Oral Health Meets Commercial Determinants: An Opportunity to Bridge Individual and Structural Approaches
ABSTRACT
Oral diseases are among the most prevalent conditions affecting Australians, yet oral health agendas often focus on individual treatment rather than prevention at the population level. Viewing oral health through a commercial determinants of health lens provides an opportunity to bridge this treatment-centred approach with a prevention-focused agenda that targets structural determinants of oral health—the causes of the causes. We highlight the role of structural and commercial factors, operating outside an individual's control, that drive the high prevalence of oral disease and inequities at a population level. Good oral health is a human right, and the role of commercial actors must be acknowledged and addressed to improve health and reduce inequities.
Summary
- In Australia, initiatives to improve oral health invariably focus on increasing dental visits.
- While there has been a greater understanding of the social determinants that drive inequalities in health outcomes, dental practitioners should also consider the broader commercial forces which contribute to oral disease in order to make meaningful steps in reducing the burden of disease.
1 Introduction
Protecting and promoting oral health requires both prevention and treatment. Yet oral health agendas are often reduced to oral healthcare—the treatment end of the spectrum. While improving access to affordable dentistry is crucial, it is often detached from the complex determinants that drive oral health inequities at a population level.
Oral diseases—including dental caries (tooth decay), periodontal (gum) disease and oral cancer—are ubiquitous, affecting close to 3.5 billion people worldwide in 2017 [1]. These oral diseases disproportionately impact populations experiencing social disadvantage [2]. In Australia, dental caries is common in children from low-income households, especially for Indigenous children, with inequities persisting into adulthood [3]. Oral diseases do not occur in a vacuum and are influenced by a range of individual and social factors. Thirty years ago, the social determinants of health offered a transformative lens to consider the problem of health inequalities [4]. This highlighted the need for both clinicians and policymakers move from a model focused on individual behaviours and broaden their view to consider these social determinants as part of population-level programmes to prevent oral health disease. Scholarship has now expanded beyond the social determinants to include commercial drivers of health—those factors in the commercial sphere that impact on health and equity.
Initially the focus of commercial determinants of health (CDoH) was on the industries whose primary products were considered to be the drivers of poor health [5]. These ‘harmful products’ included tobacco, alcohol and ultra-processed foods and were linked to a range of non-communicable diseases such as obesity, diabetes, stroke, cancer and lung disease [6]. However, oral health was often absent despite the well-accepted common risk factor approach and the links between tobacco, sugar and oral diseases being well established.
Commercial actors use their influence to shape policies and systems in ways that maximise profits at the expense of health, through lobbying, marketing, promoting self-regulation, funding scientific research or engaging in political and public discourse [7].
Considering oral health from a commercial determinants of health (CDoH) lens offers a useful starting point to bridge the individualistic, treatment-centred approach with a population oriented and prevention-focused agenda that targets the structural determinants of oral health—the causes of the causes [4, 5]. Additionally, we argue that oral health can help to bridge the old and new worlds of CDoH scholarship—the former grounded in ‘harmful products’ while the latter takes a more holistic perspective of wider commercial influences on health. While the commercial determinants of oral health include harmful products (like tobacco and sugary drinks), they also encompass system-level dynamics, such as the privatisation of essential services, offering a useful illustration of the more structural, systemic commercial determinants that characterise the ‘new school’ of commercial determinants.
2 Old School and New School Commercial Determinants
Many understandings of CDoH are still grounded in the idea of ‘harmful products’ or ‘unhealthy commodities’—traditionally tobacco, alcohol and ultra-processed foods. New conceptualisations, visible in The Lancet series on CDoH, take a more holistic approach, looking at the “systems, practices and pathways through which commercial actors drive health and equity.” [5] This new approach to CDoH is grounded in social determinants—the causes of the causes, and goes far beyond products to consider deregulation, privatisation, financialisation, supply chains, the creation of science and more.
To advance scholarship and action on CDoH, we need to help people make the leap from old school CDoH (harmful products) to new school CDoH (systems, practices and pathways). This includes looking at products and services that are essential to health—like healthcare [8]. Given the extensive role of private and commercial players from harmful substances to determining oral healthcare for the majority population, oral health is an important case study to underscore this scholarship transition. Oral health inequities are driven by both harmful and essential products and services, as well as wider systems forces.
