course 4 Oral diseases disproportionately affect disadvantaged populations in society 4 The economic burden of oral diseases is very high 6 There are gaps in the oral health workforce 6 3. The burden of the main oral diseases 7 Dental caries 8 Severe periodontal disease 10 Edentulism 11 Oral cancer 13 4. Key challenges and opportunities towards oral health for all in the European Region 15 5. A road map towards UHC for oral health 21 References 23 v © W H O / Di nu B ub ul ic i Foreword Good oral health is essential in people’s everyday life: it impacts eating, speaking, communication behaviour and overall personal confidence. Oral Health varies over the life course from early years to old age and is integral to general health. Oral health has long been neglected in the global health agenda. This has resulted in an increased burden of various oral diseases and conditions. Oral diseases are among the most common noncommunicable diseases worldwide, affecting an estimated 3.5 billion people globally and 466 million in the European Region. Oral diseases disproportionally affect disadvantaged and marginalized populations with stark and persistent inequalities in the burden of disease and access to oral health care. Yet many oral diseases are preventable and can be treated. People can be equipped with knowledge, support and tools to maintain healthy teeth and mouths. Cost-effective interventions and public health programmes are available which can tackle oral disease and health inequalities, and also risks common to other noncommunicable diseases. The adoption by WHO Member States of a historic resolution on oral health at the World Health Assembly in 2021 and development of a comprehensive Global Strategy on Oral Health, is the foundation for accelerating joint global actions and country work. It supports development of the Global Oral Health Strategy and Action Plan with a monitoring framework and specific targets towards universal oral health coverage to be achieved by 2030. These policies will provide us with a clear path towards ensuring oral health for all in the European Region. This regional summary is based on the WHO Global oral health status report published in 2022. It provides a comprehensive picture of the oral disease burden in the WHO European Region, the resources available for oral health and the challenges to be considered in the future. The oral health status report includes country profiles, and will serve as a baseline for planning and tracking progress. This report is a call towards universal oral health coverage. It provides a guidance and support to governments to integrating oral health promotion and care into primary health care and to focus on preventative initiatives. It supports and enables a network of trained oral health professionals to meet population need with essential oral health services included in national health benefit packages, either free of charge or at an affordable price for people. My hope is that this report will contribute to comprehensive efforts to improve oral health, so that no one is left behind with preventable and treatable oral diseases. Dr Hans Henri P. Kluge WHO Regional Director for Europe vii What is oral health? 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. © W HO / An ne S tu rm G ue rr an d viii
Towards global oral health equity through universal health coverage1 © W H O / M al in B rin g Oral diseases, while largely preventable, pose a significant global health burden and affect people throughout their life course, causing physical symptoms, functional limitations and detrimental impacts on emotional, mental and social well-being. In 2021, at the Seventy-fourth World Health Assembly, the landmark resolution WHA74.5 on oral health was adopted (1). It recognizes that oral health should be embedded within the noncommunicable disease (NCD) agenda and that essential oral health care intervention should be included in universal health coverage (UHC) benefit packages. As such, it calls on Member States to shift from the traditional curative approach to oral health care towards a promotive and preventive approach. The WHO European Region is home to 53 countries with a combined population of more than 900 million. Although the South-East Asia Region has the highest number of major oral disease cases among the WHO regions because of its large population, the European