Interview: "Why is the epidemic against oral health silent?" —Dr. C M Marya

Imagine losing a tooth not because of an accident but because dental care was too expensive or seen as unnecessary. For billions around the world, this is a reality, and the consequences go far beyond just a missing tooth.

Oral diseases today affect nearly half of the global population, with cases growing at a faster rate than the population itself. According to the latest data from the World Health Organization (WHO), the global burden of oral disease exceeds that of mental disorders, cardiovascular disease, diabetes, chronic respiratory diseases, and all cancers combined, with approximately one billion more cases. The rapid rise in cases is driven by a combination of lack of awareness about proper oral hygiene practices, limited access to affordable dental care, poor dietary habits with high sugar intake, increased tobacco use, and socioeconomic disparities and healthcare inequalities. The financial burden, estimated at $710 billion annually, impacts both individuals and national healthcare systems, making this an urgent yet overlooked public health challenge.

The interview provides an insightful look at the systemic neglect of oral health, barriers to preventive care, the growing gap between awareness and action, and the significant role of education in changing public perception and attitude.

Oral diseases are estimated to affect nearly 3.5 billion people worldwide. In your experience, how do people’s perceptions of oral health impact their overall well-being, especially when oral health is often considered secondary to general health?

Well, from my experience over the past 25 years in dentistry, I’ve noticed that a significant portion of the Indian population (which makes up 17.78% of the world’s population) has a limited understanding of the importance of oral health. Many people assume that since we have 32 teeth, losing one or two isn't a big deal. In fact, I've heard patients say, "Even if we lose a tooth or two, it doesn't really matter because we still have plenty left."

This misconception is a major problem because people don't understand the cascade effect of losing a single tooth and how this affects quality of life—nutrition, speech, self-esteem, and even job opportunities. They often realise [or rather, live] the consequences only after it's too late. And, as these issues accumulate, they end up costing a lot more in terms of both time and money.

The same lack of awareness extends to the broader connection between oral health and overall health. Poor oral hygiene can lead to systemic issues, including diabetes and heart disease. For example, studies have found that individuals with periodontal disease are two to three times more likely to develop heart disease due to bacteria from gum infections entering the bloodstream and contributing to arterial plaque buildup. Similarly, gum disease can worsen diabetes by making blood sugar levels harder to control. Yet, this critical link remains largely unknown to the general public.

People also don’t always connect the dots between oral health and cancer either. In certain parts of India, oral cancer rates are tragically high, largely due to tobacco use. Even though cigarette and tobacco packs come with graphic warnings, their effectiveness remains questionable. Studies have shown that while these warnings increase awareness, they do not always translate into behavioural change. Cultural habits, addiction, and a lack of personal risk perception often overshadow the warnings. For many, oral cancer seems like a distant possibility until they experience its devastating effects firsthand.

The real issue is that oral health education still hasn’t reached where it needs to be—at the level of community-driven prevention.

In your experience, how have socioeconomic factors influenced oral health outcomes in different communities in India, both during your time as a student and now as a professor? What do you think can be done to bridge these gaps?

Honestly, not much has changed in terms of the underlying factors, though there’s certainly been progress in terms of awareness, especially thanks to social media. When I was a student, the challenges were mostly around income, education, access to healthcare, and cultural or social barriers—and those same issues still apply today.

Income is perhaps the most direct factor impacting access to dental care. Even with the presence of primary health centers and community clinics, the sheer demand in a country as populous as India makes it difficult for many people to receive timely care. In rural areas, where access is already limited, many people cannot afford private care, and even in urban areas, cost remains a barrier. For example, the gap between basic services and advanced treatments like root canals is vast, and it's only natural that for many, the financial burden of these procedures outweighs the perceived benefits.

Education is another very important element. People may not recognize the long-term consequences of untreated dental issues or simply lack the knowledge about proper oral hygiene. This lack of awareness down the line contributes to a reactive approach, where dental problems are only addressed when they’ve reached a critical stage.

Access to healthcare is another significant challenge, particularly in rural areas. In these regions, even if a village has an Anganwadi or a community health center, the infrastructure and resources are often inadequate. Many centers lack the basic equipment or materials necessary for comprehensive care. Even when care is available, it might often be limited to extractions or basic procedures, neglecting preventive care and more advanced treatments. The geographical distance from health centers further compounds the issue. Without reliable and affordable transportation, many people would simply avoid seeking care.

Then, there are cultural and social barriers. Trust in healthcare providers can be an issue, especially in remote areas where people may have less exposure to formal healthcare systems.

