Global health threats are also oral health threats

If you were to select a global health threat, what would come to your mind first? It would likely be a pandemic like COVID-19 or Ebola fever or other highly infectious diseases that do not stop at borders. In 2019, the World Health Organization (WHO) put together a list of 10 health threats to highlight their dangers to the global community.¹ The 10 threats were selected because of their potential to cause significant illness, death, societal disruption, and public health impact as well as considering their likelihood of occurring. They require increased attention from governments, health care professionals, communities, and stakeholders in all countries, irrespective of their level of health system public health capacities.

The 10 threats selected indeed comprise infectious diseases like influenza, Ebola, HIV, and dengue fever as well as high-prevalence diseases and broader risks to population health such as noncommunicable diseases or climate change and air pollution.

Although not mentioned explicitly, all 10 of WHO’s global health threats are relevant for oral health and oral health care, directly or indirectly (Table ). We discuss 3 global health threats in more detail: high-threat pathogens, antimicrobial resistance (AMR), and weak primary health care. Each issue is an independent threat, yet all 3 are interlinked.

Oral health care professionals might take false comfort in assuming that their daily clinical work is far away from global health threats.

Table.

Ten global health threats as defined by the World Health Organization in 2019 and their relation to oral health^∗

GLOBAL HEALTH THREAT	ORAL HEALTH IMPLICATIONS
1. Air Pollution and Climate Change	Oral health care has a significant environmental footprint Measures to reduce waste and carbon emission
2. Noncommunicable Diseases	Oral diseases are the most common noncommunicable diseases Bidirectional relationship of oral and general health Common risk factors of oral diseases are shared with other noncommunicable diseases
3. Global Influenza Pandemic	Oral health care providers at increased infection risk Counseling at-risk patients to get vaccinated Importance of being a role model for vaccination and infection control
4. Fragile and Vulnerable Settings	Oral health care among the most vulnerable health services, particularly in humanitarian emergencies, war, or disaster situations Refugees and immigrants disadvantaged in accessing oral health care services
5. Antimicrobial Resistance	Oral health care providers contribute substantially to antibiotic prescribing Compliance with prescription guidelines needed Importance of infection control measures
6. Ebola and Other High-Threat Pathogens	High infection risk for providers and patients (especially airborne and bloodborne infections) Oral health care service disruption with limitations of accessing oral health care as a consequence
7. Weak Primary Health Care	Oral health care services are not generally part of primary health care in all health systems worldwide The essentiality of oral health care services makes it mandatory to strengthen primary health care by making oral health care an integral and universally available element
8. Vaccine Hesitancy	Promote all recommended vaccinations for children and adults Oral health care professionals lead by example
9. Dengue Fever	Gingival bleeding may be an intraoral symptom No elective oral health care during a dengue infection recommended
10. HIV Infection	32 million people worldwide living with HIV; more than 1 million new infections in 2021 Significant oral manifestations of an HIV infection Oral manifestations can be early infection symptoms and indications of compliance with antiretroviral therapy

^∗Source: World Health Organization.¹

High-Consequence Pathogens

High-threat pathogens (called high-consequence pathogens by the Centers for Disease Control and Prevention) are highly contagious or lethal “viral, bacterial, [fungal,] prion, and related infections and diseases of unknown origin.”² It is a core public health function to protect populations from such threats, and more than 250 Centers for Disease Control and Prevention experts work in this area.

Much has been said and written about the COVID-19 pandemic and its impact on oral health care. The uncertainty of transmission risks during the early parts of the pandemic led to unprecedented disruptions of oral health care services. Among all of the health services, oral health care was the most affected by partial or full service closures worldwide.3, 4, 5, 6 Reassuringly, the principles of universal infection control, measures against airborne transmission, adaptations of service management, and the rapid availability of effective vaccines made it possible to resume oral health care services completely.

