WHO's Global Oral Health Status Report 2022: Actions, Discussion and Implementation

Oral DiseasesEarly View EDITORIALOpen Access WHO's global oral health status report 2022: Actions, discussion and implementation Nityanand Jain, Corresponding Author Nityanand Jain [email protected] orcid.org/0000-0002-7918-7909 Faculty of Medicine, Riga Stradinš University, Riga, Latvia Correspondence Nityanand Jain, Faculty of Medicine, Riga Stradinš University, 16 Dzirciema street, Riga LV-1007, Latvia. Email: [email protected]Search for more papers by this authorUpasna Dutt, Upasna Dutt orcid.org/0000-0002-5778-6214 Department of Public Health, Turpanjian College of Health Sciences, American University of Armenia, Yerevan, ArmeniaSearch for more papers by this authorIgor Radenkov, Igor Radenkov orcid.org/0000-0002-1652-9545 Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, North MacedoniaSearch for more papers by this authorShivani Jain, Shivani Jain orcid.org/0000-0002-0648-745X Department of Oral and Maxillofacial Surgery, Genesis Institute of Dental Sciences & Research, Ferozepur, IndiaSearch for more papers by this author Nityanand Jain, Corresponding Author Nityanand Jain [email protected] orcid.org/0000-0002-7918-7909 Faculty of Medicine, Riga Stradinš University, Riga, Latvia Correspondence Nityanand Jain, Faculty of Medicine, Riga Stradinš University, 16 Dzirciema street, Riga LV-1007, Latvia. Email: [email protected]Search for more papers by this authorUpasna Dutt, Upasna Dutt orcid.org/0000-0002-5778-6214 Department of Public Health, Turpanjian College of Health Sciences, American University of Armenia, Yerevan, ArmeniaSearch for more papers by this authorIgor Radenkov, Igor Radenkov orcid.org/0000-0002-1652-9545 Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, North MacedoniaSearch for more papers by this authorShivani Jain, Shivani Jain orcid.org/0000-0002-0648-745X Department of Oral and Maxillofacial Surgery, Genesis Institute of Dental Sciences & Research, Ferozepur, IndiaSearch for more papers by this author First published: 20 January 2023 https://doi.org/10.1111/odi.14516 Upasna Dutt and Igor Radenkov contributed equally (co-second authors). AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL The Global Oral Health Status Report (GOHSR) directed towards the promotion and achievement of the universal health coverage (UHC) for oral health by the year 2030 was published by the World Health Organization (WHO) in November 2022. The report reviews the latest evidence-based data on the status of oral health worldwide in terms of oral disease burden, risk factors, distributions of dental practitioners, health benefits package and the national health response for oral health crises (World Health Organization, 2022). The first of its kind report aims to foster discussion and implementation of the policy reforms on a national and international level amongst the 194 member states. Most importantly, the report presents the first-ever country-wise oral health profile with critical data on the oral health situation in each of the WHO member state. 1 KEY FINDINGS OF THE GOHSR: A RENEWED CALL FOR ACTION The WHO estimates that globally close to 3.5 billion people (approximately 50% of population) suffer from one or the other form of oral disease (Figure 1). In fact, the global burden of oral diseases exceeds the combined global burden of the next five most prevalent non-communicable diseases by almost a billion cases. Amongst the leading cause of oral health diseases, the report identifies untreated dental caries (both deciduous and permanent teeth), severe periodontal disease, edentulism and cancer of lip and oral cavity as the leading causes of oral disease burden (Table 1). Congenital malformations especially, undifferentiated orofacial clefts (estimated 4.6 million cases globally), noma (no surveillance data available) and traumatic dental injury (estimated 1 billion cases globally) are the other identified oral diseases with a significant impact on the health and well-being of populations. FIGURE 1Open in figure viewerPowerPoint Country-wise cumulative prevalence of top five leading causes of oral diseases (global burden of disease; 2019). India and China had the highest caseloads (632 million and 599 million, respectively) whilst Nauru and Tuvalu