Region has the highest prevalence of cases at 50.1%; major oral diseases affected almost 466 million people in 2019. Oral diseases disproportionately affect the most vulnerable and disadvantaged populations, with people of low socioeconomic status carrying a higher burden of oral diseases throughout their life course, regardless of a country’s overall income level. This regional summary draws on the WHO Global oral health status report (2), published in 2022, which provides a comprehensive overview of the global oral disease burden, the global health importance of oral health and the impact of oral diseases over the life course. The summary focuses on the oral health status in the European Region and is split into four sections: (a) oral diseases are global and regional health problems; (b) the burden of the main oral diseases; (c) key challenges and opportunities towards oral health for all in the European Region; and (d) road map towards UHC for oral health 2030. 2 Oral diseases are global and regional health problems2 © W H O /F ai th K ilf or d Vo rt in g Oral diseases present an increasing global and regional burden • Oral diseases are the most widespread of the more than 300 diseases and conditions that affect humanity. About 3.5 billion people worldwide were affected by oral diseases in 2019. Between 1990 and 2019, estimated case numbers of oral diseases increased by more than 1 billion. This translates to a 50% increase, which is larger than the population increase of about 45% during the same period. • Over the last thirty years (1990–2019), estimated case numbers of major oral diseases (caries of deciduous and permanent teeth, edentulism, severe periodontal disease and other oral disorders combined) in the European Region grew by more than 42 million – a 10% increase, slightly higher than the estimated population increase of 9.6% during the same period. • Among the WHO regions, the European Region had the second lowest number of cases (466 million) of the major oral diseases combined in 2019 but had the highest prevalence at 50.1%. Oral diseases are among the most common NCDs, and their increasing burden adds to the burden of NCDs in the European Region, which is the highest among all WHO regions (3). Oral diseases share risk factors with other NCDs and have impacts along the life course • Shared, modifiable NCD risk factors include a high intake of free sugars, all forms of tobacco use and harmful alcohol use. Taking a common risk factor approach to the prevention of oral diseases by embedding oral health within the broader NCD agenda ensures that progress can be made across a range of NCDs, including oral diseases, diabetes, cancer and cardiovascular diseases. • Each year in the European Region, there are more people celebrating their 80th birthdays than there are being born. By 2050, people aged 65 years and over are expected to make up one quarter of the population in the Region, an increase of more than 70% in 20 years (4). As all oral diseases are chronic, progressive and cumulative in nature, oral health promotion and routine care are necessary to support healthy ageing. Oral diseases disproportionately affect disadvantaged populations in society • Stark and persistent inequalities in oral health status exist across different population groups. Inequalities result from a complex array of interconnecting factors, many of which are beyond individuals’ control. Oral diseases disproportionately affect poor and vulnerable members of societies, often including people who are on low incomes; people living with disability; 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. • In addition to the huge financial burden that occurs due to delayed care, those affected suffer from stigma. Some people have painful and traumatizing prior experiences of seeking oral care which frequently results in further delays of accessing care. • Access to oral health services is uneven within and among countries. Availability of oral health services is not aligned with the needs of the population. Those with the greatest need often have the least access to services. See the case study: The challenge of oral health care for people living with disabilities [France] on the next page. 4 Case Study – The challenge of oral health care for people living with disabilities (France) Philippe Aubert, 42 years old and 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 (6). “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. “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 (5), 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 (6). 