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The Berlin Declaration on Oral Health and Oral Health Services

Prof. Aubrey Sheiham

Department of Epidemiology and Public Health, University College London Medical School


Although there are sufficient dentists in the world today, the majority of people do not have access to adequate, affordable and acceptable oral health services. Discussions about the effectiveness of dental procedures and dental care in general are dominated by the concerns of dentists in industrialized countries. Are lasers useful in periodontal treatment? Which glass ionomer cement should be used? Such questions are academic to the millions of people living in deprived communities and countries. Their needs are ignored despite high and deteriorating levels of dental diseases. The oral health of children in many developing countries is worse than in developed countries and the former cannot afford the appropriate resources to deal with the diseases. In all countries the dental profession and governments place most emphasis on the curative and technological aspects of dentistry rather than promoting prevention and community programs for oral health which are more effective at improving oral health and would have greater impact on the oral health of dentally deprived communities. The curative methods cannot be sustained at all levels of development.

Because of the contradictions which exist but are generally ignored by policy makers and dental professionals The Oral Health Alliance in collaboration with the German Foundation for International Development formulated the Berlin Oral Health Declaration and recommended strategies based on the principles in the declaration directed at reducing inequities in oral health status and availability of services. The strategies outlined in the Berlin Oral Health Declaration should help redress the imbalance in oral health between the deprived and other citizens. The principles of natural justice should dominate the discussions. They are based on equity, on balancing the scales between right and wrong, between what is fair and what is unfair. Equity in health implies that ideally everyone should have a fair opportunity to attain their full potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided. By definition, inequity means injustice. Despite efforts in the past decade to make health systems more equitable, in the poorer countries and communities things are getting worse in terms of people's health and access to health care.

Oral health has not been given the attention it deserves. As a result, people who are poor and living in difficult circumstances, whether in developing or industrialized countries, continue to be dentally neglected, a situation that has every likelihood of worsening as the global debt crisis and privatization of health services occur. Although oral diseases are not life-threatening, they are important public health problems. The reasons for their importance are their high prevalence, public demand, and their impact on individuals and society in terns of pain, discomfort, social and functional limitation and handicap and the effect on the quality of life. In addition the financial impact on the individual and community is very high and this is going to increase due to the infection control measures required for the prevention and control of hepatitis and HIV/AIDS.

An important feature of oral diseases is that effective preventive methods which are simple and cheap are available, but in many cases these methods are not appropriately applied. The development of dental programs incorporating effective, simple and cheap preventive methods and which involve local people and build upon their strengths and capacities have a better chance of ultimately improving both services and community oral health. These community-based programs are more likely to lead towards self-reliance and self-management of oral health programs.

The recognition that many communities are dentally deprived has unfortunately produced a number of inappropriate responses. The worst is that programs developed in one setting have transferred without adaptation to a completely different one. Most present programs concentrate their efforts on the provision of curative services giving little attention to health promotion.

To redress some of those inappropriate approaches policies should need to be directed towards enabling people to adopt healthier lifestyles. Distribution of cheap and nutritious food, control of advertising of health damaging products, provision of clear information, access to leisure and exercise facilities. Health care should be based on the principle of making high quality health care accessible to all. Oral health development is not achieved through the unmodified transfer of skills or programs, personnel or equipment to deprived communities. Adaptation rather than uncritical adoption should be the rule.

Epidemiology is a fundamental tool in the development and evaluation of health plans and programs. It is necessary to develop indicators different from those normally used. They should measure social, economic and health impacts. Social-dental indicators are more relevant measures of needs and should reflect pain, discomfort, function and aesthetics as well as clinical indicators of dental health such as caries, bleeding gums and pocketing number position of teeth. Other impact measures include loss of sleep, work loss and opportunity costs.

Priorities should not be developed solely on the basis of the demand for treatment promotion can alter a community's perception of the problems and hence priorities. Priorities should be established through a partnership between the community and the professional advocates for oral health. The community should be involved in setting goals that are stated in terms of oral health, oral diseases, health promotion, equity, training and personnel and health service.

Oral Health Promotion should have the highest priority and follow the principles as defined in the Ottawa Charter for Health Promotion (1986). Health Promotion means building healthy public policy, creating supportive environments, strengthening community action, developing coping skills and re-orienting dental services. Health promotion policy must take into consideration: the uneven distribution of health and disease, the uneven distribution of health hazards in the physical and social environment and of personal behavioral risk factors and opportunities to adopt a healthier personal lifestyle as well as the uneven distribution and quality of health care. Oral health strategies should be integrated with general preventive approaches within an overall context of health which lead to improvements in the quantity and quality of life. The preventive measures should be simple and effective and not contradict each other or confuse the community. Services and oral health promotion strategies should be modified on the basis of scientific knowledge regarding the effectiveness, efficiency and cost-benefit of common interventions.

