Oral Health as a Neglected Public Health Priority: A Scoping Review of Systemic Barriers to Oral Health Integration in Low- and Middle-Income Countries

Oral Health as a Neglected Public Health Priority: A Scoping Review of Systemic Barriers to Oral Health Integration in Low- and Middle-Income Countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Oral Health as a Neglected Public Health Priority: A Scoping Review of Systemic Barriers to Oral Health Integration in Low- and Middle-Income Countries Jema Kiazolu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9671286/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Oral diseases constitute one of the most prevalent yet persistently neglected non-communicable disease (NCD) burdens globally, disproportionately affecting populations in low- and middle-income countries (LMICs). Despite substantial epidemiological evidence demonstrating their public health significance, oral health remains insufficiently integrated within national health strategies, universal health coverage (UHC) benefit packages, and global health financing frameworks in many LMICs. Objective This scoping review examined the structural, governance, financing, and institutional barriers contributing to the marginalization of oral health within LMIC public health agendas and explored policy approaches for improving integration within primary healthcare and UHC systems. Methods This study employed a scoping review methodology guided by the Arksey and O’Malley framework and reported in accordance with PRISMA-ScR guidelines. Literature searches were conducted across PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar for studies published between 2004 and 2026. Eligible sources included peer-reviewed studies, policy analyses, reviews, and global health reports addressing oral health governance, financing, workforce, surveillance, and policy integration in LMIC contexts. A thematic narrative synthesis approach was used to analyze the findings. Results Thirty-two sources met the inclusion criteria. The review identified several interconnected barriers contributing to oral health neglect, including weak governance and political prioritization, exclusion of oral healthcare from publicly financed health systems, workforce maldistribution, inadequate surveillance systems, institutional separation of dentistry from public health, limited integration within global health financing architecture, and persistent social and structural inequalities affecting access to care. These barriers collectively reinforce the continued marginalization of oral health within LMIC health systems. Conclusion The persistent neglect of oral health in LMICs reflects broader structural and policy failures rather than a lack of epidemiological evidence. Strengthening oral health integration requires coordinated reforms involving UHC inclusion, financing expansion, workforce development, surveillance strengthening, and integration within broader NCD and public health frameworks. Greater political commitment and multisectoral collaboration are essential for advancing oral health equity in LMIC settings. Health Policy oral health policy universal health coverage public health systems low- and middle-income countries health governance oral health inequalities scoping review non-communicable diseases Figures Figure 1 I. INTRODUCTION Oral diseases affect an estimated 3.5 billion people globally, making them among the most prevalent health conditions affecting humanity (GBD 2021 Oral Disorders Collaborators, 2025 ). Untreated dental caries alone affects approximately 2.5 billion individuals with permanent dentition and over 530 million children with primary dentition worldwide (World Health Organization, 2024 ). Periodontal disease, edentulism, and oral cancers add further to this substantial burden, which is concentrated in populations experiencing socioeconomic disadvantage and, critically, in low- and middle-income countries (LMICs) where health system capacities are most constrained (Peres et al., 2019 ; Qin et al., 2022 ). Yet despite this epidemiological reality, oral health occupies a peculiar position within global and national public health: extensively documented in clinical and research literature, yet systematically absent from the policy decisions, financing allocations, and health system designs that determine who receives care and when. Across most LMICs, oral health is excluded from universal health coverage benefit packages, omitted from national NCD strategies, absent from health information systems, and marginalized within global health financing architectures (Winkelmann et al., 2023 ; Watt et al., 2019 ). The result is a self-reinforcing cycle of neglect in which absence of data justifies absence of policy, which perpetuates absence of investment, which sustains absence of care. This constitutes a profound public health governance failure. The consequences are not merely clinical but social and economic: untreated oral disease reduces workforce productivity, impairs child learning and development, generates catastrophic out-of-pocket health expenditure for low-income households, and contributes to systemic health complications that burden broader health systems (National Academies of Sciences, Engineering, and Medicine, 2021 ; Freire dos Santos et al., 2025 ). The failure to integrate oral health into public health agendas is, therefore, not a technical oversight but a political and structural choice that perpetuates preventable suffering with measurable societal costs. Importantly, this gap has been identified but inadequately analyzed. The existing