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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 1-5

Gender and oral health in Africa


1 Department of Surgery and Maxillofacial Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State University, Abraka, Nigeria
2 Department of Periodontics, University of Benin, Benin City, Edo State, Nigeria

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Clement C Azodo
Room 21, 2nd Floor, Prof. A.O. Ejide Dental Complex, University of Benin Teaching Hospital, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_9_18

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  Abstract 


Oral health constitutes an important part of general health. Caries and periodontal disease are the most common dental diseases globally. In Africa, the challenges of cancrum oris, acute necrotizing gingivitis, oral cancer, oral manifestations of HIV/AIDS, and maxillofacial trauma are also common especially among the low-socioeconomic communities. Gender is one variable that contributes to oral health status globally. Other variables include race and ethnicity, socioeconomic status, attitude to dentistry, level of education, and cultural values. There is an interplay between these variables and they can increase or diminish the effect gender has on oral health. Gender-based health inequities are apparent in early childhood and even in adulthood. Many families provide better nutrition for boys in the interest of maximizing future productivity given that boys are generally seen as breadwinners. The unfortunate practice of son preference, which occurs worldwide in different levels of severity, often leads young girls being neglected and therefore more likely to develop poor oral health, which is then left untreated. Good oral health has been associated with positive oral health beliefs and stability of beliefs. Women tend to have better and more stable oral health beliefs. This may contribute largely to why women have better oral health in modern society. Gender influence on oral health status is appreciable especially in an economically challenged region of Africa. For optimum oral health, efforts should be geared toward appropriate health care reforms, education of female children, elimination of gender discrimination, and implementation of oral health policies.

Keywords: Africa, gender, oral health


How to cite this article:
Etetafia O M, Azodo CC. Gender and oral health in Africa. Indian J Oral Health Res 2019;5:1-5

How to cite this URL:
Etetafia O M, Azodo CC. Gender and oral health in Africa. Indian J Oral Health Res [serial online] 2019 [cited 2019 Oct 18];5:1-5. Available from: http://www.ijohr.org/text.asp?2019/5/1/1/261154




  Introduction Top


The World Health Organization (WHO) recognizes oral health as an integral part of general health. Oral health used to be defined simply as the absence of disease but now the new definition by FDI World Dental Federation is “the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex,” This definition became necessary to convey oral health as a fundamental human right.[1] The oral cavity is usually referred to as the gateway to the whole body. This is one reason why diseases affecting the oral region can spread to the general body if unattended to and the oral cavity could be the first to manifest a general disease conditions. Furthermore, oral diseases and conditions, including oral cancer, oral manifestations of HIV/AIDS, dental trauma, craniofacial anomalies, and cancrum oris, all have broad impacts on oral health and well-being. Oral health and general health share common risk factors related to diet, the use of tobacco, and the excessive consumption of alcohol and the solutions to control oral disease are to be found through shared approaches with integrated chronic disease prevention.[2] In women, tooth loss has largely been associated with aging, menstruation, pregnancy, menopausal status, and living alone whereas in men, tooth loss and higher periodontal scores have been associated with age, smoking, and educational levels.[3] Women play a paramount role in promoting health (oral health inclusive) and well-being even though this role is not well recognized and promoted in the African region. This paper seeks to review the various aspects of oral health where gender and sex play a predominant role in the African region.


  Oral Health and Quality of Life Top


Oral health is fundamental to the ability to breathe, eat, swallow, speak, or even smile. Impairment of these functions can seriously interfere with the ability to interact with others, attend school, and work.[4] Oral diseases directly affect the quality of life by having a serious impact on an individual's well-being and ability to fulfill desired socioeconomic functions. An unhealthy mouth leads to mandatory food selection to prevent aggravation of an existing ache. In some cases, unilateral mastication becomes a habit while some others go for foods with softer texture. Some general health diseases manifest in the mouth, and oral lesions may be the first signs of other life-threatening diseases such as HIV/AIDS. The oral health of an individual can be an indicator of the personality and value system of the individual. Poor oral health may lead to tooth loss and impair the systemic health of an individual. It may also impact on one's self-image,[4] employment opportunities, and earnings.[5],[6]


  Oral Disease Pattern in Africa Top


The profile of oral disease is not homogenous across Africa, with health indicators varying among countries and across different groups within the countries.[7]

Caries and periodontal disease are the two common oral disease conditions considered to be global. In Africa, the trend is similar; however, the economic status tends to lower the incidence of these conditions compared to the developed countries.