This implies a constant review of the scientific basis for health education methods and messages, training and education of health workers, life history of oral diseases, oral pathology, preventive and treatment strategies, infection control, research and research methods, social science in oral health and community based programs.

Preparation of oral health personnel should emphasize both education and training. The curricula of all oral health workers should reflect the major shift from the medical to the social model of health which implies the incorporation of social and behavioral sciences. Personnel preparation should be part of a process which ensures career advancement and flexibility. In considering the curricula for oral health workers the civil service grade of the worker on qualification should be used in a positive rather than negative way to ensure more community orientation as well as adequate remuneration and not merely to prolong the length of the training unnecessarily to qualify for a higher grade.

Two principles of the primary health care approach have to be considered in almost all programs if lasting solutions to problems are to be found. These are community participation and multisectoral cooperation and integration. An important element in achieving equity in oral health and oral health services is the success of the multisectoral approach in securing community development. So that efforts do not become mere palliatives reinforcing the unjust structures that perpetuate poor health services, health should be viewed as interrelated with the problems of unemployment, high prices and inadequate housing. Prevention should be based on the principles of Health Promotion: re-orienting oral health services, creating supportive environment, building healthy public policy, supporting community action, developing coping skills. Integration and common risk factor approach should be the cornerstones of health promotional activities. The fundamental concepts are tackling causes common to a number of chronic diseases; including oral hygiene education as part of general hygiene; developing population rather than high-risk strategies. The approach can be developed because of risk factors common to a number of chronic diseases, including dental caries, periodontal disease and oral cancer. Diets which lead to caries also contribute to obesity, coronary heart disease and diabetes. Periodontal diseases and oral cancer are related to smoking. Smoking causes cancers elsewhere in the body and respiratory diseases. Integrating activities with groups concerned about those chronic diseases should be more effective than disease specific activities.

Oral cleanliness should be seen as part of grooming and body cleanliness. It is logical that instead of separating oral cleanliness education from general hygiene they should be combined. These programs should emphasize lay competence, be supportive and non-mystifying, and should not "blame the victim".

In planning oral health services all possible resources should be considered, including the role of independent practitioners, which should be complimentary to that of government service staff. The six A's should always be considered in order to improve health services. These are availability, accessibility, accountability, affordability, accommodation and acceptability. The problem of unequal distribution of oral health personnel within the health service exists in nearly all countries. There have been several approaches to motivate dentists to work in rural and deprived areas. All have failed although training, salary and conditions were favorable. Greater success has occurred with auxiliary personnel. Training more auxiliary personnel may be an important way of increasing coverage. But this should not be allowed to lead to the creation of two-tier service in respect of appropriateness and quality of care. The important role that such auxiliary personnel can play needs therefore to be supported strongly by governments and professional bodies.

It is important to remember that countries committed to the Alma Ata Declaration are committed to all aspects of the Primary Health Care Approach. However, primary health care is not a menu from which people can pick and choose. An important mechanism for getting integration and multisectoral cooperation implemented is to include them in the list of things to be evaluated in any program. Integration would also be facilitated by the removal of inequalities in career structures between different members of the health team.

Planning of training and education of personnel in oral health should be a part of comprehensive planning for improving oral health. It is important that all health personnel receive additional training as post qualification or continuing education, particularly to support the concept of primary oral health care assume critical advocacy roles respect of healthy public policy. The following are suggested as necessary in the future education and training of oral health personnel to acquire the skills for health promotion action and for working in an integrated manner: A fundamental reorientation of the education of oral health personnel is required to make it more relevant to the needs of the population. Training of oral health personnel should be based on a holistic approach and not on the care of thirty two teeth. There is a need for preparatory courses in education theory and practice, particularly in the development of communication skills. The training of students should be related to a country's National Plan for Oral Health.

Every effort should be made to assist developing countries to become independent of imported oral materials and equipment. The knowledge and expertise of various people working on appropriate technologies needs to be shared. Appropriate technologies include also those in the education and administration fields. As such they involve personnel, methods and learning aids.

The Berlin Oral Health Declaration raises numerous fundamental questions. They deserve answering by dental professional organizations, universities, planners and governments.

Mailing address:

Department of Epidemiology and Public Health

University College London Medical School

66-72 Grower Street, London WC1E 6EA


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