literature robustly documents oral health inequalities and social determinants, yet research specifically examining why oral health remains deprioritized at the policy and governance level — and what structural changes are required to reverse this neglect — is sparse. This policy analysis scoping review addresses this gap by mapping the barriers to oral health integration in LMIC national public health agendas, synthesizing available policy evidence, and proposing a multilevel framework for systemic change. II. THEORETICAL BACKGROUND This review is grounded in political economy frameworks applied to global health, health systems science, and the social determinants of health paradigm. Understanding why oral health is deprioritized in LMIC public health agendas requires engagement with theories of health policy formation, governance, and institutional change that go beyond epidemiological framing. The World Health Organization’s Commission on Social Determinants of Health (Solar & Irwin, 2010 ) positions health outcomes as products of political, economic, and social structures that determine how resources, power, and opportunities are distributed within societies. Applied to oral health policy, this framework directs attention to the structural conditions — governance arrangements, financing mechanisms, professional power distributions, and political economy forces — that determine whether oral health receives policy attention and public investment. From this perspective, the neglect of oral health in LMIC national agendas is not a technical knowledge problem but a governance and power problem. Bambra et al.’s ( 2011 ) political economy of health framework further illuminates how ideological commitments to cost-containment, market-based healthcare, and disease-specific vertical programming systematically disadvantage oral health, which is perceived as a ‘discretionary’ or ‘elective’ health need rather than an essential public health priority. This perception is reinforced by the historical development of dentistry as a market-oriented private profession operating outside public health systems in most countries, creating institutional path dependencies that resist integration (Freeman et al., 2020 ). The concept of ‘issue salience’ in health policy analysis (Reich, 1994 ) is particularly relevant for understanding oral health neglect. Policy issues gain traction when they possess high political visibility, organized advocacy constituencies, measurable outcome indicators linked to political accountability, and alignment with dominant policy paradigms. Oral health lacks all of these features in most LMIC contexts: it has low political visibility, a fragmented professional advocacy constituency with limited public health orientation, absent from routine surveillance systems and SDG monitoring, and disconnected from the disease-specific vertical programs that dominate global health financing (Watt et al., 2019 ; Winkelmann et al., 2023 ). Kingdon’s ( 1984 ) multiple streams framework — which posits that policy change occurs when problem, policy, and political streams converge to create a ‘window of opportunity’ — provides a useful heuristic for understanding both the persistence of oral health neglect and the conditions under which change may be possible. This review analyses the barriers that keep these streams from converging for oral health in LMIC contexts and examines what policy entrepreneurs and institutional actors would need to do to open such a window. III. METHODOLOGY Study Design This study employed a scoping review design with a policy analysis orientation to examine the systemic barriers preventing the integration of oral health into national public health agendas in low- and middle-income countries (LMICs). The review followed the methodological framework developed by Hilary Arksey and Lisa O’Malley and further refined by Danielle Levac et al., while reporting was guided by the PRISMA Extension for Scoping Reviews checklist. A scoping review methodology was considered appropriate because the research question spans multiple interdisciplinary domains, including oral health policy, health systems governance, public health financing, universal health coverage (UHC), and non-communicable disease (NCD) integration. The review aimed to map and synthesize the breadth of available evidence regarding structural and institutional barriers to oral health policy integration rather than evaluate the effectiveness of a single intervention or generate pooled quantitative estimates. In addition to evidence mapping, the review incorporated a policy analysis perspective to examine how governance structures, political economy dynamics, financing arrangements, and institutional priorities contribute to the persistent marginalization of oral health within LMIC public health systems. Search Strategy A comprehensive literature search was conducted across four electronic databases: PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar. The search was performed between January and March 2026 to identify literature examining oral health policy integration, health systems governance, financing, and public health prioritization in low- and middle-income country (LMIC) contexts. Search terms were developed iteratively based on the study objectives and relevant conceptual frameworks in oral health policy and global health governance. Keywords and Boolean operators included combinations of “oral health policy,” “oral health governance,” “oral health integration,” “oral health LMIC,” “oral health and universal health coverage,” “oral health and non-communicable diseases,” “health