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. © W HO /P hi lip pe A ub er t 5 The economic burden of oral diseases is very high • In the European Region, the annually due to oral diseases is about US$ 113 billion, the second highest among the WHO regions. At the same time, productivity losses from oral diseases are estimated to be around US$ 104 billion. • Within the Region, 10 countries spend less than US$ 10 per person per year on oral health care, while 14 countries spend between US$ 11 and US$ 50 (Fig. 1). The 29 countries that spend between US$ 51 and US$ 1000 are all high income. Because oral services in the Region are largely fee-for-service, patients often directly bear high out-of-pocket costs. • Oral health care is often associated with high out-of-pocket expenditures because private practitioners predominantly provide the services, which are usually only partially or not at all covered by government programmes and/or insurance schemes. Fig. 1. Per capita dental expenditures in US$ per country in the WHO European Region (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 Outside European Region Not applicable 0 1000 2000500 km There are gaps in the oral health workforce • Oral health care is often characterized by low workforce numbers, a predominance of private provision models, underresourced public services, inadequate task sharing and skill mixes within teams, limited or no access for rural, remote or disadvantaged populations, and lack of financial protection and coverage. • In the European Region, vast inequalities in access to oral health services exist within and among countries. For example, the number of dentists per 10 000 population ranges from 0.5 to 17.8, with a regional average of 5.6, higher than the global average of 3.3. For countries where data are available, the number of dental prosthetic technicians per 10 000 ranges from 0.1 to 8.1, with a regional average of 4.0, and for dental assistants and therapists, it ranges from 0.1 to 42.6, with a regional average of 12.1; the global averages are 0.6 and 1.9, respectively. Data Source: World Health Organization (2). Map Creation Date: 28 February 2023. Map Production: WHO Geographic Information System Centre for Health, Department of Data and Analytics (DNA)/Data, Analytics and Delivery for Impact (DDI) Division. 6 The burden of the main oral diseases3 © W H O / M al in B rin g Dental caries Dental caries is a gradual loss and breakdown of tooth hard tissues that results when free sugars contained in food or drink are converted by bacteria into acids that destroy the tooth over time. Dental caries affects all age groups, starting with the eruption of the first teeth, increasing in prevalence until late adulthood and remaining at high levels until older age. Dental caries is the most common NCD worldwide, with more than one third of the global population living with untreated dental caries. Consumption of free sugars is the main dietary factor in the development of dental caries. Between 1990 and 2019, the European Region recorded the largest decline in prevalence of caries of deciduous teeth in children aged between 1 and 9 years (7.2%; Fig. 2) and the second largest decline in prevalence of caries of permanent teeth (3.9%; Fig. 3) among the WHO regions. Despite the decline, the Region has the highest regional prevalence of caries of permanent teeth (33.6%) affecting 294 million people. The prevalence of dental caries in deciduous teeth in children between 1 and 9 years old reaches 39.6% with almost 41 million cases. The overall burden of dental caries thus reaches almost 335 million cases of caries in 2019. © W HO / Ni ko la H ar an zo vá 8 Percentage 0.0 15.0 30.0 45.0 60.0 Bosnia and Herzegovina Serbia North Macedonia Albania Montenegro Republic of Moldova Tajikistan Romania Bulgaria Belarus Lithuania Slovakia Croatia Kyrgyzstan Czechia Hungary Uzbekistan Georgia Latvia Armenia Slovenia Estonia Turkmenistan Kazakhstan Russian Federation Azerbaijan Ukraine Poland Türkiye Israel Sweden Italy Norway Greece Finland Spain Netherlands Belgium Portugal Andorra Cyprus Luxembourg Iceland France San Marino Malta Austria Germany Monaco Switzerland Ireland Denmark United Kingdom 52.7 49.1 48.6 48.6 48.5 48.3 48.3 48.2 48.1 48.1 48.0 48.0 47.9 47.9 47.9 47.8 47.7 47.6 47.5 47.5 47.5 47.4 47.3 46.9 46.9 46.8 46.5 46.0 43.8 38.7 38.6 36.1 36.1 34.2 34.2 33.2 31.6 30.2 29.8 29.3 29.3 29.2 29.2 29.2 29.1 29.1 29.1 29.1 27.9 26.4 25.4 20.3 19.5 Fig. 2. Estimated prevalence of caries of deciduous teeth in people aged 1 to 9 years per country in the WHO European Region (2019) Data Source: World Health Organization (2). 