To bridge these gaps, we need to focus on two main aspects: expanding access to affordable care and promoting preventive care. First, public healthcare services should be made more widely accessible. This means improving infrastructure and ensuring that primary health centers are equipped to handle a broader range of dental issues and not just basic procedures. In regions like Haryana, where many community health centers are already equipped with dental units and staffed with dentists, there is a significant opportunity to expand services. Preventive care, in particular, holds the potential for the greatest impact. While prevention is more cost-effective than treatment, it remains under prioritised in India. Simple, affordable initiatives, such as fluoride varnish programs in schools, could drastically reduce dental decay, yet they are not widely implemented. Educating communities about the importance of preventive care is also crucial. Programs that focus on oral hygiene, diet, and early detection can reduce the burden of more serious dental issues later on.

The effects of climate change on human health, including oral health, are becoming more noticeable, making this an acute and present situation. In your experience, how have environmental and climate-related changes, such as access to nutrition or the rise of sugary foods, impacted oral health in recent years?

The effects of environmental and climate-related changes on oral health are indeed becoming more noticeable. If we look back a few decades ago, the introduction of sugar during World War II had a huge impact on dental health, particularly in the West. Sugar became more widely available, and with that came a rise in dental caries, especially with the growth of bakeries and the availability of sweets. Back then, India wasn’t as exposed to these sugary foods, so dental caries weren’t as prevalent. But as India’s food availability and access have improved, we’re seeing the same trend emerge here now. Sugar is increasingly recognized as a major contributor to not just dental health issues but also other systemic conditions like diabetes and obesity.

Now, when we talk about climate change, the impact is indirect but significant. For example, climate change affects nutrition in various ways. In some areas, you have “food deserts” where access to fresh fruits and vegetables is limited. Fortunately, this is less of an issue in India, but we do face other nutritional challenges, particularly in rural areas. Poor nutrition contributes to a range of oral health problems, from tooth decay to gum disease. In addition, climate-related shifts also lead to resource limitations. India is still a developing nation, and resources for healthcare, including oral health, are often stretched thin. The government’s priorities tend to focus more on pressing medical issues, like polio or maternal health, leaving oral health programmes underfunded.

What’s important to note here is that the effects of climate change and environmental changes are intertwined with broader health issues. To truly address the rising burden of oral health problems, we need to look at these factors holistically. For instance, integrating oral health education into existing nutritional and public health programmes could make a huge difference. By tackling malnutrition, we can also prevent some of the oral health issues that stem from poor diets.

Given the increasing impacts of climate change and environmental shifts on human health, do you believe dental curricula should better integrate the implications of these changes on oral health?

Absolutely. Dental curricula should address the implications of climate change on oral health, but it's important to recognize that the issue isn't entirely new. Environmental and occupational factors affecting oral health, like industrial environments or poor dietary habits, have been part of dental education for years, although the focus has traditionally been more theoretical. The real challenge lies in translating this knowledge into practical, real-world applications.

For example, we teach students about conditions like enamel erosion and the impact of gastric reflux or certain industrial jobs that can harm teeth, but it’s not always connected to the broader context of climate and environmental changes. The information is out there—it’s just that the way we’re applying it in everyday practices could be stronger. While dental students are aware of issues like the link between diet and oral health, there's a gap in how we apply this knowledge to current environmental changes. The curriculum might not be directly addressing the implications of climate change, but it can certainly be adapted to better highlight how environmental shifts affect oral health. For instance, we need to help students understand how these environmental factors, such as climate change and dietary shifts, are creating new challenges in oral health.

Ultimately, it's not about adding entirely new topics to the curriculum but rather making sure that students are able to connect the dots and apply their understanding to the real-world problems that are emerging due to these changes.

Given the urgent need for preventive care and better oral health awareness, how do you see the role of public health dentists evolving compared to those in private practice? Do you think one has a greater responsibility in addressing the gaps we’ve discussed?

The key difference is in the approach. Public health dentists are all about prevention and education, and we often tend to work in underserved areas. We’re focused on tackling the root causes and making long-term changes in people’s habits. Private practice, on the other hand, tends to be more treatment-focused. Take, for example, a patient with tobacco stains who walks in for scaling. It’s not just about cleaning the stains. It's about addressing the underlying habit, explaining the risks of oral cancer, and creating awareness. Without that, we’re just treating symptoms, not preventing disease. While private practitioners do excellent work, they often operate within a treatment-based model, whereas public health dentistry is about reshaping communities’ oral health behaviours. Given the gaps we have discussed, I believe the role of public health dentists will only become more vital in bridging these disparities.

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