financing dentistry,” “oral health surveillance,” “primary healthcare oral health,” “oral health inequalities,” “oral health neglect developing countries,” and “health system barriers oral health.” Boolean operators (“AND,” “OR”) and database-specific search adaptations were applied to optimize retrieval sensitivity and relevance. In addition, reference lists of included studies, major review articles, and relevant global policy documents from the World Health Organization and other international organizations were manually screened to identify additional eligible sources not captured through the initial database search. The search strategy prioritized literature addressing governance, financing, workforce, surveillance, equity, and policy integration dimensions of oral health within public health systems, particularly in LMIC settings. Inclusion and Exclusion Criteria Studies and policy documents were included if they examined oral health policy, governance, financing, workforce development, surveillance systems, or health system integration within low- and middle-income country (LMIC) or global public health contexts. Eligible sources included peer-reviewed original studies, systematic reviews, scoping reviews, policy analyses, conceptual papers, and authoritative reports published by major international health organizations. To ensure contemporary policy relevance, only literature published in English between 2004 and 2026 was considered. Studies were also required to address barriers, determinants, inequalities, or policy frameworks related to the integration of oral health into public health agendas, universal health coverage (UHC) systems, primary healthcare, or non-communicable disease (NCD) strategies. Studies were excluded if they focused exclusively on clinical treatment outcomes, laboratory-based dental research, or individual-level behavioral interventions without broader policy or health systems relevance. Literature limited solely to high-income country settings without transferable implications for LMIC health systems was also excluded. Editorials, opinion pieces lacking analytical or empirical grounding, conference abstracts, duplicate publications, and non-English sources were excluded from the final synthesis. Study Selection and Data Synthesis All retrieved records were exported and screened for duplication prior to the review process. Title and abstract screening was conducted to assess relevance based on the predefined inclusion and exclusion criteria. Articles considered potentially eligible underwent full-text review to determine final inclusion. Sources that did not sufficiently address oral health policy integration, governance, financing, workforce, surveillance, or public health system barriers were excluded during the eligibility assessment stage. Following full-text screening, 32 sources met the inclusion criteria and were included in the final synthesis. Data from included studies were extracted using a standardized data extraction framework capturing key study characteristics, including author, year of publication, geographic setting, study design, policy domains examined, major barriers identified, and proposed recommendations for oral health integration. The extraction process also documented themes related to governance structures, political economy dynamics, universal health coverage (UHC), health financing, workforce distribution, surveillance systems, and institutional integration. A thematic narrative synthesis approach, informed by the methods described by James Thomas and Angela Harden, was used to organize findings into major structural and policy domains. Given the heterogeneity of the included literature, quantitative meta-analysis was not appropriate. Instead, findings were synthesized descriptively to identify recurring patterns, systemic barriers, and policy implications related to the integration of oral health into LMIC public health agendas. The study selection process was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Records identified through database searching and additional sources underwent screening, eligibility assessment, and final inclusion based on the predefined criteria. A PRISMA flow diagram summarizing the study selection process is presented in Fig. 1 . Ethical Considerations Ethical approval was not required for this study because it involved the review and synthesis of publicly available literature and did not include primary data collection involving human participants. All included sources were appropriately cited and referenced in accordance with academic standards for scholarly reporting. IV. RESULTS The literature search identified studies and policy documents examining the governance, financing, workforce, surveillance, and institutional dimensions of oral health integration within public health systems. Following screening and eligibility assessment, 32 sources were included in the final synthesis. The included literature comprised systematic reviews, scoping reviews, policy analyses, conceptual papers, burden of disease studies, and global health reports addressing oral health inequalities, universal health coverage (UHC), health system governance, and non-communicable disease (NCD) integration in low- and middle-income country (LMIC) contexts. The findings were synthesized thematically into major domains reflecting the structural and policy barriers contributing to the persistent marginalization of oral health within national public health agendas. 