The prevalence of oral cancer is also on the increase in Africa. In developing countries, the incidence of oral and pharyngeal cancer is estimated to be 25 cases per 100,000 inhabitants. Rapid urbanization and the increasing use of tobacco and alcohol are considered to greatly increase the incidence of oral precancer.[8] The highest prevalence of infections by HIV/AIDS is found in Africa.[9] Fungal infections, necrotizing gingivitis, and oral hairy leukoplakia are widespread. A study[8] in South Africa showed that 74.4% of HIV-infected patients presented with one or more oral mucosal lesions.

Trauma to the maxillofacial region has increased in many countries as a result of interpersonal violence, community clashes, road traffic accidents, boat accidents, bomb blasts, assaults, and various levels of war. Some harmful practices, such as the removal of tooth germs of deciduous canines, extraction of upper and lower anterior teeth, and the trimming or sharpening of upper anterior teeth, still prevail in Africa.[10] Access to oral health services in many countries in Africa is limited and the few available services are costly and not within the reach of the general populace. Teeth are often left untreated or are extracted to relieve pain or discomfort. This is reflected in the components of the Decayed, missing, and filled Teeth index as shown for some countries.[11] Tooth/teeth loss with ageing is still considered by many a natural process. Many still prefer the option of tooth removal to alleviate pain instead of conservative options. There is low awareness of the consequences of tooth loss. Some countries in Africa have, in recent years, experienced an increase in tooth loss among adults; the proportion of edentulous adults aged 65 years varied between 6% in Gambia and[12]-25% in Madagascar.[11]

The diagnosis and treatment of craniofacial anomalies such as cleft lip and cleft palate still present a number of challenges to public health. Orofacial clefts occur in around 1 per 500–700 births and the rates vary substantially across ethnic groups and geographical areas.[13] It appear to be environment-related as a higher maternal risk for orofacial cleft has been reported to be associated with the mother's use of tobacco, and alcohol and overall nutritional level.[13] The African region still faces the challenge of lack of recent, reliable and comparable data and there is absence of processes for converting the data into information for planning.[9] The dentist to population ratio in Africa is approximately 1:150,000 and significant proportions of children and adults have never seen a dentist.[11]


  The Impact of Gender on Different Aspects of Oral Health and Oral Diseases Top


Gender and socioeconomic status and oral health

Being poor at any point during childhood, even if an individual later experienced an increase in socioeconomic status, was related to worse oral health.[14] It is worthy of note that good dentition promotes positive social interactions, while poor dentition promotes the opposite, in addition to causing stress and depression in the individual with poor dentition.[15]

Gender influence on oral health

Gender is an expression of behavior and lifestyle choices. Gender and sex can both be considered as sources and components of health disparity. Both contribute to men and women's susceptibility to various health conditions including cardiovascular disease and autoimmune disorders.[16] Gender-based health inequities are apparent in early childhood and even in adults. Many families provide better nutrition for boys in the interest of maximizing future productivity given that boys are generally seen as breadwinners.[17] In the overview of women's health, WHO stated that “Gender inequity, poverty among women, weak economic capacity, sexual and gender-based violence including female genital mutilation are major impediments to the amelioration of women's health in the African region.[18] Due to social (gender) and biological (sex) differences, women and men experience different health risks, health-seeking behaviors, health outcomes, and responses from health systems”.[18] For instance, in non-Western regions, males tend to have a health advantage over women due to gender discrimination, evidenced by infanticide, early marriage, and domestic abuse for females.[19] The unfortunate practice of son preference, which occurs worldwide in different levels of severity, often lead young girls to be neglected and therefore more likely to develop poor oral health, which is then left untreated.[20] Some nonbiological factors such as behavioral, social, cultural, and economic variables influence oral health,[21] and these issues also pertain to women, who often make less money than men and often have socially and culturally defined roles.

