Opinion: Tooth decay is a disease of inequality. Here’s how governments can improve dental care

Dr. Ifeanyi M. Nsofor
4 min readAug 7, 2019


New research from The Lancet’s oral health series shows that tooth decay affects 34% of the global population and could affect up to 90% of indigenous children. Tooth decay is one of the most common and neglected noncommunicable diseases. It is a disease of inequity, disproportionately affecting some of the world’s poorest people. This should not be allowed to continue.

Generally, people of lower socioeconomic class have poorer oral health because cost is a major impediment to access — and it is impossible to deal with tooth decay without dental care. Dental treatment is not cheap. In most high-income countries, dental treatment costs 5% of total health expenditure and 20% of out-of-pocket health expenditure. To put it in context, the amount spent in the U.S. for dental treatment was equivalent to combined 2016 national budgets of Nigeria, South Africa, Kenya, Ghana, Ethiopia, and Puerto Rico.

The disproportionate lack of dental health care among disadvantaged populations is a global issue. In the U.S., 2014 data shows that Hispanics and African Americans are less likely to have used health or dental care in the past year compared to whites. In Europe, there are significant socioeconomic inequalities in the lack of use of dental care. Africa has just about 8,000 dentists to service more than 1.2 billion people. In comparison, there are about 200,000 dentists providing services to 300 million people in the U.S.

To reverse this dental health inequity, there are five interventions that governments, particularly those in Africa and Asia, should consider:

1. Provide dental care prevention in communities where people reside

Community health workers can do this. They can be trained to provide health education targeted at prevention of tooth decay. Rwanda’s use of 45,000 community health workers to improve health care is a great example. In Rwanda, each village of about 100–150 households elects two women and one man as community health workers, who provide referrals on different health interventions. Dental health prevention and referrals could be added to their existing roles.

2. Get kids into school and provide dental care there

In the Philippines, a partnership of the government, school authorities, and school-based management committees is using the Fit for School program to improve dental health in schools. The program includes daily group activities of hand washing with soap and tooth brushing with fluoride toothpaste, and twice a year deworming. The use of fluoride toothpaste prevents tooth decay. This is the sort of school-based public health intervention that should be scaled by communities, governments, civil society organizations, donors, and the private sector.

But first, we need to make sure all children have access to education. Globally, 263 million children and youth are out of school. In South Asia, 11.3 million primary school age children and 20.6 million secondary school age children do not attend school. Of all the regions, sub-Saharan Africa has the highest rate of exclusion: more than one-fifth of children aged between 6–11 years and one-third of youth between the ages of 12–14 are not in school.

3. Impose a ‘sweet tax’ on companies that produce sugary drinks and other candies

The current status of tooth decay is worsened by the heavy marketing of soft drinks by major multinationals. By 2020, marketing soft drinks will cost Coca-Cola $12 billion in Africa and PepsiCo $5.5 billion in India, according to Marion Nestle, author of the book “Soda Politics: Taking on Big Soda (and Winning).”

Imagine the impact if Coca-Cola, PepsiCo, and other culpable firms pay a 1% “sweet tax” of their marketing budgets. That alone would make available at least $170 million by 2020, which could be used to fund training of community health workers in provision of dental health promotion, distribution of toothbrushes and fluoride toothpastes through community health workers, and the scale-up of the programs like the Philippines’ Fit for School program.

4. African governments must train more dentists and assistant dentists to meet the current deficit

There are lessons from China in this regard. In China, assistant dentists are trained through three-year or four-year diploma dentistry courses, offered by more than 100 training schools. These assistant dentists practice independently, providing a range of services similar to that of university-trained dentists. Assistant dentists can then be deployed to underserved communities across Africa by providing better salaries and opportunities for training to become dental surgeons.

5. Universal health coverage must be the long-term solution to reverse dental health inequities

Tooth decay is basically an outcome of lack of promotive, preventive, curative, rehabilitative, and palliative dental services. Forty years after the Alma-Ata Declaration, which identified primary health care as the vehicle to deliver quality health care for all, about 100 million people are still being pushed into extreme poverty because they have to pay for health care. Governments must prioritize primary health care so that people can get the right dental health education that can prevent a lifetime of tooth decay and other dental health inequities.

None of these suggestions will be easy to implement, but the global health community knows that with persistence and political will, the battle can be won eventually.

Originally published at https://www.devex.com on August 7, 2019.



Dr. Ifeanyi M. Nsofor

Dr. Ifeanyi McWilliams Nsofor is a Senior New Voices Fellow at the Aspen Institute. He is a leading global health equity advocate.