4.1 Global Policy Frameworks and Oral Health: Persistent Gaps The global policy architecture for health provides the institutional environment within which national oral health priorities are shaped and implemented. Analysis of major international health frameworks demonstrates that oral health has historically received limited operational integration despite increasing recognition of its public health significance. Although oral health is referenced within several global health strategies, its inclusion has often remained largely rhetorical, with limited incorporation into financing structures, accountability systems, universal health coverage (UHC) packages, and national implementation frameworks in many low- and middle-income countries (LMICs). Table 1 summarizes the relationship between major global health policy frameworks and oral health integration. Table 1. Global Health Policy Frameworks and Their Relationship to Oral Health Integration Policy Framework Core Principles Relevance to Oral Health Integration Primary Health Care (PHC) Approach (Alma-Ata, 1978) Universal, equitable, community-based essential healthcare Oral health historically remained peripheral to PHC implementation and service delivery WHO Action Plan for Oral Health 2016–2025 Prevention-oriented and equity-focused oral health integration Limited implementation in LMICs due to financing, governance, and workforce constraints Universal Health Coverage (UHC) Framework Financial protection and equitable access to essential services Dental services frequently excluded from national UHC benefit packages WHO Global Action Plan for NCDs 2013–2030 Integrated prevention using shared risk factor approaches Oral diseases acknowledged conceptually but weakly integrated into national NCD strategies Sustainable Development Goals (SDGs) 2030 Health equity, well-being, and reduced inequalities Oral health lacks dedicated indicators within SDG monitoring systems The World Health Organization Action Plan for Oral Health 2016–2025 acknowledged the need for integrated, prevention-oriented oral health systems and emphasized stronger intersectoral collaboration. However, implementation across many low- and middle-income countries (LMICs) has remained constrained by insufficient financing, weak accountability mechanisms, limited political prioritization, and inadequate institutional capacity for integration within broader health system reforms. The inclusion of oral health within the WHO Global Action Plan for Non-Communicable Diseases (NCDs) 2013–2030 represented an important conceptual shift by positioning oral diseases within the shared risk factor framework alongside cardiovascular disease, diabetes, chronic respiratory diseases, and other NCDs. Nevertheless, evidence suggests that this recognition has rarely translated into substantial budget allocations, service integration, or sustained national-level implementation in many LMIC settings (Peres et al., 2019). A particularly significant limitation within global health governance is the absence of dedicated oral health indicators within the Sustainable Development Goals (SDGs) monitoring framework. This omission contributes to the institutional invisibility of oral health within national reporting and accountability systems that guide health priority-setting and financing decisions. Without measurable SDG-linked indicators, oral health lacks the political leverage and international reporting obligations that have facilitated the integration of other global health priorities into LMIC national health agendas (Foláyan et al., 2025). 4.2 Health Financing Exclusions and Fiscal Invisibility The exclusion of oral healthcare from publicly funded health financing systems represents one of the most significant structural barriers to oral health integration in LMIC public health systems. In many low- and middle-income countries, dental services remain heavily dependent on out-of-pocket expenditure, making oral healthcare financially inaccessible for large segments of the population, particularly low-income and rural communities that experience the highest burden of untreated oral disease (Winkelmann et al., 2023; Proano et al., 2024). As a result, oral health inequalities are reinforced through financing arrangements that prioritize acute and curative medical services while marginalizing preventive and essential oral healthcare within national health budgets and universal health coverage (UHC) benefit packages. The political economy of health financing further compounds this exclusion. Ministries of health in resource-constrained settings frequently face competing priorities and limited fiscal space, requiring difficult decisions regarding which services are included within publicly financed healthcare systems. Oral health often receives low prioritization because it is commonly perceived as a specialized or elective service rather than an essential component of public health and primary healthcare. The absence of robust oral health surveillance data, limited advocacy capacity, and the historical separation of dentistry from mainstream public health systems further weaken the ability of oral health programs to compete for national funding allocations (Watt et al., 2019; Singh et al., 2022). Amaral et al. (2025) demonstrated through analyses from the Global Burden of Disease Study that national variations in untreated dental caries are strongly associated with broader structural and socioeconomic indicators, including the Human Development Index, income inequality, and access to essential health services. These findings suggest that the unequal distribution of oral disease is shaped not only by individual behaviors or biological factors, but also by systemic inequities embedded within national health financing and social protection systems. Evidence from countries that have incorporated oral health services into publicly funded primary healthcare and universal health coverage (UHC) frameworks further indicates that financing integration can contribute to improved access, earlier prevention, and reductions in oral health inequalities. 