Should dental care be included in universal healthcare?

Should Dental Care Be Part of Universal Healthcare?

Yes, dental care should be integrated into universal healthcare systems, as oral diseases affect over 3.5 billion people globally and share common risk factors with other non-communicable diseases, making integration essential for achieving equitable health outcomes and reducing financial hardship. 1, 2

The Case for Integration

Oral health must be recognized as an integral component of essential health services rather than remaining isolated from mainstream healthcare. 2 The current separation between medical and dental insurance paradigms creates significant barriers to accessing medically necessary oral care, particularly for uninsured and underinsured populations. 3

Shared Risk Factors and Disease Prevention

Integrating oral health into universal health coverage is justified because sugar, alcohol, and tobacco consumption—the primary drivers of oral disease—are the same risk factors underlying cardiovascular disease, diabetes, obesity, and other non-communicable diseases. 1 This overlap means that:

• Addressing oral health through UHC enables comprehensive prevention strategies targeting common risk factors across multiple disease categories 1
• Dietary interventions for oral health simultaneously reduce risks for metabolic diseases, making integrated care more cost-effective 3, 4
• Primary care providers can deliver oral health screening, fluoride varnish application, and preventive services during routine medical visits 3, 5

The Failure of Isolated Dental Systems

The current treatment-dominated, high-technology approach in high-income countries fails to address underlying disease causes or reduce oral health inequalities. 1 In low- and middle-income countries, westernized dentistry remains unavailable, unaffordable, and inappropriate for the majority of populations, especially the rural poor. 1

Key system failures include:

• Private sector dominance in most countries except Thailand and Sri Lanka, limiting access for disadvantaged populations 6
• Inadequate public sector spending on primary oral health care, with resources directed primarily toward expensive tertiary interventions 7
• Severe workforce shortages, with dentist-to-patient ratios of 1:2800 in underserved communities versus 1:1500 nationally, resulting in 45% of children having untreated caries compared to 19% nationally 4

Implementation Framework for UHC Integration

Primary Care-Focused Delivery Model

Universal health coverage must restructure oral health delivery around primary care rather than hospital-centric specialty services. 3 This requires:

• Deploying midlevel dental providers (dental therapists, dental health aide therapists, expanded-function dental hygienists) who can deliver preventive and basic restorative services under dentist supervision in underserved areas 3, 4, 8
• Engaging primary care providers (pediatricians, family physicians, nurse practitioners, community health nurses) to provide oral health screening, fluoride varnish application, and care coordination during routine medical visits 3, 5
• Establishing dental homes by 12 months of age for all children, with "two is too late" recognition that high-risk populations require intervention starting with first tooth eruption 3, 5, 4

Financial Protection Mechanisms

UHC must provide adequate financial coverage for essential oral health services to prevent catastrophic health expenditures. 7, 2 Essential oral health care should include:

• Urgent care for pain relief and infection control 2
• Basic preventive services including fluoride varnish (every 3-6 months starting with first tooth eruption), dental sealants, and silver diamine fluoride for caries arrest 5, 4
• Basic restorative care and appropriate rehabilitative services to maintain health, productivity, and quality of life 2

Current financing mechanisms are absent in most countries and deficient even in relatively advanced systems. 6 China's target to reduce out-of-pocket health expenditure to 25% by 2030 provides a benchmark, though achieving this requires systemic reforms beyond increased funding alone. 3

Workforce Expansion Strategy

Addressing the dental workforce crisis requires training and deploying midlevel providers who can work in underserved areas. 3, 4, 8 Evidence from Alaska's dental health aide therapist program demonstrates:

• Improved oral health access and outcomes in remote villages 3
• Positive reception by healthcare providers and community members 3
• Safe and effective expansion of dental care delivery when properly supervised 3

The Canadian federal government's discontinuation of dental therapist training in 2011 due to urban migration and professional opposition illustrates a critical pitfall: workforce expansion initiatives must include retention strategies and overcome resistance from established professional societies. 3

Addressing Common Pitfalls

The Sugar Industry's Influence

A major barrier to effective oral health policy is the sugar industry's influence on dental research, policy, and professional organizations through well-developed corporate strategies. 1 Integration into UHC must include:

• Coherent and comprehensive regulation of sugar consumption through upstream policies (taxation, marketing restrictions, labeling requirements) 1
• Clear conflict of interest policies limiting sugar industry influence on research, policy, and practice 1
• Recognition that combating commercial determinants of oral diseases should be a major policy priority 1

Avoiding Technology-Driven Escalation

Not all dental care is essential oral health care, and UHC should not replicate high-income countries' increasingly high-technology, interventionist approach that fails to address disease causes. 1, 2 Instead:

• Focus public sector spending on primary prevention rather than expensive tertiary interventions 7
• Prioritize cost-effective interventions with demonstrated population health impact 2
• Develop country-specific monitoring frameworks reflecting local disease burden rather than adopting global indicators designed for different contexts 3

Integration Without Subordination

Oral health must be integrated into primary care while maintaining specialized expertise and avoiding complete subordination to medical priorities. 2 This means:

• Oral health personnel are part of the essential healthcare workforce, not auxiliary services 2
• Dental professionals retain clinical autonomy while collaborating with medical providers on shared risk factors 3, 4
• Health information systems must include dental-specific indicators and surveillance data 6

Evidence Quality Considerations

The strongest evidence comes from recent Lancet Public Health guidelines on China's UHC experience 3, which demonstrate that increased resources alone are insufficient without systemic delivery system restructuring. The 2019 Lancet series on global oral health 1 provides the most comprehensive critique of current dental systems and rationale for integration. The 2021 Journal of Dental Research consensus on essential oral health care 2 offers the clearest definition of what should be included in UHC.

The evidence consistently shows that strong political commitment and targeted financial investment produce positive outcomes when combined with delivery system reform, but fragmented hospital-centric systems restrict effectiveness regardless of funding levels. 3