Addressing the Silent Crisis of Oral Health in Conflict Areas and War Zones

Sir, Amidst the turmoil of ongoing global conflicts, the plight of displaced persons is a stark and heartbreaking reality. Wars and violence have swept across regions, uprooting millions from their homes and denying them their basic rights and necssities. In the Middle East and North Africa alone, there are more than 45 armed conflicts.¹ These crises areas continue to displace millions, stripping them of their basic rights to security, clean water, food, shelter and access to healthcare.

The statistics are staggering. By the end of year 2023, over 110 million people globally have been forcibly displaced, with more than 36.4 million classified as refugees.² The majority of these displaced persons find refuge in low- and middle-income countries, where resources are already stretched thin.² Alarmingly, 40% of displaced persons are children under 18, who are particularly vulnerable to the health impacts of displacement.²

In the Gaza Strip, the current war has displaced 1.7 million Palestinians, nearly 75% of the population.³ With 2.2 million people in urgent need of humanitarian assistance and protection, the conditions are dire. The destruction of healthcare infrastructure has left only 17% of primary care facilities operational, and just 16 out of 36 hospitals remain partially functional. Access to clean water and nutritious food is severely limited, exacerbating the health crisis. Almost 10.5% of children screened by UNRWA between January-May of 2024 showed malnutrition, with 1.7% severely malnourished, and some Palestinians surviving on just 3% of the minimum daily water intake.⁴

One of the silent casualties in these conflict zones is oral health, a crucial yet often overlooked aspect of overall well-being. Oral health care has become a luxury that few can afford amidst these challenges. Dental conditions, such as untreated caries and periodontal diseases, are rampant but neglected due to the prioritization of life-threatening injuries. The few dental clinics that remain operational are overwhelmed, with only about sixty out of 1,500 licensed dentists able to provide urgent care. Many dentists have lost their clinics and homes, with some resorting to providing services in makeshift tents. These dire circumstances were highlighted in interviews with some dentists still in Gaza, who continue to serve their community despite immense challenges.

Dentists in Gaza have recently observed a troubling increase in oral health issues linked to malnutrition. The lack of nutritious food and the dependence on donated canned food have led to vitamin deficiencies, such as scurvy, causing dental problems like gingivitis and bleeding gums. Dentists also noticed reduced salivary flow, weakened dental enamel and higher susceptibility to infections. In children this not only results in higher risk for dental decay but also impedes the proper development of the jaw and teeth.

To address this urgent crisis in Gaza and in all other conflict areas and war zones, there is a pressing need for comprehensive, evidence-based protocols to manage oral health across different phases of emergency situations and humanitarian crises. A recent joint policy brief⁵ from the World Dental Federation (FDI) and the United Nations High Commissioner for Refugees (UNHCR) emphasized the importance of being prepared to any emergency by integrating oral health into primary healthcare systems and providing specialized training for other healthcare providers. During emergency responses, evidence-based protocols should prioritize trauma management, pain relief, disease stabilization, treatment and prevention to halt the progression of oral diseases and conditions. In the post-emergency phase, mechanisms for data collection should be established to inform evidence-based interventions and policy innovations. Empowering refugee communities by involving them in healthcare planning and implementation strengthens the long-term sustainability of health systems and enhances community resilience.

Coordinated efforts at national and international levels are essential to implement these protocols effectively. Advocacy for the inclusion of oral health in global health agendas is crucial, as is the support for local dental missions and partnerships with international organizations.

Local partnerships and community engagement play a vital role in tailoring interventions to the specific needs of affected populations. By leveraging local resources and expertise, humanitarian organizations can develop culturally sensitive oral health programs that promote resilience and community empowerment. These initiatives not only alleviate immediate suffering but also lay the groundwork for long-term health equity and sustainability.

It is also crucial to include plans for oral health care in crisis management strategies for all phases of the crisis. These plans should integrate oral health into emergency programs for non-communicable diseases, primary care and maternal and child health care. By prioritizing oral health amidst humanitarian crises, we uphold the universal right to health and contribute to building healthier and more resilient communities worldwide.

In these challenging times, our efforts must go beyond immediate relief to champion justice, equity and peace. By addressing the root causes of conflicts and displacement, we pave the way for a future where every individual, regardless of circumstance, can access the healthcare they need and deserve.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.