had the lowest caseloads (5181 and 4382, respectively). Data accessed from Institute of Health Metrics and Evaluation Global Burden of Disease Database (IHME GBDx; available from https://vizhub.healthdata.org/gbd-results/; accessed 28th December 2022). TABLE 1. Top five countries with the highest prevalence of the leading causes of oral disease burden in 2019 (for all ages and both sexes combined). Oral disease Total cases with 95% confidence interval (global; 2019) Countries with highest Oral disease caseload No. of cases per country (2019) % share of global caseload Caries of permanent teeth Estimate—2,029,495,070 Upper—2,348,141,439 Lower—1,737,975,382 India 366,858,183 18.1% China 330,136,487 16.3% United States of America 75,034,853 3.7% Indonesia 69,024,654 3.4% Pakistan 52,232,325 2.6% Severe periodontal disease Estimate—1,086,825,543 Upper—1,379,710,922 Lower—810,684,261 India 221,084,427 20.3% China 209,627,097 19.3% United States of America 42,149,181 3.9% Indonesia 38,105,664 3.5% Pakistan 32,999,906 3.0% Caries of deciduous teeth Estimate—520,065,521 Upper—639,369,160 Lower—405,848,491 India 98,199,025 18.9% China 67,172,112 12.9% Pakistan 24,968,276 4.8% Nigeria 21,082,438 4.1% Indonesia 18,343,127 3.5% Edentulism Estimate—351,808,988 Upper—450,669,731 Lower—274,129,977 China 64,187,526 18.2% India 34,905,533 9.9% United States of America 24,995,120 7.1% Brazil 21,880,208 6.2% Russian Federation 15,849,308 4.5% Lip and oral cavity cancer Estimate—1,401,286 Upper—1,723,916 Lower—1,128,231 India 327,648 23.4% China 177,782 12.7% United States of America 170,538 12.2% Pakistan 92,840 6.6% Spain 36,953 2.6% Note: Data accessed from Institute of Health Metrics and Evaluation Global Burden of Disease Database (IHME GBDx; Available from https://vizhub.healthdata.org/gbd-results/; Accessed 05th January 2023). Geographically, South-East Asian and Western Pacific countries have the highest caseloads of oral diseases, attributable mostly due to the presence of densely populated countries in these regions. Shockingly, global caseload of oral disease even managed to surpass the estimated population growth rate (50% and 45% increase, respectively) between 1990 and 2019, indicating that the current measures and policies to curb the spread of oral diseases have explicitly failed. Economically, global burden of the oral diseases has amounted to an annual expenditure of about US$ 387 billion in direct costs and another US$ 323 billion in indirect costs (Table 2). Direct costs include both public and private expenditure done in outpatient dental care and offices of dentists whilst indirect costs include productivity losses due to the above identified leading causes of oral disease burden. In terms of indirect costs, edentulism has the highest global burden costing about US$ 167 billion followed by severe periodontal disease costing US$ 82 billion. Caries of the permanent and deciduous teeth incurred indirect costs amounting to almost US$ 22 billion and US$ 1.55 billion globally, respectively. TABLE 2. Top five countries with highest direct and indirect annual expenditure related to the leading five oral diseases in 2019. Type of expenditure Global expenditure Country with highest expenditure Expenditure per country (in US$, billion) % share of global expenditure Per capita expenditure per country (in US$) Direct expenditure 387.093 billion US$ United States of America 133.51 34.5% 405.46 China 61.55 15.9% 43.96 Germany 30.88 8.0% 372.15 Japan 28.73 7.4% 227.70 Italy 19.12 4.9% 316.82 Indirect expenditure 322.686 billion US$ United States of America 78.47 24.3% 238.46 China 45.71 14.2% 31.19 Japan 23.66 7.3% 187.53 Germany 19.40 6.0% 232.24 France 11.99 3.7% 184.16 Note: Data accessed from Heidelberg University Open Research Data Translational Health Economics (Available from https://heidata.uni-heidelberg.de/dataset.xhtml?persistentId=doi:10.11588/data/JGJKK0; accessed 5th January 2023). During the COVID-19 pandemic, the oral health index also suffered a colossal backslash with little to no importance given to the oral diseases, resulting in a toll on the overall health status of the countries. But the pandemic aside, what explains such huge burden of oral diseases? The report explores three different root causes for this situation. Firstly, the social determinants