9 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 Outside European Region Not applicable 0 1000 2000500 km Fig. 3. Estimated prevalence of caries of permanent teeth per country in the WHO European Region Data Source: World Health Organization (2). Map Creation Date: 28 February 2023. Map Production: WHO Geographic Information System Centre for Health, Department of Data and Analytics (DNA)/Data, Analytics and Delivery for Impact (DDI) Division. Severe periodontal disease Periodontal disease is a chronic inflammation of the soft and hard tissues that support and anchor the teeth. Severe periodontal disease, defined as the presence of a pocket of more than 6 mm depth, is a condition of public health concern. Poor oral hygiene is a major behavioural risk factor for periodontal disease, in addition to common NCD risk factors like tobacco use. The European Region experienced a 16.1% increase in prevalence of severe periodontal disease between 1990 and 2019, with a 17.9% prevalence in 2019 among people aged 15 years or older (Fig. 4). High-income countries are generally associated with having a higher prevalence rate than upper middle- and lower middle-income countries. Because the prevalence of periodontal disease peaks around the age of 55 and remains high until old age, it is likely the Region will experience an increasing burden of disease given its large and growing ageing population. © W H O / Kh al ed M os ta fa 10 Percentage 0.0 20.0 30.0 40.0 50.0 Denmark Germany Norway Belgium Finland Monaco Slovenia Poland Lithuania Croatia Latvia Estonia Sweden Andorra Switzerland Russian Federation Belarus Malta San Marino Türkiye Ukraine Luxembourg Portugal Italy Czechia Austria Iceland Romania Netherlands Georgia Republic of Moldova Slovakia Cyprus France Armenia Greece Bosnia and Herzegovina Montenegro Serbia Israel Azerbaijan Kazakhstan North Macedonia Albania Turkmenistan Bulgaria Uzbekistan Kyrgyzstan Tajikistan United Kingdom Hungary Spain Ireland 33.5 27.4 25.0 24.8 23.8 23.2 22.3 22.2 21.3 21.3 21.3 20.6 20.5 20.2 20.1 19.4 19.0 19.0 19.0 18.9 18.9 18.6 18.4 18.2 18.1 18.0 17.7 17.5 17.3 17.3 17.2 17.2 16.9 16.2 15.8 15.8 15.7 15.7 15.7 15.5 15.4 15.3 15.2 14.9 14.6 13.9 12.7 11.7 10.8 10.6 8.6 6.7 4.9 Fig. 4. Estimated prevalence of severe periodontal disease in people aged 15 years or older per country in the WHO European Region (2019) Edentulism Losing teeth is generally the end point of a lifelong history of oral disease, primarily advanced dental caries and severe periodontal disease, but tooth loss can also result from trauma; all can possibly lead to tooth extraction. Edentulism is a stark indicator of social and economic inequalities, with disadvantaged populations disproportionately experiencing total tooth loss. Data Source: World Health Organization (2). 11 In 2019, the European Region had the second greatest proportion of cases of edentulism (25.2%), about 88 million people aged 20 years or more. This translates to a prevalence of 12.4%, the highest among the WHO regions and almost double the global prevalence of 6.8%. The Region had a 9.0% increase in prevalence between 1990 and 2019, compared with the global average increase of 8.0%. Maintaining functional teeth is critical for supporting healthy ageing. In 2019, almost one in three (31.3%) adults aged 60 years or older in the European Region suffered from complete tooth loss, compared with the global average of 22.7% (Fig. 5). Country prevalence of edentulism in this age group ranges from 22.3% to 42.1%. Percentage 0.0 12.5 25.0 37.5 50.0 Kazakhstan Kyrgyzstan Armenia Netherlands Tajikistan Slovenia Georgia Azerbaijan Turkmenistan Türkiye Uzbekistan Bosnia and Herzegovina Ireland Russian Federation Belgium Austria Ukraine North Macedonia Serbia Albania Montenegro Hungary Israel Czechia Croatia Luxembourg Greece Finland Bulgaria United Kingdom Portugal Slovakia France Italy Romania Cyprus San Marino Norway Estonia Republic of Moldova Poland Iceland Germany Belarus Sweden Andorra Denmark Monaco Malta Latvia Lithuania Switzerland Spain 42.1 41.1 40.9 39.7 39.0 37.9 37.4 36.7 36.6 36.6 36.2 35.6 35.6 35.0 34.9 34.6 34.6 34.4 34.1 33.7 33.7 33.1 32.8 32.6 32.0 31.8 31.7 31.4 30.7 30.7 30.5 29.8 29.8 29.4 29.3 29.0 28.9 28.6 28.4 28.2 27.9 27.9 27.5 27.4 27.3 26.8 26.0 25.1 24.3 24.0 23.7 22.9 22.3 Fig. 5. Estimated prevalence of edentulism in people aged 60 years or older per country in the WHO European Region (2019) Data Source: World Health Organization (2). 