4.3 The Evidence Base and Included Studies The studies included in this review reflect a multidisciplinary evidence base spanning global health policy, oral epidemiology, public health governance, health systems research, and health equity analysis. The literature consisted of systematic reviews, scoping reviews, conceptual papers, burden of disease analyses, and policy-oriented studies examining the structural determinants of oral health inequalities and the barriers to integrating oral health within national public health systems. Collectively, these studies provide evidence that oral health neglect in LMICs is closely linked to governance failures, financing exclusions, workforce inequities, weak surveillance systems, and the broader marginalization of oral health within global health architecture. Table 2 summarizes the key evidence sources included in the review and their relevance to oral health policy integration. Table 2. Summary of Key Evidence Sources and Policy Relevance Author/Year Geographic Scope Study Type Key Policy-Relevant Findings GBD Oral Disorders Collaborators (2025) Global Systematic burden analysis Oral diseases remain among the world’s most prevalent conditions, with disproportionately high burden in LMICs Peres et al. (2019) Global Review article Oral diseases represent a major public health challenge requiring structural policy responses Watt et al. (2019) Global Policy review Oral health neglect reflects governance failures, financing gaps, and institutional silos Winkelmann et al. (2023) Global Policy analysis Universal health coverage cannot be fully achieved without oral health inclusion Schwendicke et al. (2015) Multiple countries Systematic review and meta-analysis Socioeconomic inequalities strongly influence untreated dental caries burden Northridge et al. (2020) United States Review article Structural barriers to oral healthcare persist despite insurance expansion Amaral et al. (2025) Global Burden analysis Structural socioeconomic indicators predict inequalities in untreated dental caries Qin et al. (2022) Global Systematic analysis Absolute burden of untreated dental caries continues to rise in many LMICs Stennett et al. (2026) Global Scoping review Upstream oral health interventions remain underimplemented due to policy neglect Freeman et al. (2020) Global Conceptual paper Existing oral health systems structurally exclude vulnerable populations Foláyan et al. (2025) Global Scoping review Oral health inequalities intersect with broader SDG equity and development challenges Lai et al. (2025) Global Public health analysis Commercial and social determinants contribute to unequal oral disease burdens Singh et al. (2022) Developing countries Scoping review Oral health inequalities in developing countries are driven by governance and workforce barriers 4.4 Structural Barriers to Oral Health Policy Integration Beyond financing exclusions, the findings of this review demonstrate that the marginalization of oral health within LMIC public health systems is driven by multiple interconnected structural barriers operating across governance, workforce, surveillance, institutional, and community levels. These barriers interact in ways that reinforce the continued exclusion of oral health from national policy priorities, universal health coverage (UHC) frameworks, and public health system planning. Table 3 summarizes the major structural barrier domains, their manifestations within LMIC settings, and the supporting evidence identified in the literature. Table 3. Structural Barriers to Oral Health Integration in LMIC Public Health Agendas Barrier Domain Manifestations in LMIC Contexts Key Supporting Evidence Governance and Political Economy Limited policy prioritization, weak advocacy capacity, and exclusion of oral health from national strategic plans Watt et al. (2019); Peres et al. (2019) Health Financing Dependence on out-of-pocket payments and exclusion of dental services from publicly funded benefit packages Winkelmann et al. (2023); Proano et al. (2024) Workforce Maldistribution Concentration of dental professionals in urban private sectors and shortages in rural areas Ogunbodede et al. (2015); Singh et al. (2022) Health Information Systems Limited oral health surveillance data and weak integration into national health information systems Amaral et al. (2025); GBD Oral Disorders Collaborators (2025) Professional and Institutional Silos Separation of dentistry from primary healthcare and public health systems Freeman et al. (2020); Tsakos et al. (2023) Global Health Architecture Limited inclusion of oral health within major global health financing and development initiatives Watt et al. (2019); Winkelmann et al. (2023) Community and Demand-Side Barriers Low oral health literacy, financial constraints, stigma, and competing social priorities El-Yousfi et al. (2019); Vaishampayan et al. (2025) Governance and Political Economy Oral health governance in many low- and middle-income countries (LMICs) is characterized by limited political prioritization, fragmented institutional leadership, and weak advocacy capacity within national health systems. Where oral health programs exist, they are often positioned within small dental divisions of ministries of health with limited