of oral health were found to be in common to those of other non-communicable diseases. The political, socio-economic, familial and historical circumstances largely determine the behaviours that people adopt and the opportunities and choices available to them. Inequitable wealth and manpower distribution and increasing racial polarization and marginalization in the society are adding fuel to the fire. Secondly, the ever-growing power and sophistication of targeted commercial advertisements have led to an uneven balance. On one hand, companies have promoted detrimental habits (smoking, alcoholism) whilst on the other hand, fluoridation and use of fluoridated products have promoted beneficial habits. The report overviews the global status and the urgent need to educate and implement various other fluoridation techniques for safe oral health for adults and children—not on the preventive treatment protocol but on the availability of affordable fluoridated toothpaste in over 78 countries. The final factor is the negligent attitude of the policy planners and insurance companies towards the inclusion of oral health care under the umbrella of the universal health care. In today's world, most of the dental practices are private and/or run by private enterprises that not only drive the cost of services but also monopolies on the current situation by creating disparities in workforce access and distribution. Furthermore, lack of funding in oral health research and instrumentalization of proper surveillance tools remain equally contributing factors. The WHO estimates that presently there are just under 4 million oral care providers globally (3,984,325), comprising about 2.5 million (2,465,296) dentists, 1.2 million (1,242,053) dental assistants and therapists and nearly 300,000 (276,976) prosthetists/technicians. However, these estimates are grossly underestimated. Since not all countries have made available the latest statistics, along with differences in the definitions and accreditations and inclusion of non-practising professionals and ‘quackery professionals’ makes modelling extremely unreliable. Interestingly, only 1.4% of the total number of dentists work in low-income countries whilst more than 80% of all dentists worldwide work in either high- or upper-middle-income countries (World Health Organization, 2022). WHO's European and American regional countries reported the highest dentist-population ratio (5.67 and 5.64 per 10,000, respectively) whilst the African region reported 17× lower dentist-population ratio of just 0.33 per 10,000. Oral and dental diseases are not only about the facio-maxillary region but an individual's overall health. The prevalence of oral diseases equally across the spectrum of different age groups have also led to other adverse health effects including body-image issues, sleeplessness, social isolation, pain, discomfort, fear, anxiety and functional limitations. Severe periodontal disease has been strongly linked to the promotion of diabetes mellitus and cardiovascular events, and to a lesser extent, to cerebrovascular disease and chronic obstructive pulmonary disease. Challenges posed by the increased use of antibiotics and subsequent antimicrobial resistance (AMR) are aptly highlighted in the report. As stated in the report, WHO's Global Action Plan plays a vital role in spreading awareness about AMR and controlling the active infection rates in a timely manner and reaching an international census of the desired monitoring structure. The core structure of the pyramid of oral health care is alarming to the extent that there is a fundamental structure of the disease burden but not a significant reform in terms of a gold standard that member states can work upon within the skeleton of the workforce in each country. The four primary oral healthcare frameworks that should be implemented include—(1) political priority, commitment and leadership; (2) governance and policy frameworks; (3) funding and resource allocation; and (4) engagement of communities and other stakeholders. The focus to use the already existing resources and allocating new resources to be utilized by the member states to achieve a common goal is essential. WHO further promotes the use of advancements in digital health (telehealth, video-supported health) in dental