12 Oral cancer In 2020, the European Region had the second highest estimated number (69 856) of new cases of oral (lip and oral cavity) cancers among the WHO regions, accounting for 18.5% of the total estimated number of cases globally. More than 26 500 deaths in the Region were attributable to oral cancers in 2020. Within the Region, country incidence of oral cancer ranges from 1.0 to 6.3 per 100 000 people (Fig. 6). Differences largely follow patterns of the main risk factors, including tobacco use and alcohol consumption. Human papillomavirus infection is increasingly contributing to oropharyngeal cancers of specific populations. Age-standardized incidence per 100 000 population 0.0 1.75 3.5 5.25 7.0 Hungary Slovakia Poland Latvia Romania France Portugal United Kingdom Russian Federation Serbia Belgium Ukraine Spain Republic of Moldova Montenegro Netherlands Germany Czechia Luxembourg Croatia Belarus Ireland Switzerland Slovenia Lithuania Denmark Norway Austria Uzbekistan Bulgaria Turkmenistan Sweden Bosnia and Herzegovina Finland Estonia Italy Kazakhstan Georgia Greece Türkiye Kyrgyzstan Iceland Cyprus Azerbaijan Albania Malta Israel Tajikistan North Macedonia Armenia 6.3 6.1 6.0 6.0 5.4 5.4 5.3 5.1 5.1 4.9 4.6 4.5 4.5 4.4 4.4 4.3 4.3 4.3 4.2 4.2 4.2 4.0 3.9 3.9 3.6 3.6 3.5 3.4 3.3 3.3 3.2 3.1 3.1 3.0 3.0 2.8 2.7 2.7 2.4 2.1 1.8 1.8 1.8 1.8 1.8 1.6 1.6 1.4 1.3 1.0 Fig. 6. Estimated age-standardized incidence rates of lip and oral cavity cancers in people of all ages per 100 000 population per country in the WHO European Region (2020) Note. Based on 50 countries where data were available. Data Source: World Health Organization (2). 13 © W HO / An ne S tu rm G ue rr an d Key challenges and opportunities towards oral health for all in the WHO European Region 4 © W H O / Bo sn ia a nd H er ze go vi na Challenges Opportunities 1. Oral health governance ■ Thirty-four countries (66.7%)a did not have a national oral health policy. ■ Eleven countries (23.4%)b did not have dedicated staff for oral diseases in the NCD Department of the Ministry of Health. ■ Of the 22 countries represented, five (22.7%) had completely phased out dental amalgam in line with the Minamata Convention on Mercury, and the remaining 17 (77.3%) are in the process of phasing it down (7). ■ Develop new national oral health policies that align with the WHO Global Strategy on Oral Health (8) and national NCD and UHC policies. The Global Oral Health Action Plan (9) outlines 100 proposed actions (for Member States, the WHO Secretariat, international partners, civil society organizations and the private sector) across six strategic objectives. The accompanying global monitoring framework identifies 11 core and 29 complementary indicators to track and monitor progress on implementation of the Global Oral Health Action Plan. ■ Allocate dedicated staff and funds for oral health at the Ministry of Health or other national governmental health agency, ensuring integration with the NCD and UHC agendas. ■ Thirty-eight countries (71.7%) are parties to the Minamata Convention on Mercury, which aims to protect human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds. Become a party to the Minamata Convention on Mercury and accelerate implementation of measures to phase down the use of dental amalgam in accordance with the Minamata Convention on Mercury. 