What is the Price of a Smile?

© Stephan Rebernik 2012


The lack of basic resources in many developing countries remains responsible for the death of millions of children annually. Some of the illnesses responsible for such high morbidity and mortality rates can be avoided through simple preventive measures including immunization, access to drinking water, proper hygiene, and appropriate nutrition.  Numerous developing countries cannot afford basic health expenditures to cover minimal interventions for their population. This creates difficulties in health planning and in many cases the already scarce public health resources are poorly distributed or concentrated in more affluent populations , increasing the gap between social classes. The vast majority of funds are spent on disease treatment, whilst prevention and health promotion are far from reaching universal access.1

Within this tragic scenario lies the field of dentistry, a branch of healthcare known for its expensive treatments even in high-income countries. Among underprivileged populations, dental treatment is not seen as a right, but as a luxury. It may take a whole day of walking or riding a bus to reach the nearest dental office. However, privatization of access is not the only problem: a single visit could expend all funds necessary to buy food for a whole family for an entire month. In addition, public dentistry establishments in remote areas often have to deal with precarious infrastructure, few professionals, a lack of medical materials, and limited time to treat everyone. Due to this inaccessibility, the high-costs, and other basic priorities to ensure families’ survival, oral health is neglected, leading to the progression of oral diseases. This leads to even more expensive treatments in the future, generating more costs to nations and their inhabitants.1,2

In order to diminish the incidence of diseases, including infirmities which affect the mouth and its structures, one of the wisest and most feasible measures is to establish policies for prevention of illnesses and health promotion. In dentistry, for instance, fluoridation of public water supply, approved by the World Health Organization in 1969, was an outstanding process adopted to diminish the index of dental caries. Consequently, within a decade, the index of teeth affected by caries diminished by more than 50% among 12-year olds in countries such as Brazil.3 Such a grand impact made the Center for Disease Control and Prevention (CDC/USA) consider fluoridation of water supply to be one of the ten greatest public health achievements of the 20th Century.3

Another successful measure adopted in dentistry is a minimal intervention technique, which requires no anesthesia. This method known as Atraumatic Restorative Treatment (ART) emerged during the 80’s in Tanzania, Africa, with the aim to preserve the teeth of poor rural populations. Resources such as piped water, dental devices, and electricity were not available, making conventional dental treatment unfeasible. ART does not require these resources, and instead treats carious lesions using a material used to restore the tooth releases fluoride to the buccal medium, making all teeth in the mouth more resistant to acidic pH, effectively preventing further decay.4 Several studies performed on cohorts of children living in rural areas have shown that three years after ART was completed, the majority of restorations were still appropriate.2,4 This intervention increased the odds for individuals to have their teeth in good condition during adulthood which not only decreases dental expenses, but also gives them the ability to chew, speak, and smile without misgivings. For those who have so little, it can mean a lot.2, 5, 6

Due to its low cost and effectiveness, ART has been adopted in may places all over the world, including Indonesia, Zimbabwe, Thailand, Cambodia, Brazil, Nepal, China, and even in high income countries such as the USA and Netherlands. It is included in textbooks as a therapeutic and preventative measure, and is taught in paediatric dentistry as a practice to seal dental surfaces prone to developing dental caries. ART is easy to learn and costs less than the conventional dental restorations. Its applications have had a remarkable, positive impact on public health for diminishing the burden of dental pain and suffering around the world.6-8

Preventative measures including, but not limited to, fluoridation of water supplies and ART diminish the cause of soreness, infection, discomfort, injury, and suffering. Public policies to prevent diseases and promote health, when applied in accordance with appropriate evidence, have positive effects on reducing morbidity and mortality rates amidst individuals lacking access to health services.  This decreases the need for future treatment, cuts public health expenditures in the administrative sphere and empowers governments to search out other initiatives to enhance the health status of its population.1-8

When introduced early in one’s life, preventive oral care empowers individuals to maintain their oral health throughout life, diminishing the incidence of diseases as well as expenditures for treatments.1-8


  1. Yee R, Sheiman A. 2002. The burden of restorative dental treatment for children in Third World countries. 52: 1-9.
  2. Hof M, Frencken J, Helderman WP, Holmgren C. 2006. The Atraumatic Restorative Treatment (ART) approach for managing dental caries: a meta-analysis. International Dental Journal. 56: 345-351.
  3. Narvai P. 2000. Dental caries and fluorine: a twentieth century relation. Ciência & Saúde Coletiva. 5: 381-392.
  4. Phantumvanit P, Songpaisan Y, Pilot T, Frenchken J. 1996. Atraumatic Restorative Treatment (ART): a Three-year Community Field Trail in Thailand- Survival of One-surface Restorations in the Permanent Dentition. Public Health Dent. 56: 141-145.
  5. Schriks A, Amerongen W. Atraumatic perspectives of ATR: psychological and physiological aspects of treatment with and without rotatory instruments. 2003. Community Dent Oral Epidemiol. 31: 15-20.
  6. Frencken J. Evolution of the ART approach: highlights and achievements. 2009. J Appl Oral Sci. 17: 78-83.
  7. Mallow P., Durward C, Klaipo M. 1998. Restoration of permanent teeth in young rural children in Cambodia using the Atraumatic Restorative Treatment (ART) and Fuji II glass ionomer cement. International Journal of Pediatric Dentistry. 8: 35-40.
  8. Frencken J, Makoni F, Sithole W. 1996. Atraumatic Restorative Treatment (ART) and Glass-Ionomer Sealants in a School Oral Health Program in Zimbabwe: Evaluation after 1 year. Caries Res. 30: 428-433.