Thus far, oral health scholarship has mainly considered commercial determinants through a harmful products lens. The 2019 Lancet Oral Health Series illustrated the impact of marketing, lobbying, corporate social responsibility and supply chain practices of the sugar-sweetened beverage (SSB) industry on oral health outcomes [9]. Other studies have likewise focused on the marketing and lobbying activities of tobacco, SSBs and alcohol companies [9-11]. More recently, Broomhead and Baker argued that structural factors (such as labour markets, privatised economies, market regulation and international trade) also impact oral health outcomes [12].
The CDoH field has advanced substantially since the Lancet Oral Health series was published, and there is now an opportunity to expand the conceptualisation of the commercial determinants of oral health. Below, we draw on the CDoH model developed in The Lancet to present an explicit analysis of the commercial determinants of oral health: who are the key commercial actors and sectors?; what are their practices?; and, what are the effects of commercial determinants on oral health inequities?
3 Commercial Practices That Influence Oral Health
There are seven core commercial practices that influence population health and health inequities: political, scientific, marketing, supply chain and waste, labour and employment, financial and reputational management [5]. While some practices can promote health, many others worsen health and exacerbate health inequities.
Table 1 provides illustrative examples of the breadth of commercial practices that can influence oral health, as well as suggesting actions. For example, there is good evidence internationally on the effectiveness on taxes on SSB in reducing consumption, yet industry influence in Australia has stymied action here. There is a need for the dental profession—from the individual practitioner to researchers and professional associations—to build the local evidence base not only for SSB taxes but also on sugar marketing and sponsorship, and work with other health organisations to deliver a suite of changes that mirror the action taken on tobacco. The more immediate and early impact of sugar on oral health, particularly seen in data on preventable hospitalisations, provides a strong case for oral health to lead action on this aspect of commercial determinants.
| Practice | Definition | Examples | Potential actions |
|---|---|---|---|
| Political | Practices to secure preferential treatment and/or prevent, shape, circumvent or undermine public policies in ways that further corporate interests |
The Australian Beverages Council, National Retail Association and Australian Association of Convenience Stores rejected a call for sugar-sweetened beverage (SSB) tax, labelling it a misguided measure and instead advised to invest in increasing consumer education [14]. Lobbying from professional dental associations to restrict practitioner numbers has ensured that demand continues to outstrip supply, leading to higher costs and under-served populations. |
Government-led regulations to improve transparency in lobbying activities and restrict marketing harmful practices. Enforcing monitoring and benchmarking of commercial practices against best practice evidence for accountability. |
| Scientific | Practices involving the production and use of science to alter product and/or otherwise secure industry favourable outcomes | Historically, the sugar industry funded research on dental caries that deliberately ignored or downplayed the role of sugar [11]. This has contributed to a treatment focused philosophy rather than an emphasis on prevention, with subsequent research directed to technological and therapeutic approaches to disease management. |
Advocate for more government research funding for advancing the oral health evidence to mitigate commercial influences. Monitor the role of political lobbying to misguide research allocation. Implement rigorous conflict of interest rules for scientific publications and conferences. |
| Marketing | Practices to promote sales of products or services |
Dentistry has been described as diverging from the tenets of the medical profession to become more aligned to free-market values than to those of a healing profession [15]. This is expressed in the way in which the dental profession advertises commercially to create the demand for services, at least in part due to greater societal consumerism. Dental industry marketing of new technologies to dental practitioners is also shifting the way in which services are then marketed to patients. Artificial intelligence and teledentistry may allow dentists to serve vulnerable populations in inaccessible areas [16, 17]. However it also presents ethical and legal concerns around potential biases in algorithms, lack of accountability, informed patient consent and questions around liability in the case of errors harms. |
Restrict harmful marketing practices and adopting best practice evidence prioritising health over profit. Artificial intelligence needs to be open and transparent with respect to training data and algorithms to provide assurance that these tools will not adversely influence treatment decisions that favour profit over health. |
| Supply chain and waste | Practices involved in the creation, distribution, retail and waste management of products or services |
Like other clinical settings, strict infection control requirements can generate substantial waste (such as use of single-use instruments, sterile wrappings, gloves and tissues), contributing to climate change concerns that may impact on health [18]. |
Explore options to reduce reliance on single-use materials. Focus on prevention to reduce the requirement for treatment which contributes to substantial waste. |
| Employment | Practices to manage those employed directly within or under contract to the organisation within its supply chain | A study of US dentists found that those employed in larger, consolidated practices had lower rates of job satisfaction (including schedule flexibility, paid time off and clinical autonomy) [19]. |
Creating fair and safe working conditions for employees. Build skillset among oral health professionals for interventions beyond oral healthcare. |
| Financial | Practices to support financial position of the organisation | As in other healthcare settings, private equity acquisition of dental practices has increased dramatically [20]. Australia has seen a growing trend of corporate and private health fund ownership of dental practices, raising concerns about profit motives influencing the delivery of health care. |
Governments commit to measuring the impact of private equity (and other commercial organisation) ownership on health outcomes, developing safeguards where needed. Development of clinical guidelines and better utilisation of clinical data. |
| Reputational management | Efforts to shape legitimacy and credibility, reduce risk and enhance corporate brand image | During the COVID-19 pandemic, Philip Morris donated ventilators in Greece, after which its chief executive was invited to a roundtable with the Greek Prime Minister [5]. | Strong government-led policies to improve corporate reporting on corporate social responsibility |
4 Pathways Through Which Commercial Actors Influence Oral Health
The CDoH model describes the pathways through which commercial actors impact health and health equity [5]. It draws on the social determinants of health ‘rainbow’ model that positions an individual in the centre and shows how multiple levels of factors influence their health [4].
