The regions of the world have different oral health profiles. In addition to oral precancer and oral cancer, countries in Africa must urgently address a number of very serious oral conditions including noma (cancrum oris), ANUG (acute necrotizing ulcerative gingivitis), and oral manifestations of HIV/AIDS. Analyses have shown that oral manifestations of this disease often include candida infections, hairy leukoplakia, oral ulcers and gingival bleeding, necrotizing periodontitis, leukoplakia and Kaposi?s sarcoma3.

Most ? particularly developing ? countries still lack reliable data on the frequency and severity of oro-dental trauma10. Some countries report dental trauma in about 10-15% of children, and a significant proportion of dental trauma derives from road accidents or violence and unsafe playgrounds or schools. In industrialized countries, the costs of immediate and follow-up care for dental trauma patients are high, while such information is not available in developing countries of Africa.

Diagnosis and treatment of craniofacial anomalies such as cleft lip and palate present a number of challenges to public health. Oro-facial clefts occur in around 1 per 500-700 births, the rate varying substantially across ethnic groups and geographical areas11 and appear to be environment-related, a higher risk being associated with the mother?s use of tobacco and alcohol and her nutritional level. There are many parts of the world, in particular parts of Africa for which there is little or no information available on the frequency of craniofacial anomalies. There is to date no consistent evidence of trends over time, nor is there consistent variation by socioeconomic status, but these aspects have not yet been adequately studied. Other conditions that may lead to special health care needs include Down?s syndrome, cerebral palsy, learning and developmental disabilities, and genetic and hereditary disorders with oro-facial defects.

Oral disease burdens and common risk factors

Given their prevalence worldwide, oral diseases are major public health problems. Their impact on individuals and communities in terms of pain and suffering, functional impairment and reduced quality of life is considerable, and they are the fourth most expensive to treat in most industrialized countries. Were it available in many low-income countries, treatment of dental caries in children alone would exceed the total child health care budget.

A core group of modifiable risk factors is common to many chronic diseases and injuries. The four most prominent NCDs - cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases - share common risk factors with oral diseases that are lifestyle-related and preventable. The greatest burden of all diseases is on the disadvantaged and socially marginalized. A major benefit of the common risk factor approach is the focus on improving health conditions for the whole population as well as for high risk groups, thereby reducing inequities. The WHO Global Strategy for the prevention and control of noncommunicable diseases represents a new approach to managing the prevention and control of oral diseases.

WHO STRATEGIES AND APPROACHES IN ORAL DISEASE PREVENTION AND HEALTH PROMOTION

WHO's goals are to build healthy populations and communities and to combat ill-health. Four strategic directions provide the broad framework for WHO's technical work and in relation to oral health.

1. Reducing the burden of oral disease and disability, especially in poor and marginalized populations.
2. Promoting healthy lifestyles and reducing risk factors to oral health that arise from environmental, economic, social and behavioural causes.
3. Developing oral health systems that equitably improve oral health outcomes, respond to people's legitimate demands, and are financially fair.
4. Framing policies in oral health, based on integration of oral health into national and community health programmes, and promoting oral health as an effective dimension for development policy of society.

The threat posed by noncommunicable diseases and the need to provide urgent and effective public health responses led to the formulation of a global strategy for prevention and control of these diseases, endorsed in 2000 by the 53rd World Health Assembly (resolution WHA 53.17). Priority is given to diseases ? including oral diseases ? which are linked by common, preventable and lifestyle related risk factors (e.g. unhealthy diet, tobacco use).

As emphasized in the World Oral Health Report 200312, the high relative risk of oral disease relates to sociocultural determinants such as poor living conditions, poor access to safe water or sanitary facilities, low education levels, and lack of traditions, beliefs and culture in support of oral health. Communities and countries with inappropriate exposure to fluorides also have a higher risk of dental caries. Control of oral disease depends on the availability and accessibility of oral health systems but risk reduction is only possible if services are oriented towards primary health care and prevention. In addition to the distal sociocultural and environmental factors, the model emphasizes the role of intermediate, modifiable risk behaviours, i.e. oral hygiene practices, sugars consumption (amount, frequency of intake, types) as well as tobacco use and excessive alcohol consumption.

Clinical and public health research has shown that individual, professional and community measures are effective in preventing most oral diseases13. However, optimal intervention in relation to oral disease is not universally available or affordable because of escalating costs and limited resources. This, together with insufficient focus on primary prevention of oral diseases, poses a considerable challenge particularly for developing countries of Africa, and where populations for the most part are underserved. In several African developing countries the most important challenge is to offer essential oral health care within the context of primary health care programmes. Such programmes should meet the basic health needs of the population, strengthen active outreach to the community, organize primary care, and ensure effective patient referral.

The major challenges of the future will be to translate knowledge and experiences of disease prevention into action programmes. The development of such programmes is particularly difficult if oral health care is not fully integrated into national or community health programmes.