medicine. Finally, the report staunchly advocates for the inclusion of oral health care in either the BBP (basic benefits package) or the UHC benefits package. Are these key findings essential and possible to implement at this stage? Owing to the status of oral health today and the alarming requirement, urgent discussion and implementation are the hour's talk. 2 DISCUSSION & IMPLEMENTATION OF THE KEY FINDINGS Clearly, despite the collective efforts by the local governments, intergovernmental bodies, the UN's programs, youth associations, patient group associations, academia, research institutions and various other institutions, there is still much to be done in the prevention, early diagnosis and successful treatment of oral health diseases globally. In this regard, the WHO has recently published the draft Global Oral Health Action Plan (2023-2030) on January 11, 2023 that aims to foster discussion and implementation of the key findings highlighted in the GOHSR (available at https://www.who.int/publications/m/item/draft-global-oral-health-action-plan-(2023-2030); accessed 29th January 2023). Primary prevention remains the number one tool in oral health, as most oral conditions are preventable (Bourgeois & Llodra, 2014; Kwan et al., 2005). The global trend in healthcare in general is that the GDP (gross domestic product) of a society is positively correlated with the amount of money spent on the healthcare systems (World Health Organization. Health expenditure, 2022). This presents a great problem for lower income countries trying to implement primary prevention strategies in their healthcare programs as almost all the health expenditures of a country originate from its own budget. This trend is especially exemplified in dental practices—the richest societies have access to the best preventative measures and services and are more geared towards the more lucrative, cosmetic dental medicine, meanwhile poor income countries do not have access to enough dental professionals and cannot get even the most basic dental health coverage (Hayashi et al., 2014). This makes implementing these strategies easier said than done. Apart from inadequate resources, other obstacles may include poor prior planning of such programs and the support of key stakeholders in the society (Molete et al., 2020). However, at the same time, it provides opportunities for creation and implementation of innovative solutions, as highlighted by the GOHSR report (Table 3). TABLE 3. Major challenges and potential solutions for achieving better oral health and oral care, as highlighted in the GOHSR report. Challenges Towards Better Oral Health & Care Potential solutions Use of dental amalgam as a filling material Implementation of at least two of the nine measures of the Minamata Convention on Mercury, 2013 including: Primary prevention of dental caries National policy on reducing amalgam use Promotion of mercury-free alternatives Promotion of research and development Education of dental students to avoid use Remove insurance cover on amalgam-fillings Encouraging insurance cover on alternatives Restrict use of amalgam to encapsulated form Adoption of best environmental practices High carbon footprint and environmental degradation arising from dental practices Steps needs to be taken to make dental practice sustainable including reducing the impact of three largest contributing factors: Patient and staff travel (65% contribution) Products and procurement of materials (19% contribution) Direct energy utilization (15% contribution) Implementation of effective stock management, recycling or replacing disposable plastic materials with reusable alternatives. Computer use, economical printing, e-health, digital health, digital x-ray can reduce the footprint considerably. Inclusion of oral healthcare in universal healthcare pyramid A five-stage pyramid model should be adopted (from bottom to top): Fundamental prevention through self-care and management of risk factors Community oral health programmes, such as water fluoridation schemes Essential oral health care as the entry level to the formal health care system Advanced oral care provided by a dentist Specialized oral health care for complex and advanced disease management The basic principle should be that the need and demand are highest at the lower