Gender difference in tooth eruption

Tooth erupting is the process of movement of the tooth from the jaw bone into the oral cavity. It occurs in succession as the child grows up. At age 6 months, the lower primary incisor tooth has erupted and 2 ½ years all the milk teeth have erupted into the mouth. By the age of 6 years, the permanent teeth have started to erupt, and at age 21, all the permanent teeth are in the mouth. There may be slight variation in the timing of eruption. Considering gender, it has been discovered that in girls every permanent tooth erupts earlier than in boys and that occurred in all groups.[22] This explains one reason why girls have a higher rate of caries than boys; that girls teeth emerge earlier, and are therefore exposed to cariogenic environments for longer periods of time than boy's permanent teeth.[22]

Adolescence oral health challenges

Adolescence is a life stage characterized by the onset of puberty, triggered by hormonal changes in an individual, which typically occurs earlier in girls. The individual is undergoing many psychological, hormonal, physiological changes in addition to learning to be more independent, manage emotions, and handle excess energy.[23] Adolescents are particularly at risk for certain oral health concerns including shift in the type of dental caries they develop, high-carbohydrate and high-sugar diets, increased independent snaking on sugary foods and drinks, development of periodontal disease (acerbated by hormonal changes, smoking, alcohol consumption, and certain sexually transmitted infections), structural/functional/esthetic problems from teeth placement or temporomandibular disorders (TMDs), third molar emergence issues, oral and systemic manifestations of eating disorders (including anorexia nervosa, bulimia nervosa, and the female athlete triad), and increased potential for accidental dental trauma.[23]

Gender influence on adolescence oral health

Girls are at an increased risk to develop certain oral health complications (ulcers, swollen salivary glands, gingivitis and increased plaque formation, and oral herpes sores) because starting in adolescence they experience monthly menses.[24] Athletic activities are common in adolescence, which may have a profound impact on their oral health, for both boys and girls. It is generally found that girls suffer more accidental dental trauma than boys during athletic activity; the male-to-female ratio of traumatic dental injury is about 1.0:1.5.[23] The kind of disordered eating found among girls (anorexia nervosa, bulimia nervosa, and the female athlete triad) can be accompanied by unhealthy weight management methods including dieting, fasting, vomiting, use of diet pills, diuretics, and laxatives.[23] This has a negative impact on both general and oral health. Oral health-related problem resulting from disordered eating include erosion of the teeth on the side closest to the tongue, decreased tooth height, chipped teeth, erosion of fillings/release of fillings in treated teeth, traumatized oral mucous membranes and pharynx, dry lips, xerostomia (dry mouth), fluid imbalance, burning tongue sensation, decreased salivary flow, and enlarged parotid glands.[25]

Gender influence on oral health beliefs in young adults

Young men and women have different beliefs regarding oral health, with women tending to have more favorable, accurate, and stable beliefs pertaining to dentistry.[26] It has also been found that individuals with more stable and favorable oral health beliefs have fewer missing teeth (due to caries), less periodontal disease, greater oral hygiene, greater self-rated oral health, and a greater number of restoration while those with less favorable oral health beliefs have poorer oral health.[26]

Gender influence on attitude to oral health

Gender has an influence on the attitude of individuals to oral health. People with negative attitudes toward dentistry only seek oral treatment when a problem has established itself, contrasting with the observation that dentistry is best at promoting oral health when used primarily as a preventive measure.[27] A study discovered that young adult females had better knowledge of oral health, better attitudes toward oral health, healthier lifestyles, and better oral health behaviors than the males.[28] In particular, women brush their teeth, use addition cleaning devices, and visit the dentist more frequently than their age-matched male counterparts.[28] As a result of their knowledge, health and attitude, girls had lower dental plaque, calculus, and gingivitis in the young adult stage. The explanations that best fitted the sex differences include the idea that as follows

  • Since the social role of women often have them being responsible for the health of their families, women are more likely to be knowledgeable and have a better attitude toward maintaining health
  • Females are more interested in health than males and that this interest is related to women's increased knowledge in this field.[28] It is interesting that men have higher rates of gingivitis than females because females have a predisposition to gingival infection due to female sex hormones and less intense immune response, indicating how important a good oral environment is to good oral health, regardless of biological predispositions. Another study indicated that women's biological predisposition to developing caries is strongly mitigated by new dental behaviors indicated by women's higher use of preventive dental behavior than men.[29] In a rural population in South Africa, even with less scientific methods of cleaning the teeth, females appeared to pay more attention to plaque control than the males resulting in better oral hygiene in the females.[30]