authority, staffing, and financial resources. This institutional marginalization reduces the ability of oral health programs to influence broader national health planning, financing decisions, and universal health coverage (UHC) reforms. In addition, the historical organization of dentistry as a predominantly curative and privately oriented profession has limited its integration within public health systems and population-based prevention strategies (Freeman et al., 2020; Watt et al., 2019). The shared risk factor framework provides an important policy opportunity for improving oral health integration within broader non-communicable disease (NCD) strategies. Oral diseases share several upstream determinants with other major NCDs, including tobacco use, excessive sugar consumption, alcohol use, and socioeconomic disadvantage. Evidence demonstrating consistent socioeconomic gradients in untreated dental caries and periodontal disease supports the argument that oral health inequalities are structurally linked to broader social and economic inequities rather than solely to individual behaviors. Despite this alignment, oral health remains insufficiently incorporated into many national NCD prevention and health promotion programs in LMIC settings (Schwendicke et al., 2015). Health Information Systems and Surveillance Deficits Weak oral health surveillance systems represent a major structural barrier to evidence-informed policymaking and resource allocation in many LMICs. Oral health indicators are frequently absent from national health information systems, routine health surveys, and disease surveillance platforms, resulting in limited availability of reliable population-level data on oral disease burden, treatment access, and oral health inequalities. In many countries, dental conditions are inconsistently recorded within hospital and primary healthcare reporting systems, further contributing to the underrepresentation of oral health within national health statistics and planning processes (GBD Oral Disorders Collaborators, 2025; Qin et al., 2022). The absence of robust surveillance data creates a self-reinforcing cycle of policy neglect. Without reliable epidemiological and financing data, oral health is less likely to be incorporated into national burden of disease estimates, priority-setting frameworks, and health budget allocations. In turn, limited political attention and financing reduce investment in oral health surveillance infrastructure and research capacity. Strengthening the integration of oral health indicators into national health information systems, demographic health surveys, and universal health coverage (UHC) monitoring frameworks is therefore essential for improving visibility, accountability, and evidence-based policy development in LMIC settings (Amaral et al., 2025). Workforce Maldistribution The distribution of the oral health workforce in many low- and middle-income countries (LMICs) remains highly unequal, with dental professionals concentrated primarily in urban and privately operated healthcare settings. Rural, remote, and socioeconomically disadvantaged populations frequently experience severe shortages of oral health personnel, limiting access to preventive, diagnostic, and restorative dental services. In several regions, particularly sub-Saharan Africa and parts of South and Southeast Asia, dentist-to-population ratios remain critically low relative to population needs, contributing to substantial geographic disparities in oral healthcare access (Ogunbodede et al., 2015; Singh et al., 2022). The dominance of dentist-centered service delivery models further constrains the scalability of oral healthcare within resource-limited health systems. Evidence increasingly supports the expansion of mid-level oral health worker cadres, including dental therapists, oral health therapists, and community-based oral health workers, as cost-effective strategies for extending preventive and basic oral healthcare services to underserved populations. However, implementation of these workforce models has faced resistance in some settings due to regulatory limitations, professional protectionism, and inadequate policy support. Integrating oral health promotion, screening, and preventive education into existing community health worker and primary healthcare programs may provide a more feasible pathway for improving population-level access to essential oral healthcare services in LMIC contexts. 4.5 Oral Health in Global Health Architecture: Financing Marginalization A critical yet frequently underexamined dimension of oral health policy neglect is its limited integration within the broader global health financing and development architecture that shapes health system priorities in many LMICs. Major international health financing mechanisms and development initiatives have historically prioritized communicable diseases, maternal and child health, immunization, and other high-visibility global health concerns, while oral health has remained comparatively marginalized within funding agendas, technical assistance programs, and international health partnerships. Large global financing initiatives, including programs focused on HIV/AIDS, tuberculosis, malaria, and immunization, have provided limited direct support for oral health system strengthening or preventive dental services in LMIC settings (Watt et al., 2019). This marginalization within global health architecture has important downstream consequences for LMIC health systems. Limited international financing and technical support reduce the visibility of oral health within national policy agendas and constrain