Guest EditorialThe Berlin Declaration on Oral Health and Oral Health ServicesA. Sheiham*

Although there are sufficient dentists in the worldtoday, the majority of people do not have access toadequate, affordable, and acceptable oral health ser-vices. Discussions about the effectiveness of dentalprocedures and dental care in general are dominatedby the concerns of dentists in industrialized countries.Are lasers useful in periodontal treatment? Whichglass-ionomer cement should be used? Such questionsare academic to the millions of people living in de-prived communities and countries. Their needs areignored despite the prevalence of dental diseases. Theoral health of children in many developing countriesis worse than that of children m developed countries,and the former eannot afford the appropriate re-sotirces to deal with the diseases. In all eotrntries, thedental profession and government place more em-phasis on the curative and technological aspects ofdentistry than on promoting prevention and com-munity programs for oral health, which are more ef-fective and would have greater impact on the oralhealth of dentally deprived communities.

• Head. Department of Epidemiology and Public Health, Univer-sity College London, Medical School. 66-72 Gower Slreel. Lon-don WC1E6EA. England.

Editor's note: The purpose of the Guest Editorial is to allow authorsto present their opinions on controversial issues. The views ex-pressed by the author do not necessarily reflect the views of Quin-tessence International or its editors.

Copies of the Berlin Oral Health Declaration arc obtainable fromDrW, Mautsch.Oral Heallh Alhance. Departmenl of Dental Pros-thetics. University of Aachen, Pauwelstiasse 30. D-52074 AiH:hen,Germany.

Because of the contradictions that exist but are gen-erally ignored by policy makers and dental profes-sionals. The Oral Health Alliance, in collaborationwith the German Foundation for International De-velopment, formulated the Berlin Oral Health Dec-laration and recommended strategies based on theprinciples in the declaration directed at reducing ineq-uities in oral health status and availability of services.The strategies outlined in the Berlin Oral Health Dec-laration should help redress the imbalance in oralhealth between deprived and privileged citizens. Eq-uity in health imphes that ideally everyone shouldhave a fair opportunity to attain her or his full po-tential and. more pragmatically, that no one shouldbe disadvantaged from achieving this potential. De-spite efforts in the past decade to make heahh systemsmore equitable, in the poorer countries and commu-nities people's health and access to health care aredeclining.

Oral health has not been given the attention it de-serves. As a result, people who are poor and living indifficult circumstances, whether in developing or in-dustrialized countries, continue to be dentallyneglected, a situation that has every likehhood ofworsening as the global debt crisis and privatizationof health services occur. Although oral diseases arenot hfe threatening, they are important public healthproblems because of their high prevalence and theirimpact on individuals and society in temis of pain,discomfort, and social and functional limitations. Inaddition, the financial impact on the individual andcommunity is very high.

An important feature of oral diseases is that effec-tive, inexpensive preventive methods are available, butin many cases these methods are not appropriatelyapplied. The development of dental programs thatincorporate effective, simple, and inexpensive preven-tive methods and involve local people have a betterchance of ultimately improving both services andcommunity oral health. These community-based pro-

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grams are more likely to lead to self-relianee and self-management of oral health programs.

Tbe recognition that many communities are den-tally deprived bus unfortunately produced a numberof inappropriate responses. The worst mistake is thatprograms developed in one setting bave been trans-ferred witbout adaptation to a completely differentlocale. Most present programs concentrate tbeir ef-forts on tbe provision of curative services and givelittle attention to health promotion.

To redress some of tbose inappropriate approaches,policies should be directed toward enabling people toadopt healthier lifestyles. Cbeap and nutritious foodshould be distributed, advertising of health-damagingproducts should be controlled, clear informationshould be provided, and leisure and exercise facilitiesshould be accessible. Health care should be based onthe principle of making high-quality health care ac-cessible to all. Oral health development is not achievedthrough the unmodified transfer of skills, programs,personnel, or equipment to deprived communities.Adaptation rather than uncritical adoption should bethe rule.

Epidemiology is a fundamental tool in the devel-opment and evaluation of health plans and programs.It is necessary to develop indicators, different fromthose normally used, that measure social, economic,and health impacts. Sociodental indicators are morerelevant measures of needs and should reflect pain,discomfort, function, and esthetics, as well as clinicalindicators of dental health, such as caries, bleedinggingiva, pocketing, and number and position of teeth.Other impact measures include loss of sleep, loss ofwork, and opportunity costs.

