Radical Reform Needed to Address Dental Decay Worldwide

Commentary: Sugar Industry Ties to Professional Dental Organizations Must be Addressed

By Scott Maier

Oral diseases, such as tooth decay, gum disease and oral cancers, are a major health burden affecting 3.5 billion people worldwide, but are largely ignored by the global health community, according to a series on oral health in The Lancet that publishes July 20, 2019.

Cristin Kearns portrait

Cristin Kearns, DDS, MBA, commentary corresponding author and studies co-author.

In a commentary accompanying the series, Cristin Kearns, DDS, MBA, of UCSF, and Lisa Bero, PhD, of the University of Sydney, express growing concern that the dental profession will not make meaningful progress in combatting the oral health epidemic until it addresses the sugar industry’s influence on dental research and professional bodies.

“Dental research organizations have only recently woken up to the fact that their research activities haven’t focused on sugars for many years, and very few people realize that these organizations have financial relationships with global candy, ice cream, sugary beverage and snack companies,” said Kearns, an assistant professor in the UCSF School of Dentistry and Philip R. Lee Institute for Health Policy Studies. “While these relationships may be slightly less shocking when one considers these companies also sell oral health products, we can’t lose sight of the fact that in many cases, these are the same companies that are opposing sugar reduction policies, such as sugary beverage taxes.”

The commentary lists the corporate members of the European Organisation for Caries Research (ORCA), which include Cloetta, a Nordic confectionary company; Unilever, a global consumer goods company selling ice cream and sugary beverages; and Mars Wrigley Confectionary, a leader in production of chewing gum, chocolate mints and fruity confections. International Association for Dental Research (IADR) corporate members include Unilever and Mondelēz International, one of the world’s largest snack companies.

The authors note that industry funding presents a conflict of interest (COI) and a risk of bias in how research is designed, conducted and published. It can drive research agendas away from studying product harms or towards topics that may distract from these harms, such as dental caries interventions with commercial applications (e.g., xylitol, oral hygiene instruction, fluoridated toothpaste and sugar-free chewing gum), rather than prevention.

“Dental research organizations have made inconsistent progress towards the disclosure and management of COI,” wrote Kearns and Bero, who also is a prominent researcher in the field of pharmaceutical COI. “The extent of undisclosed financial ties with the sugary food and beverage industry is uncertain because existing transparency databases focus mainly on pharmaceutical industry payments. Furthermore, disclosure alone does not manage COI.”

The authors advise adding dentistry to the key recommendations spelled out in a 2009 report by the U.S. Institute of Medicine (now National Academy of Medicine) on conflicts of interest in medical research, education, and practice for pharmaceutical, medical device and biotechnology companies. 

Recommendations for Managing COI Between Sugary Food and Beverage Industry and Dental Organizations

  • Adopt COI policies consistent with the 2009 Institute of Medicine Report for the organization and any related entities (e.g., dental journals).
  • Publicly report industry payments to dentists, researchers, health care institutions, professional societies and continuing dental education providers.
  • Bar researchers with a COI from doing research with human participants, except when the investigators’ expertise is essential to the safe and rigorous conduct of the research.
  • Prohibit or end relationships with industry that present unacceptable risks of undue influence over professional decision-making or a loss of public trust.
  • Reduce industry influence in the development of clinical practice guidelines by requiring the majority of guideline committee members and committee chair be free of financial COI.
  • Establish policies at the board level to identify, limit and manage institution-level COI.
  • Develop incentives to promote the institutional adoption and implementation of policies recommended by the Institute of Medicine report for medical research, education and practice. 

The Lancet Oral Health Series includes two papers and two commentaries from 13 academic researchers from 10 countries. The series provides an analysis of the health and economic burdens of dental decay, which disproportionately affect low- and middle-income countries, and issues a call for action on oral health within the global agendas for non-communicable diseases and universal health coverage. 

The two Lancet studies, on which Kearns is also a co-author, advocate for widespread dental reform. The researchers encourage closing the divide between dental and general health care; educating and training the future dental workforce to focus on prevention; tackling oral health inequalities through inclusivity and accessibility; strengthening policy to address the underlying causes of oral diseases; and redefining the oral health research agenda to address knowledge gaps in lower- and middle-income countries.

Untreated dental decay is the most common health condition worldwide, and lip and oral cavity cancers are among the top 15 most common cancers. Sugar consumption, the underlying cause of tooth decay and a common risk factor for obesity and associated diseases, is rising rapidly across many low- and middle-income countries. The papers emphasize that prevention of tooth decay requires global implementation of the World Health Organization’s guideline recommending individuals consume less than 10 percent of total energy from free sugars, preferably below 5 percent.

Kearns has received grant funding from the Laura and John Arnold Foundation outside of the work in the commentary. Both Kearns and Bero report no conflict of interest. A full list of authors and affiliations, as well as funding information and conflicts of interest disclosures for other series authors can be found on each paper.

The University of California, San Francisco (UCSF), is dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes UCSF Health, which comprises three top-ranked hospitals as well as affiliations throughout the Bay Area.