levels and decrease at the higher levels. Cost of services should have an inverse relation. A good portion of the strategies towards oral health promotion are centred around limiting the exposure to harmful factors such as alcohol, tobacco and sugar-rich food and beverage consumption (Table 4). Many countries have successfully reduced tobacco product consumption by creating attractive graphic campaigns that counteracted the highly effective marketing tricks of the multi-billion tobacco companies. Compulsory labelling on the tobacco products has proved to be very instrumental in public education and awareness. Campaigns that included more emotional and more personal stories have also been shown to be effective. India's inclusion of smoking advertisements before the projection of movies at cinema houses and inclusion of ‘Tobacco smoking is injurious to health’ tagline in scenes where actors are smoking are prime examples. Furthermore, the quantity of advertisements to which the smoker is exposed is crucial in determining the success rate of such campaigns (Durkin et al., 2009). TABLE 4. WHO recommended ‘Best buys’ policy options and cost-effective interventions for prevention and control for non-communicable diseases including oral diseases (only a selection is presented here). Primary objective Policy interventions Reduce tobacco use Implement WHO's Framework Convention on Tobacco Control (WHO FCTC) Reduce affordability of tobacco products by increasing taxes Implement smoke-free environments in all indoor workplaces, public places and public transport Effective health warnings and mass media campaigns Ban all forms of tobacco advertising, promotion and sponsorship Reduce alcohol use Implement the WHO's global strategy to reduce harmful use of alcohol Regulating commercial and public availability of alcohol Restricting or banning alcohol advertising and promotions Using pricing policies such as excise tax increases on alcoholic beverages Encourage healthy eating habits Implement the WHO Global Strategy on Diet, Physical Activity and Health Increase consumption of fruit and vegetables Implement public awareness programmes on diet and physical activity Manage food taxes and subsidies to promote healthy diet Note: More detailed interventions and measures are available from the WHO's Global Action Plan for Prevention and Control of Non-communicable Diseases 2013–2020 appendix 3 (available from https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf?sequence=1&isAllowed=y; accessed on 5th January 2023). One of the most neglected factors when it comes to maintaining good oral health and oral disease prevention is the mental well-being of the individuals in a community or population. Tobacco and alcohol consumption are often used as a mean to relieve anxiety and depression in people from all sections of the society (Fluharty et al., 2017; Keyes et al., 2012; Stubbs et al., 2017). These harmful behaviours are introduced to individuals from a very early age—whether by media promotions or through exposure to elders with similar behaviour. Mental health and well-being are still seen as a general stigma in many cultures and a lot of people simply refuse to acknowledge the existence of their problems. Additionally, many people do not have access to mental health specialists (Morales et al., 2020), thereby, directly affecting the efficacy of anti-smoking and anti-alcohol campaigns in these countries and indirectly impacting oral health. Although effective media campaigns have the potential to influence societal behaviour (Ribeiro et al., 2022; Sharma et al., 2022), their implementation is once again limited by the financial power of a country's economy. A possible way to circumvent this issue is online advertisements. Online advertisements do not require as much financing as traditional printed material such as flyers and pamphlets (one-time investments). Online advertisements also have an unprecedented superiority in terms of creativity and outreach and can not only help in correction of detrimental habits but also promote primary prevention. Yet, their effectiveness would be dependent on the placement of such advertisements (entertainment vs educational websites) (Hashemi et al., 2022). Fluoride and fluoride products are known to prevent the rate of tooth decay. The