opportunities for workforce development, implementation research, surveillance strengthening, and integration into primary healthcare reforms. In addition, the commercial determinants of oral health, including the influence of sugar industries, unhealthy food marketing, and broader economic interests linked to dietary transitions, further complicate efforts to advance prevention-oriented oral health policies. These structural dynamics contribute to the continued under prioritization of oral health within both global and national public health systems (Lai et al., 2025). V. DISCUSSION This policy-oriented scoping review demonstrates that the persistent marginalization of oral health within LMIC public health systems is driven less by a lack of epidemiological evidence than by structural governance failures, financing exclusions, institutional fragmentation, and broader political economy dynamics that limit the integration of oral health into national health priorities. The findings reveal that oral health neglect is reinforced through interconnected barriers operating across financing systems, workforce distribution, surveillance infrastructure, policy governance, and global health architecture. Collectively, these barriers contribute to the continued exclusion of oral health from universal health coverage (UHC) reforms, national non-communicable disease (NCD) strategies, and broader public health planning processes. The review further highlights that oral health policy neglect functions as a self-reinforcing cycle. Weak surveillance systems limit the visibility of oral disease burden within national health data, reducing policy attention and financing allocations. Limited financing and institutional prioritization subsequently constrain workforce expansion, preventive programming, and research investment, which further perpetuates weak integration within health systems. Addressing these structural dynamics therefore requires coordinated multisectoral reforms rather than isolated technical interventions focused solely on clinical service delivery. The governance analysis also suggests that oral health experiences what may be described as a “multiple invisibilities” problem within many LMIC health systems. Oral health is frequently underrepresented in national health accounts, surveillance systems, NCD strategic plans, UHC benefit packages, and SDG monitoring frameworks. These overlapping forms of institutional invisibility reinforce one another and contribute to a cycle in which the absence of data limits policy prioritization, while limited policy attention reduces investment in oral health systems and surveillance infrastructure. The political economy dimensions of oral health neglect are equally important. The historical development of dentistry as a predominantly private and curative profession, rather than a population-based public health service, has contributed to institutional arrangements that limit integration within publicly funded primary healthcare systems. Similar challenges have been observed in other historically marginalized areas of healthcare, including mental health, where institutional separation, financing constraints, and limited political salience have historically impeded integration into primary healthcare reforms (Freeman et al., 2020; Tsakos et al., 2023). The shared risk factor framework provides an important opportunity for strengthening oral health integration within broader NCD prevention strategies. Oral diseases share common upstream determinants with several major NCDs, including tobacco use, unhealthy diets, excessive sugar consumption, alcohol use, and socioeconomic disadvantage. Positioning oral health within integrated NCD prevention frameworks may therefore provide stronger political and institutional pathways for policy integration than isolated disease-specific advocacy approaches (Watt et al., 2019). Finally, the findings underscore the importance of adopting a life-course and equity-oriented perspective in oral health policymaking. Evidence linking early childhood oral disease with impaired child development, educational outcomes, and long-term health trajectories suggests that oral health should be understood not only as a clinical issue but also as a broader social and developmental concern. Framing oral health within child development, human capital, and health equity agendas may strengthen its policy relevance within LMIC public health systems and development planning processes (Stennett et al., 2026; Foláyan et al., 2025). 5.1 Limitations Several limitations should be considered when interpreting the findings of this review. First, the review included only English-language literature, which may have excluded relevant studies and policy documents published in other languages, particularly from non-English-speaking LMIC contexts. Second, the included sources were heterogeneous in design and scope, encompassing systematic reviews, scoping reviews, conceptual papers, policy analyses, and global health reports. While this diversity was appropriate for a scoping review, it limited direct comparability across studies and precluded quantitative synthesis. Third, because this study employed a scoping review methodology, formal critical appraisal and risk-of-bias assessment of included studies were not conducted. The objective of the review was to map and synthesize the breadth of evidence related to oral health policy integration rather than evaluate intervention effectiveness or establish causal relationships. Fourth, the review relied primarily on published and accessible literature, which may not fully capture