Recent local studies have shown that affordable fluoridated toothpaste is effective in caries prevention and should be made available by health authorities in developing countries16. One of WHO?s policies is to support this measure. This is particularly important in light of the changing diet and nutritional status in these countries. The WHO Global Oral Health Programme is currently undertaking further demonstration projects in Africa in order to assess the effects of affordable fluoridated toothpaste.

Diet, nutrition and oral health

Diet and nutrition affect oral health in many ways. Nutrition, for example, influences craniofacial development, oral cancer and oral infectious diseases. Dental diseases related to diet include dental caries, developmental defects of enamel, dental erosion and periodontal disease. WHO/FAO recently published a Global Strategy on Diet, Physical Activity and Health17, based on analysis of the best available evidence on the relationship between diet and physical activity patterns and the major nutrition-related chronic diseases. The strategy aims at reducing the growing burden of NCDs in both developing and developed countries. Recommendations are made to facilitate the formulation of regional strategies and national guidelines to reduce the burden of nutrition-related chronic diseases. Among other recommendations, free (added) sugars should remain below 10% of energy intake and the consumption of foods/drinks containing free sugars should be limited to a maximum of four times per day. In order to minimize the occurrence of dental erosion which seems to be closely related to the consumption of acidic beverages, the amount and frequency of intake of soft drinks and juices should be limited. Many countries currently undergoing nutrition transition do not have adequate fluoride exposure. It is the responsibility of national health authorities to ensure implementation of feasible fluoride programmes for their country.

The WHO Oral Health Programme contributes to the implementation of the Global Strategy on Diet, Physical Activity and Health. There are many intervention activities at national level but the following areas should be addressed:

• legislation and policy
• oral health services
• schools: curricula, school lunches and school health
• food industry, supermarkets
• restaurants, catering, etc.
• non-governmental organizations (NGOs) (health related and others)
• media
• monitoring, surveillance and research.

The Ministries of Health should ensure that mechanisms for intersectoral collaboration are carefully considered. Strategies include taxation and pricing, food labelling, school lunch policies and support to nutrition programmes.

Tobacco and oral health

Prevalence of tobacco use has declined in some high-income countries but continues to increase in low-income and middle-income countries, especially among young people and women9. Undoubtedly, the increasing number of smokers and smokeless tobacco users among young people in some parts of the world will considerably affect the general and oral health of future generations. The prevalence of tobacco use in most countries is highest among people of low educational background as well as the poor and marginalized. In several countries of Africa the use of tobacco is higher among males than females9.

Tobacco is a risk factor for oral cancer, oral cancer recurrence, adult periodontal diseases and congenital defects such as cleft lip and palate in children. It suppresses the immune system's response to oral infection, compromises healing following oral surgery and accidental wounding, promotes periodontal degeneration in diabetics and adversely affects the cardiovascular system. Moreover, the risks of tobacco use greatly increase when it is used in combination with alcohol or areca nut. Most of the oral consequences of tobacco use impair quality of life, be they as simple as halitosis (bad breath), as complex as oral birth defects, as common as periodontal disease or as troublesome as complications during wound healing.

The WHO Oral Health Programme has designed several strategies to control tobacco-related oral diseases and adverse conditions18. Oral health-related activities are integrated in the overall WHO tobacco-free initiative and the Programme encourages the adoption and implementation of WHO tobacco-cessation and control policies by international and national oral health organizations. In addition, oral health professionals should strengthen their contributions to tobacco-cessation programmes.

Oral health through Health Promoting Schools

The Health Promoting School can be characterized as a school constantly strengthening its capacity as a healthy setting for living, learning and working. To help individuals and groups advocate Health Promoting Schools, WHO has produced an "Information Series on School Health". Guidelines are given on how to assist school and community leaders in improving the health and education of young people, and individual documents in the series encourage schools to address one or more important health issues. Training-of-trainers programmes for schoolteachers are conducted to increase national capacities for integration of oral health promotion in schools.

The WHO Oral Health Programme has prepared an oral health technical document to strengthen the implementation of an oral health component of the Health Promoting Schools programme19. Strong arguments for oral health promotion through schools include the following:

• Pupils and students can be accessed during their formative years, from childhood to adolescence. These are important stages in people's lives when lifelong oral health related behaviour as well as beliefs and attitudes are being developed.
• Schools can provide a supportive environment for promoting oral health. Access to safe water, for example, may allow for general and oral hygiene programmes. Also, a safe physical environment in schools can help reduce the risk of accidents and concomitant dental trauma.
• The burden of oral disease in children is significant. Most established oral diseases are irreversible, will last for a lifetime and have an impact on quality of life and general health.
• School policies, the physical environment and education for health are essential for the attainment of oral health and control of risk behaviours, such as intake of sugary foods and drinks, tobacco use and alcohol consumption.
• Schools can provide a platform for the provision of oral health care, i.e. preventive and curative services.