16 Challenges Opportunities 2. Oral health promotion and oral disease prevention ■ Thirty-seven countries (72.5%)a have not implemented a tax on sugar-sweetened beverages. ■ Fluoride toothpaste was affordable in all 30 countries where data were available. However, the data was not available for the remaining 23 countries. ■ Despite great advances in the implementation of the WHO Framework Convention on Tobacco Control and reduction of alcohol consumption, the region has the highest prevalence of tobacco smoking among adults and the highest per-capita alcohol consumption in the world. High- impact interventions, such as increases in alcohol taxes, are the least implemented policy measures in the Region (10). ■ Implement policy measures aiming to reduce intake of free sugars, such as (a) nutrition labelling: front-of-pack or other interpretative labelling to inform about sugars content, including mandatory declaration of sugars content on pre-packaged food; (b) reformulation limits or targets to reduce sugars content in foods and beverages; (c) public food procurement and service policies to reduce offering food high in sugars; (d) policies to protect children from the harmful impact of food marketing, including for foods and beverages high in sugars; and (e) taxes on sugar-sweetened beverages and sugars or foods high in sugars. ■ The addition of fluoride toothpaste to the WHO model lists of essential medicines in 2021 (11) is an opportunity to improve affordability and availability of fluoride toothpaste and products. ■ Optimize digital technologies for oral health care to improve oral health literacy, health worker training, early detection of oral diseases and oral health surveillance within national health systems. ■ Implement or strengthen whole-of-government responses to address the underlying drivers that shape people’s exposure to the behavioral risk factors of NCDs. 17 Challenges Opportunities 3. Oral health workforce ■ There are large differences in dentist-to- population ratios across the European Region, pointing to inadequate skill-mix models across countries. ■ Inequalities exist in the ratio of the oral health workforce to the population among high-income, upper middle- income and lower middle-income countries. ■ Integrate oral health care into primary health care at all service levels, including required staffing, skill mixes and competencies. ■ Develop an innovative workforce model for oral health to respond to population oral health needs. Workforce trained and legally permitted to respond to the oral health needs of all population groups may include oral health professionals and other primary health care workers, including community health workers. ■ Increase the availability of mid-level oral health professionals and enhance skill mixes and task sharing among oral health professionals and other health professionals based on competency- based training while reassessing and updating national regulatory policies. 18 Challenges Opportunities 4. Oral health care in primary health care ■ Integration of oral health care into NCD management and primary health care is fragmented and, in some countries, nonexistent. ■ The predominance of private oral health care models in many countries leads to high out-of-pocket expenses, particularly for disadvantaged populations. ■ Oral health services included with UHC benefit packages should not be exclusive to a specific population group only. ■ Lack of multidisciplinar y and interprofessional approach to oral health. ■ Increase access to safe, effective and affordable essential oral health care as part of national UHC benefits packages with improved financial protection. ■ In primary care facilities in the public health sector, there was high availability of (a) oral health screening for early detection of oral diseases in 37 countries (82.2%)c; (b) urgent treatment for providing emergency oral care and pain relief in 40 countries (88.9%)c; and (c) basic restorative dental procedures to treat existing dental decay in 38 countries (84.4%)c. Expand coverage of essential oral health care by planning for the availability, accessibility, acceptability and quality of skilled health workers able to deliver an essential package of oral health care for all. ■ Expand training and strengthen interprofessional collaboration between oral health and other health professionals to improve prevention and management of co-morbidities between oral diseases and other conditions. Note. Where indicated, percentage(s) were calculated among a 51 countries, b 47 countries, or c 45 countries, which excludes countries where data were not available. 