4.1 Level 6: Ill-Health and Health Inequities
In Australia, oral diseases are common. By the age of 5–6 years, one in three children has experienced tooth decay, and one in three 35–54 year olds has moderate or severe gum disease, increasing to one in two for those aged 55–74 years [3, 21]. There is a clear social gradient in caries experience for children across parental education, household income and other socio-economic indicators [3]. Likewise, dental visiting patterns have a strong social gradient, with adults living in areas of greatest socio-economic disadvantage, with long-term health conditions or in remote areas more likely to delay or not access dental care when needed [22]. First Nations children, those with lower household income or whose parents had lower levels of education or who lived in remote areas also had lower visiting rates [3].
4.2 Level 5: Final Routes to Health and Equity Impacts
Although the causes of oral diseases are multifactorial, they share common risk factors with other non-communicable diseases [9]. High sugar consumption is the key driver of dental caries [23, 24], periodontal disease is associated with tobacco and oral cancers are associated with both alcohol and tobacco. Australian children aged 14–18 years consumed 81.9 g/day added sugar, with sugar-sweetened beverages contributing nearly half (33.9 g) [25]. Limited access to dental services (see Healthcare below) compounds the harms arising from the consumption of tobacco, alcohol and sugary drinks.
4.3 Level 4: Environments
Across the life-course, people live and interact in environments (healthcare, neighbourhood, housing, supermarkets, aged care centres, schools and kindergarten) that are shaped by commercial influences that impact oral health and drive oral health inequities.
Healthcare: Lack of public funding for dental care is a barrier to access for many Australians. Dental services in Australia have the highest out-of-pocket costs across the health system, with individuals paying 80% of the cost of dental care compared with only 23% of referred medical services and 16% of unreferred medical services [26]. Although bulk billing rates are generally high (> 95%) utilisation is uneven across states (from 44% of eligible children in South Australia to only 16% in the Northern Territory) [27].
Information: Alcohol and sugary drinks are extensively marketed and widely available in Australia, with a range of targeted and innovative marketing strategies using social media and more recently artificial intelligence [28, 29]. Sports are part of the cultural fabric of Australia. While tobacco sponsorship is now banned, alcohol, fast food and sugary drink companies are major advertisers of professional sports, emotively linking brands with beloved cultural icons. This unhealthy advertising and sponsorship drive high purchase and consumption of sugary foods and drinks and alcohol [30]. Despite strict tobacco control measures, rates of youth smoking in Australia increased in 2023 for the first time in a decade.
Social media is driving patient demand for aesthetic/cosmetic dentistry [31]. While dental practitioners are key actors in the prevention and treatment for oral health diseases, dentistry is increasingly focussing on aesthetics and cosmetics due to higher profit margins. For this reason, the dental industry is investing in innovation and technology to advance cosmetic and restorative dentistry at the expense of prevention.
Physical: In the same way that corporations have altered the physical environment to maximise sales to make them more obesogenic and alcohogenic, these same influences are increasing the risk of oral diseases [5]. The physical environment is crowded with marketing that promotes alcohol, sugary drinks and fast food. At the same time, in many communities there is limited access to free drinking water as a healthy alternative.