daily recommended dosage of fluoride can be obtained through fluoridation of water supplies or the addition of fluoride in products such as toothpaste, salt or milk (Horst et al., 2018; Iheozor-Ejiofor et al., 2015; Medjedovic et al., 2015; Pollick, 2018). Low-income and high-income societies face different issues in the implementation of fluoride use, thereby requiring a tailored approach rather than ‘one-fits-all’ approach. Poorer countries and sometimes even poor regions in the developed countries lack the sufficient finances to introduce fluoride additives to drinking water or other products (Goldman et al., 2008). In the USA, children living in low-income families but not below poverty line, are more likely to live in a county with non-fluoridated water (Sanders et al., 2019). Water fluoridation may be an indispensable strategy in reducing rates of tooth decay, as experiences from Brazil tells us (Peres et al., 2006). Meanwhile in the high-income societies there is a more and more widespread backlash against fluoridation. A good example of this would be Ireland (Powell, 2014). A persistent and often very difficult problem to solve that governments encounter when trying to improve their own dental healthcare system is the lack of a sufficient number of employees such as dentists, dental technicians etc. In fact, 69% of all dentists globally providing services to just 27% of the world's population (Gallagher & Hutchinson, 2018). This occurrence is primarily due to the developed countries producing more dentists and mass immigration. What is perhaps most striking is that most of the data that focus on the decreasing availability of primary dental healthcare are in low socio-economic countries. Implementing the actions mentioned in such countries will be questionable unless proper education about dental and oral diseases is provided. 3 CONCLUSIONS All in all, global strategies for improving dental health, although sufficient for most developed countries, might not be so feasible for countries with lower GDPs, especially from a financial and logistics aspect. As self-care and regular dental hygiene are the most effective factors in preventing dental diseases, the promotion of oral hygiene from an early age both by the schooling systems and within the family might be the best and the least costly strategy for reducing the global burden of dental diseases. AUTHOR CONTRIBUTIONS NJ conceptualized the present study whilst NJ, UD and IR were involved in data collection, data verification, formal analysis and methodology. NJ was responsible for visualizations. UD and IR wrote the initial draft of the manuscript whilst revisions and editing was done by NJ and SJ. Supervision was led by SJ. Resources and project management was done by SJ. All authors have read and agreed to the final version for publication. ACKNOWLEDGMENTS Not Applicable. FUNDING INFORMATION The study was self-supported by the authors and received no external funding. CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest. Open Research DATA AVAILABILITY STATEMENT The data that support the findings of this study are openly available in WHO Global Oral Health Status Report 2022 at https://www.who.int/publications/i/item/9789240061484. REFERENCES Bourgeois, D. M., & Llodra, J. C. (2014). Global burden of dental condition among children in nine countries participating in an international oral health promotion programme, 2012-2013. International Dental Journal, 64(Suppl 2), 27– 34. https://doi.org/10.1111/idj.12129 Durkin, S. J., Biener, L., & Wakefield, M. A. (2009). Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups. American Journal of Public Health, 99(12), 2217– 2223. https://doi.org/10.2105/AJPH.2009.161638 Fluharty, M., Taylor, A. E., Grabski, M., & Munafò, M. R. (2017). The association of cigarette smoking with depression and anxiety: A systematic review. Nicotine & Tobacco Research, 19(1), 3– 13. https://doi.org/10.1093/ntr/ntw140 Gallagher, J. E., & Hutchinson, L. (2018). Analysis of human resources for oral health globally: Inequitable distribution. International Dental Journal, 68(3), 183– 189. English. https://doi.org/10.1111/idj.12349 Goldman, A. S., Yee, R., Holmgren, C. J., & Benzian, H. (2008). Global affordability of fluoride toothpaste. Globalization and Health, 13(4), 