19 © W H O / Ca m ila E ug en ia V ar ga s A road map towards UHC for oral health5 © W H O / M al in B rin g Adoption of resolution WHA74.5 on oral health (1) was a significant milestone towards repositioning oral health as part of the global health agenda in the context of UHC. As a first step in the implementation of the resolution on oral health, Member States adopted the Global Strategy on Oral Health at the Seventy-fifth World Health Assembly in 2022 (8). The Global Oral Health Action Plan (2023–2030) is the second step in the implementation of the resolution on oral health (9). It is grounded in the Global Strategy on Oral Health’s vision, goal, guiding principles, strategic objectives and roles outlined for Member States, the WHO Secretariat, international partners, civil society and the private sector. The Global Oral Health Action Plan provides concrete guidance to progress the oral health agenda in countries and proposes a monitoring framework with targets to track progress towards 2030. Recognition of oral diseases as global and regional public health problems will continue to generate momentum and action by all stakeholders, guided by the Global Strategy on Oral Health (8). This will be possible only with the concerted efforts of all stakeholders, including governments, the United Nations system, intergovernmental bodies, nonstate actors, nongovernmental organizations, professional associations, youth and student organizations, patients’ groups, academia, research institutions and the private sector. Working together, these stakeholders can achieve the ambitious targets put forward in the draft Global Oral Health Action Plan (9) and make substantial progress towards closing the global gaps in oral health by 2030 – UHC for oral health. 22 References © W H O / M al in B rin g 1. Resolution WHA74.5. Oral health. In: Seventy-fourth World Health Assembly, Geneva, 24 May–1 June 2021. Resolutions and decisions, annexes. Geneva: World Health Organization; 2021 (WHA74/2021/ REC/1; https://apps.who.int/iris/handle/10665/352594). 2. Global oral health status report: towards universal health coverage for oral health by 2030. Geneva: World Health Organization; 2022 (https://apps.who.int/iris/handle/10665/364538). 3. Fact sheets on sustainable development goals: health targets: noncommunicable diseases. Copenhagen: WHO Regional Office for Europe; 2017 (https://apps.who.int/iris/handle/10665/340852). 4. Older people’s health needs supported in WHO European Region, post COVID-19 [news release]. Copenhagen: WHO Regional Office for Europe; 2022 (https://www.who.int/europe/news/item/11- 07-2022-older-people-s-health-needs-supported-in-who-european-region--post-covid-19). 5. HANDIDENT. A French oral health association managing the regional health access network oral health care for people with handicap. Cedex; 2023 (https://www.handident.com/). 6. Aubert P. Speech at colloquium on oral health and special needs. 8 Oct 2020, Orleans; 2020 (in French) (https://ragedexister.com/intervention-au-colloque-de-sante-orale-et-soins-specifiques- 2020-a-orleans-par-philippe-aubert/). 7. Report of the informal global WHO consultation with policymakers in dental public health, 2021: monitoring country progress in phasing down the use of dental amalgam. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/348985). 8. A75/10 Add.1. Draft global strategy on oral health. In: Seventy-fifth World Health Assembly, Geneva, 22–28 May 2022. Provisional agenda item 14.1. Geneva: World Health Organization; 2022 (https:// apps.who.int/gb/ebwha/pdf_files/WHA75/A75_10Add1-en.pdf). 9. Draft global oral health action plan (2023–2030). Geneva: World Health Organization; 2023 (https:// cdn.who.int/media/docs/default-source/ncds/mnd/oral-health/eb152-draft-global-oral-health- action-plan-2023-2030-en.pdf?sfvrsn=2f348123_19&download=true). 10. World Health Organization. Regional Office for Europe. (2021). Making the WHO European Region SAFER: developments in alcohol control policies, 2010–2019. World Health Organization. Regional Office for Europe. http://dx.doi.org/10.37426/9789289055048. License: CC BY-NC-SA 3.0 IGO 11. WHO model lists of essential medicines: 22nd essential medicines list. Geneva: World Health Organization; 2021 (https://www.who.int/groups/expert-committee-on-selection-and-use-of- essential-medicines/essential-medicines-lists). Note. All references were accessed on 31 March 2023. 24
World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100, Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.who.int/europe The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan