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Editorial

Population ageing and the implications for oral health in Africa

A myriad of oral health challenges presently confront the elderly population in Africa. Reports from the continent have found oral health impairment and poor oral hygiene to be more common in older adults and that many elderly people perceive oral health to be less important when compared with their general physical health14. In fact, the attention given to the oral health needs of the older people has been grossly inadequate, especially considering the changing demographic prole on this continent, with its enormous welfare and cost implications. The elderly population in Africa, like elsewhere, constitutes a substantial proportion of the general population, and it is increasing very rapidly. More than one-tenth (11.9%) of the African population are older than 60 years and this will continue to escalate with the increasing life expectancy in Africa from the current 50 years or so to about 65 years by 20505. Only about onefth (20.6%) of the earths 810 million persons aged 60 years or over are from developed regions6, and about one-tenth (10.6%) of these (i.e. about 215 million) live in Africa. Moreover, whilst ageing populations are expanding rapidly everywhere, they seem to be expanding even more rapidly in less-developed regions6. For example, between 2012 and 2050, current estimates suggest that this age-group will increase by about 260% in East, Middle, Northern and Western Africa, and about 150% in Southern Africa. Unfortunately, most African governments have been preoccupied with other concerns and have not given their ageing populations the serious considerations they deserve; nor are they adequately prepared to meet the emerging challenges. There are, for example, very few preventive oral healthcare programmes for elders compared with other agegroups on the continent. When compared to previous generations, older Africans today are better educated, more aware of health needs, more hopeful of retaining their natural teeth and seek care that includes where possible sophisticated restorative procedures, aesthetic dentistry and implants7. However, whilst most countries in North America, Europe and Asia provide social supports for their elderly populations, there are few statutory social insurance and retirement programmes in Africa. Social

insurance programs in most African countries do not have universal coverage, and they are often available only to government employees who constitute a very small proportion of the population and very few elderly persons draw pensions from government. Indeed, most people have to keep working to pay for the ever-rising cost of food, housing, transportation and healthcare. Payment for dental services is still based on fee-forservice in most African countries and where health insurance exists, it usually does not cover most oral health-related services. The family which has traditionally been the major source of support for most elderly Africans is going through a very rapid transformation, and its ability to support elderly members is fast diminishing. The African extended family system with its statutory role of caregiving to elderly members is now substantially altered and weakened by social change, driven by migration, urbanisation and industrialisation. The African family is no longer in a position to full the economic, cultural, and social functions for which it was previously renowned. There is also reluctance to use residential nursing homes because of a widespread belief that residents lose their respect and self-esteem. Strategically planned governmental, societal and professional efforts are therefore needed to complement family caregiving. Feminization of the aged, when combined with a poorer social and economic status for women, has been identied as a major issue in African geriatrics8. This may present a challenging trend in planning oral health-services for older people. Health insurance programmes, for example, may have to be gender sensitive by taking into consideration the special needs of elderly women. HIV/AIDS poses a very major challenge to most African societies, and the oral manifestations of this infection offer dental personnel an important role in its prevention and management. Of the estimated 33.3 million adults with HIV/AIDS at the end of 2009, an estimated 22.5 million (67.6%) were in sub-Saharan Africa9. However, most of the attention to HIV/AIDS on the continent has focused on youth, commercial sex workers and pregnant women, although there have been recent attempts to extend our attention to include elderly population8.
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2013 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2013; 30: 12

E. O. Ogunbodede Eyitope O. Ogunbodede1,2 Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, 02115, USA 2 Department of Preventive and Community Dentistry,Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria

Most societies see the loss of teeth or edentulousness as a veritable sign of ageing, akin to grey hair. Hence, the African aphorism only those that are not old enough to lose their teeth need to cover their gapped teeth. A report from Nigeria noted poor oral hygiene amongst elderly people and a preference generally for traditional oral cleansing methods1, although there is little information about the effectiveness of these methods. In Africa, a greater percentage of the populations reside in rural communities, whereas dentists and dental facilities are concentrated in urban settings10. This is due to resource constraints on the part of governments and also to the greater nancial and professionally rewards for private dental practice in urban locations. Poverty amongst elders complicates their access to care even further and especially in rural areas. The imbalance and maldistribution may be ameliorated by integrating oral healthcare into the Primary Health Care services which currently constitute the anchor and basis for the national health policies of most African countries11. The current situation of neglect for the aged portends grave danger for the continent. There is an urgent need to introduce focused policies that will strengthen both the formal and informal welfare systems and improve oral health access. The oral health needs of elders should be a shared responsibility between the governments, not-for-prot non-governmental organizations and the business communities as partners. Such arrangements should also include persons who may be chronologically young but biologically old because they are medically compromised or developmentally disabled7. It is unfortunate that no reliable data currently exist for the population of this latter group on the continent. Geriatrics is not yet a major component of the curriculum of dental schools in Africa. It has been reported that, even in the advanced countries of Europe and North America, there are signicant perceived barriers to teaching geriatric dentistry and that these have remained the same in the last three decades7. One major obstacle is the paucity of trained faculty to teach the discipline. African dental schools must rise up to this challenge and join the global initiative aimed at improving research, teaching and services in gerodontology.

References
1. Fajemilehin BR, Ogunbodede EO. Oral health behaviour among the elderly in Osun state, Nigeria. J Soc Sci 2002; 6: 15. 2. Ojofeitimi EO, Adedigba MA, Ogunbodede EO, Fajemilehin BR, Adegbehingbe BO. Oral health and the elderly in Nigeria: a case for oral health promotion. Gerodontology 2007; 24: 231234. 3. Owotade FJ, Ogunbodede EO, Lawal AA. Oral diseases in the elderly, a study in Ile-Ife, Nigeria. J Soc Sci 2005; 7: 200205. 4. Kiyak HA. Oral health promotion and psychological well-being among older people. In: Schou L ed. Oral Health Promotion in Old Age. Edinburgh, UK: The Scottish Health Education Group, 1987: 3344. 5. United Nations. World population to 2300 New York: United Nations Department of Economic and Social Affairs/Population Division, 2004: 193194. 6. United Nations. Population ageing and development 2012. Population Division, Department of Economic and Social Affairs United Nations, New York, NY 10017, USA. http://www.un.org/esa/population/ publications/2012/WorldPopAgeing (last accessed 24 December 2012). 7. Ettinger RL. Meeting oral health needs to promote the well-being of the geriatric population: educational research issues. J Dent Educ 2010; 74(1): 29 35. 8. Darkwa OK, Mazibuko FNM. Population aging and its impact on elderly welfare in Africa. Int J Aging Hum Dev 2002; 54(2): 107123. 9. UNAIDS. UNAIDS report on the global AIDS epidemic 2010. http://www.unaids.org/globalreport/ (last accessed 24 December 2012). 10. Thorpe S. Oral health issues in the African region: current situation and future perspectives. J Dent Educ 2006; 70: 815. 11. WHO. Implementation of the regional oral health strategy: update and way forward. Report of the Regional Director. WHO Regional Committee for Africa. Fifty-eighth session Yaounde, Republic of Cameroon, 1-5 September 2008. Provisional Agenda item 7.7. AFR/RC58/9. 24 June 2008. 6 pp.

2013 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2013; 30: 12