4.4 Level 3: Sectoral Public Policies
Economic: Australia has the strongest tobacco control measures in the world, but is lagging in implementing measures to reduce high sugar consumption. Despite a growing body of evidence on the effectiveness of SSB taxes globally, advocacy for a tax on SSBs in Australia has been impeded by the influence of the food, beverage and sugar industries, resulting in opposition from the major political parties and resistance to regulation [32].
Health: Water fluoridation has been one of the most successful and important public oral health policies in Australia since it was first implemented in 1956. However, there is an increasing number of local councils ceasing water fluoridation because of the cost and the perceived lack of benefit promoted by anti-fluoridation groups [33]. The Queensland state government in 2012 devolved responsibility for water fluoridation decisions and funding to local councils, resulting in residents living in lower socio-economic areas having less access to fluoridated water than those in more advantaged areas, exacerbating their already greater risk of dental disease.
Research: Oral health research in Australia is poorly funded. Only 0.23% of government research funding is allocated to oral diseases despite them contributing to 4.7% of total health expenditure [34]. There is often an emphasis in dental research on treatment modalities (e.g., new dental materials or technologies to treat disease), and more recently on commercialisation of research outcomes. This can skew the allocation of research funding from prevention to more technology-focused treatment, reinforcing the influence of commercial actors.
4.5 Levels 2: Regulatory Approaches and Upstream Policies
Deregulation of the university sector combined with a lack of government funding has seen an explosion in the cost of dental education (up to $400,000 AUD). This exacerbates the private model of service provision and the ongoing maldistribution of the dental workforce, with students from rural backgrounds less likely to study dentistry and dental graduates with increasing study debt less likely to work in lower-paid roles in the public sector.
4.6 Levels 1: Political and Economic System
There is little evidence that privatisation of previously public services improves outcomes or lowers costs [5]. Conversely, private healthcare providers have always dominated the provision of dental services, and dental services have been excluded from the universal health funding scheme since the 1970s, which could have reduced barriers to access to dental services. The fight to expand funding to improve access to treatment services has allowed focus to drift from the important work on prevention, with oral health reduced to oral health care.
5 Oral Health Is More Than Just Seeing a Dentist
Many of the commercial drivers of poor health effectively externalise the costs of their harm, predominantly to states, families and individuals [5]. Ironically (perhaps), states have then externalised these costs to families and individuals and particularly those from lower income groups, by both preferentially subsidising access to dental care for predominantly higher income groups through private health insurance rebates and under-funding public dental services.
In Australia, oral health initiatives are largely about making it easier for someone to visit a dentist. While this is important, we have not truly begun to consider the commercial forces that drive oral health diseases in the first place, such as exposure to harmful commercial products or privatisation of public services.
Using the CDoH framework we have highlighted the role of structural factors, operating outside an individual's control, that are responsible for the high prevalence of and persistent inequities in oral diseases at a population-level. Although oral health is often framed as an individual responsibility by both governments and commercial actors, the fact remains that good oral health is a human right, and government bodies are obligated to ensure the good oral health of the population. Potential actions could include monitoring and benchmarking of commercial practices against best practice evidence, government-led regulations that restrict marketing harmful practices, mobilise community to raise dental practitioners and consumers awareness on the health impacts of commercial products and practices. It is incumbent on dental practitioners to understand this emerging field if they are truly to engage with prevention. It is also a function of professional responsibility to act not only at the individual patient level, but also to advocate at the societal level for government legislation to protect against harmful commercial practices (e.g., marketing regulations). These upstream prevention efforts are essential to ensure that profits are not made at the expense of oral health and health equity. This can only be achieved by first understanding their role and influence.
Author Contributions
All authors contributed to the conceptualisation and writing.
Acknowledgement
Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians.
Conflicts of Interest
Matt Hopcraft is formerly the CEO of the Australian Dental Association Victorian Branch 2017–2023. Adyya Gupta is a recipient of a fellowship from the Victorian Health Promotion Foundation 2023–26. Jennifer Lacy-Nichols is a recipient of a fellowship from the Victorian Health Promotion Foundation 2022–25. She was contracted by the Georges Institute of Global Health to draft a report commissioned by the World Health Organisation on commercial determinants of health. She is a member of the Public Health Association of Australia, Transparency International Australia and Healthy Food Systems Australia and was a member of the expert advisory group on commercial determinants of health for WHO (2022–24). Her partner is a data analyst for a company which partners with pharmaceutical retailers and suppliers. Ankur Singh has received an Australian Research Council DECRA award.
Open Research
Data Availability Statement
The authors have nothing to report.