Priorities should not be developed solely on the ba-sis of the demand for treatment. Health promotioncan alter a community's perception of the problemsatid hence priorities. Priorities should be establishedthrough a partnership between the community andthe professional advocates for oral health. Tbe com-munity should be involved in setting goals that arestated in terms of oral health, oral disease, healthpromotion, equity, training, and personnel and healthservice.

Oral health promotion should have the highestpriority and follow the principles as defined in theOttawa Charter for Health Promotion (1986). Healthpromotion means building healthy public policy, cre-ating supportive environments, strengthening com-munity action, developing coping skills, and reorient-ing dental services. Health promotion policy must

take into consideration the uneven distribution othealth and disease; the uneven distribution of healthhazards in the physical and social environment andof personal behavioral risk factors; and the unevendistribution and quality of health care. Oral healthstrategies should be integrated with general preventiveapproaches within an overall context of health, whichleads to improvements in the quality of life. The pre-ventive measures should be simple and effective andnot contradict each other or confuse the community.Services and oral health promotion strategies shouldbe modified on the basis of scientific knowledge re-garding the effectiveness, efficiency, and cost-benefitof common interventions. This implies a constant re-view of the scientific basis for health education meth-ods and messages, training and education of heaithworkers, life history of oral diseases, oral pathology,preventive and treatment strategies, infection control,research and research methods, social science in oralhealth, and community-based programs.

Two prineiple.s of the primary health care approachhave to be considered in almost all programs if lastingsolutions to problems are to be found. These are com-munity participation and multisectoral cooperationand integration. An important element in achievingequity in oral health and oral health services is thesuccess ofthemuitisectoral approach in securing com-munity development. Health should be viewed as in-terrelated with the problems of unemployment, highprices, and inadequate housing. Prevention should bebased on the principles of health promotion: reorient-ing oral health services, creating a supportive envi-ronment, building healthy public pohcy, supportingcommunity action, and developing coping skills, in-tegration and a common risk-factor approach shouldbe the cornerstones of health promotional activities.The fundamental concepts are tackling causes com-mon to a number of chronic diseases, including oralhygiene education as part of general hygiene, and de-veloping population rather than high-risk strategies.The approach can be developed because of risk factorscommon to a number of chronic diseases. Diets thatlead to caries also contribute to obesity, coronaryheart disease, and diabetes. Periodontal diseases andoral cancer are related to smoking, which causes othertypes of cancer and respiratory diseases. Integratedleaching or preventive activities with groups con-cerned about those chronic diseases should be moreeffective than disease-specific teaching activities.

In planning oral health services, all possible re-sources should be considered, including the role of

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independent practitioners, which should be comple-mentary to that of government service staff. The "six.^ s " should always be eonsidered to improve healthservices: availability, accessibility, accountability, af-fordability, accommodation, and acceptability. Theproblem of unequal distribution of oral health per-sonnel exists in nearly all countries. There have beenseveral approaches to motivate dentists to work inrural and deprived areas. All have failed althoughtraining, salary, and conditions were favorable.Greater success has occurred with auxihary personnel.Training more auxiliary personnel may be an impor-tant way of increasing coverage, but this should notbe allowed to lead to the creation of a two-tieredservice. The important role that such auxiliary per-sonnel can play therefore must be supported stronglyby governments and professional bodies.

Planning of training and education of personnel inoral health should be a part of comprehensive plan-ning for improving oral health. It is important that

all health personnel receive additional training, par-ticularly to support the concept of prirnary oral healthcare and assume critical advocacy roles with respectto public health policy. To provide the skills necessaryfor health promotion action and for working in anintegrated manner, the education of oral health per-sonnel requires a fundamental reorientation to makeit more relevant to the needs of tbe population. Train-ing of oral health personnel should be based on aholistic approach and not only on the care of theteeth. There is a need for preparatory cotirses in ed-ucation theory and practice, particularly in the de-velopment of communication skills.

Finally, every effort should be made to assist de-veloping countries to become independent ofimported oral materials and equipment. The knowl-edge and expertise of various people working on ap-propriate technologies, including the education andadministration fields, must be shared.

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