Gender and age effect on oral health

The hormonal changes in the male and female as the individual gets older has influence on the oral health. It has been discovered that disparity in oral health increases between the genders as a population ages, which may relate to the combination of hormones, pregnancy, dieting, morning sickness during pregnancy and other social factors applied to women.[20] Moreover, androgens, such as testosterone, are not associated with dental caries rates, showing that male sex hormones do not have an obvious effect on oral health while female sex hormones antagonize oral health.[31]

Oral health challenges in pregnancy

The body changes drastically during pregnancy including significant changes in the circulatory system, respiratory system, gastrointestinal system, musculoskeletal system, and endocrine system; there are also changes in how substances affect the body, such as alcohol, tobacco, and medications.[32] The most common complications associated with these changes are nausea, vomiting (which was early established to be detrimental to oral health and aid in caries formation), congestion, heartburn, changes in food cravings, shortness of breath, and fatigue.[32] Gingivitis (inflammation of the gum), is extremely prevalent during pregnancy and is believed to be caused by the fluctuations of progesterone and estrogen, changes in oral bacteria, and decreased immune response during pregnancy.[33] These fluctuations also affect the periodontium (the bone and ligaments supporting the teeth) in such a way that makes the teeth lose, even in the absence of gum disease.[33] During pregnancy, the periodontium can become inflamed (Periodontitis) in a similar manner to pregnancy gingivitis. Periodontitis occurs when bacterial toxins create chronic inflammation of the periodontium, which is broken down, destroyed, and infected, eventually loosening the teeth.[33] Untreated periodontitis in pregnancy can induce bacteremia, which triggers a hepatic acute response, which results in the production and release of cytokines, prostaglandins, and interleukins, a cascade pathway that can initiate premature labor.[33] Periodontitis can also cause the release of substances that can lead to low birth weight by restricting blood flow through the placenta and causing necrosis of the placenta leading to intrauterine growth restriction.[34] Pregnancy oral tumors are also found in the oral cavity of pregnant women. These are vascular lesions caused by the increase in progesterone, local irritants (such as plaque and calculus) and bacterial interactions.

Oral health challenges in menopause

Menopause, which is associated with a decrease in estrogen levels at the end of a woman's reproductive years, may lead to the following oral changes which include; increased oral pain and discomfort, burning sensation, mucosal atrophy, osteoporosis, reduction in the bone holding the teeth in place, systematic tooth loss, and increased, irreversible periodontitis.[25] Saliva is the principal defense force in the oral cavity. A reduction in saliva and reduced salivary flow induced by menopause leaves the oral cavity more susceptible to attack by infectious agents.[35] The combined effect of these challenges associated with menopause could have negative impact on oral health.

Gender influence on some common oral diseases

Tooth decay (dental caries)

At young adult age, the female saliva flows at a lower rate than in males. This leads to less clearance of foreign material deposited on teeth, and the chemical composition of saliva in women changes during pregnancy to be less able to destroy microbes and less able to buffer against the ingested material.[36],[37] Researchers have also found that changes during pregnancy in food cravings, aversions, and “morning sickness,” while beneficial to the offspring may combine to make the environment of the mouth more susceptible to dental caries.[38] Overall, it can be considered that many caries risk factors such as different salivary composition, hormonal fluctuations, dietary habits, genetic variations, social roles among the family, provide a gender bias placing women at a higher caries risk than men.[20] This is supported by the large sex differences in the observed number of filled teeth in young women compared to young men.[39]

Periodontal disease

The male sex is considered as one of the risk factors for periodontal disease.[40] Other risk factors include poor oral hygiene, rural residence, low socioeconomic status, alcohol consumption, and smoking.

Temporomandibular disorder

Gender is considered as the biggest risk factor in the development of TMD.[41] It is more common in adult females than adult males in a ratio of between 3:1–9:1; hence, the finding that TMD is more common in adolescent girls seems plausible.[42] The explanation for this sex differences in TMD could be because of something related to the female hormonal axis and that general pain in women increases with progress through the changes associated with puberty, which would also exacerbate pain related to TMD.[43]


  Conclusion Top


Gender influence on oral health status is appreciable especially in an economically challenged region of Africa. For optimum oral health, efforts should be geared toward appropriate health care reforms, education of female children, elimination of gender discrimination, and prompt implementation of oral health policies. Given women's crucial role in the attainment of optimum oral health, their opinion should be considered in the planning process of oral health policies and in the implementation of such policies. In addition, oral health should be incorporated into primary healthcare to emphasize oral health as a fundamental human right.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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