Just as the pressure from COVID-19 started to ease, another high-threat infection, mpox, emerged outside of the known endemic areas in Western and Central Africa.^{7 , 8} To date, more than 83,000 cases have been reported from 110 countries, with close to 30,000 cases in the United States. The WHO still classifies mpox as a public health emergency of international concern. Despite clear infection risks in dental settings and oral symptoms in those infected, the impact of mpox on oral health care has not reached COVID-19 levels.⁹ All WHO-listed global infection threats underscore the crucial need for constant vigilance and alertness. Existing and approved infection control measures need to be regularly reviewed and updated to ensure safety for patients and staff members. This includes action in 5 key areas: the policies, guidelines, and protocols in place; patient screening when seeking oral health care; adaptations and modifications of oral health care facilities; compliance with measures for personal protective equipment; and infection control measures, including hand hygiene and selection of procedures for appropriate management of aerosols.¹⁰

Antimicrobial Resistance

Infection control is equally central to addressing AMR. Antibiotic-resistant bacteria can cause a range of illnesses, from mild to life threatening. Each year, more than 2 million people in the United States are infected with antibiotic-resistant bacteria, and at least 23,000 people die from these infections.¹¹ Infections caused by antibiotic-resistant bacteria are more difficult to treat and require expensive and complex medications, and sometimes none are effective. Prevention is critical to combating AMR. Antibiotics must be prescribed correctly and only when needed, and patients need encouragement to finish their course of antibiotics.

The US National Action Plan for Combating Antibiotic-Resistant Bacteria outlines 4 key areas to address the threat from AMR: prevention, surveillance and tracking, response, and research and development.¹² The FDI World Dental Federation, the American Dental Association, and many other professional organizations around the world have issued guidelines for antibiotic use in dental practice and advocate for stewardship of oral health care professionals in addressing AMR,^{13 , 14} including guidance on prophylactic use of antibiotics for patients at risk who are undergoing invasive procedures.^{15 , 16} In this context, the concept of One Health, highlighting the interconnections between human, animal, and environmental health, becomes increasingly relevant.^{17 , 18}

Weak Primary Health Care

Framing weak primary health care as a global health threat may seem unexpected. Yet a functioning primary health care system is crucial in preventing and responding effectively to any of the global health threats listed and in ensuring continuity of essential services during a public health emergency. At least one-half of the world’s population lacks access to essential health and oral health care services.^{19 , 20} Through providing a first point of contact for people and communities, primary health and oral health care are the foundation to improving access. Primary health care is also the basis of universal health coverage, one of the central health goals of the United Nation’s Sustainable Development Goals. Oral health care needs to be part of universal health coverage.^{21 , 22}

Conclusions

Oral health care professionals might take false comfort in assuming that their daily clinical work is far away from global health threats. Global pandemics have propelled global health threats to the forefront of media, public, political, and professional awareness. They also exemplified that oral health care is not shielded from such global threats. Oral health is part of global health, oral health care is an essential part of health care systems, and oral health care professionals are integral to the health care workforce. If there is anything that health care systems or health care professionals can do to address global health threats, then oral health care systems and oral health care professionals must be involved in such actions. It is important that we all sharpen our awareness, strengthen our vigilance, and act responsibly to protect the safety of patients, staff members, and communities at large.

Biographies

Dr. Benzian is a research professor, Department of Epidemiology and Health Promotion, and a codirector, WHO Collaborating Center for Quality-improvement and Evidence-based Dentistry, College of Dentistry, New York University, New York, NY; and a research fellow, Stellenbosch Institute of Advanced Study, Stellenbosch University, Stellenbosch, South Africa.

Dr. Beltrán-Aguilar is an adjunct profesor, Department of Epidemiology and Health Promotion, and codirector, WHO Collaborating Center for Quality-improvement and Evidence-Based Dentistry, College of Dentistry, New York University, New York, NY.

Dr. Niederman is a professor, Department Epidemiology and Health Promotion, College of Dentistry, New York University, New York, NY.