7. https://doi.org/10.1186/1744-8603-4-7 Hashemi, Y., Zarani, F., Heidari, M., & Borhani, K. (2022). Purposes of internet use among Iranian university students: Exploring its relationship with social networking site (SNS) addiction. BMC Psychology, 10(1), 80. https://doi.org/10.1186/s40359-022-00745-4 Hayashi, M., Haapasalo, M., Imazato, S., Lee, J. I., Momoi, Y., Murakami, S., Whelton, H., & Wilson, N. (2014). Dentistry in the 21st century: Challenges of a globalising world. International Dental Journal, 64(6), 333– 342. https://doi.org/10.1111/idj.12132 Horst, J. A., Tanzer, J. M., & Milgrom, P. M. (2018). Fluorides and other preventive strategies for tooth decay. Dental Clinics of North America, 62(2), 207– 234. https://doi.org/10.1016/j.cden.2017.11.003 Iheozor-Ejiofor, Z., Worthington, H. V., Walsh, T., O'Malley, L., Clarkson, J. E., Macey, R., Alam, R., Tugwell, P., Welch, V., & Glenny, A. M. (2015). Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews, 2015(6), CD010856. https://doi.org/10.1002/14651858.CD010856.pub2 Keyes, K. M., Hatzenbuehler, M. L., Grant, B. F., & Hasin, D. S. (2012). Stress and alcohol: Epidemiologic evidence. Alcohol Research: Current Reviews, 34(4), 391– 400. Kwan, S. Y., Petersen, P. E., Pine, C. M., & Borutta, A. (2005). Health-promoting schools: An opportunity for oral health promotion. Bulletin of the World Health Organization, 83(9), 677– 685. Medjedovic, E., Medjedovic, S., Deljo, D., & Sukalo, A. (2015). Impact of fluoride on dental health quality. Materia Socio-Medica, 27(6), 395– 398. https://doi.org/10.5455/msm.2015.27.395-398 Molete, M., Stewart, A., Bosire, E., & Igumbor, J. (2020). The policy implementation gap of school oral health programmes in Tshwane, South Africa: A qualitative case study. BMC Health Services Research, 20(1), 338. https://doi.org/10.1186/s12913-020-05122-8 Morales, D. A., Barksdale, C. L., & Beckel-Mitchener, A. C. (2020). A call to action to address rural mental health disparities. Journal of Clinical and Translational Science, 4(5), 463– 467. https://doi.org/10.1017/cts.2020.42 Peres, M. A., Antunes, J. L., & Peres, K. G. (2006). Is water fluoridation effective in reducing inequalities in dental caries distribution in developing countries? Recent findings from Brazil. Sozial- und Präventivmedizin, 51(5), 302– 310. https://doi.org/10.1007/s00038-006-5057-y Pollick, H. (2018). The role of fluoride in the prevention of tooth decay. Pediatric Clinics of North America, 65(5), 923– 940. https://doi.org/10.1016/j.pcl.2018.05.014 Powell, N. (2014). Ireland reviews water fluoridation. CMAJ, 186(10), E343– E344. https://doi.org/10.1503/cmaj.109-4781 Ribeiro, Y. J. S., Ferreira, L. G., Nelson-Filho, P., Arnez, M. F. M., & Paula-Silva, F. W. G. (2022). Influence of digital media in the oral health education of mother-child pairs: Study protocol of a parallel double-blind randomized clinical trial. Trials, 23(1), 639. https://doi.org/10.1186/s13063-022-06602-4 Sanders, A. E., Grider, W. B., Maas, W. R., Curiel, J. A., & Slade, G. D. (2019). Association between water fluoridation and income-related dental caries of US children and adolescents. JAMA Pediatrics, 173(3), 288– 290. https://doi.org/10.1001/jamapediatrics.2018.5086 Sharma, S., Mohanty, V., Balappanavar, A. Y., Chahar, P., & Rijhwani, K. (2022). Role of digital Media in Promoting Oral Health: A systematic review. Cureus, 14(9), e28893. https://doi.org/10.7759/cureus.28893 Stubbs, B., Veronese, N., Vancampfort, D., Prina, A. M., Lin, P. Y., Tseng, P. T., Evangelou, E., Solmi, M., Kohler, C., Carvalho, A. F., & Koyanagi, A. (2017). Perceived stress and smoking across 41 countries: A global perspective across Europe, Africa, Asia and the Americas. Scientific Reports, 7(1), 7597. https://doi.org/10.1038/s41598-017-07579-w World Health Organization. (2022). Global oral health status report: Towards universal health coverage for oral health by 2030. World Health Organization. https://www.who.int/publications/i/item/97892400614840 Accessed 18th December 2022. World Health Organization. Health Expenditure. (2022). Nutrition Landscape Information System (NLiS). https://www.who.int/data/nutrition/nlis/info/health-expenditure Accessed 29th December 2022. Early ViewOnline Version of Record before inclusion in an issue FiguresReferencesRelatedInformation