informal political dynamics, unpublished policy processes, or context-specific governance challenges influencing oral health prioritization in LMIC settings. Finally, the rapidly evolving nature of global health policy and universal health coverage (UHC) reforms means that some country-level developments may not yet be fully represented in the available literature. Despite these limitations, the review provides a comprehensive synthesis of the major structural and policy barriers contributing to the continued marginalization of oral health within LMIC public health systems. VI. POLICY RECOMMENDATIONS The findings of this review indicate that addressing the persistent neglect of oral health within LMIC public health systems requires coordinated reforms across multiple levels of governance, financing, workforce development, surveillance, and service delivery. Because the barriers identified are interconnected and structurally embedded within health systems, isolated interventions are unlikely to achieve sustainable integration of oral health into national public health agendas. Instead, comprehensive and multisectoral approaches are needed to strengthen policy visibility, expand financial protection, improve workforce distribution, enhance surveillance systems, and integrate oral health within broader universal health coverage (UHC) and non-communicable disease (NCD) frameworks. Table 4 summarizes the major policy recommendations identified through the review and their expected public health implications. Table 4. Multilevel Policy Recommendations for Oral Health Integration in LMIC Public Health Agendas Intervention Level Recommended Action Target Barrier Expected Public Health Impact Global Governance Incorporate oral health indicators into SDG and UHC monitoring frameworks Policy invisibility Increased accountability and policy prioritization Global Governance Expand inclusion of oral health within global health financing initiatives Financing constraints Improved resource mobilization for LMIC oral health systems National Policy Include essential oral healthcare services within UHC benefit packages Coverage exclusion Reduced financial barriers and improved access to care National Policy Establish dedicated oral health budget lines within national health accounts Fiscal invisibility More sustainable oral health financing Health Systems Expand mid-level oral health workforce cadres and rural deployment incentives Workforce maldistribution Improved geographic access to preventive oral healthcare Health Systems Integrate oral health into primary healthcare and community health worker programs Institutional silos Greater service integration and prevention coverage Surveillance Systems Incorporate oral health indicators into national health information systems Data limitations Stronger evidence base for policy planning and monitoring Community-Level Interventions Implement school-based prevention programs and population-level oral health promotion strategies Demand-side barriers Reduced oral disease burden and improved oral health literacy 6.1 Global Governance Level At the global governance level, strengthening the visibility of oral health within international monitoring and accountability frameworks is essential for improving policy prioritization in LMICs. The absence of dedicated oral health indicators within Sustainable Development Goal (SDG) and universal health coverage (UHC) monitoring systems contributes to the continued institutional marginalization of oral health within national and global health agendas. Establishing measurable oral health indicators linked to international reporting mechanisms could improve accountability, strengthen advocacy efforts, and increase the integration of oral health within broader health system reforms and development planning processes (Foláyan et al., 2025). Greater integration of oral health within global health financing mechanisms and international development initiatives is also necessary. External financing and technical support have played major roles in advancing health system strengthening efforts for communicable diseases, maternal and child health, and immunization programs in many LMICs. Expanding support for oral health system strengthening preventive services, workforce development, and surveillance infrastructure within international health financing initiatives could help reduce longstanding resource and implementation gaps affecting oral healthcare delivery in LMIC settings (Winkelmann et al., 2023). 6.2 National Policy Level At the national policy level, integrating essential oral healthcare services within universal health coverage (UHC) benefit packages represents a critical step toward reducing financial barriers and improving equitable access to oral healthcare. In many LMICs, reliance on out-of-pocket expenditure continues to limit access to preventive and restorative dental services, particularly among low-income and rural populations. Expanding publicly financed oral healthcare services within national health systems may contribute to earlier disease prevention, reduced treatment delays, and lower long-term health and economic burdens associated with untreated oral disease. Countries that have incorporated oral health services within publicly funded healthcare systems, including Thailand and Brazil, demonstrate that greater oral health integration within national health reforms is both feasible and potentially effective in improving access and equity (Watt et al., 2019). Strengthening national oral health governance also requires the inclusion of oral health indicators within national health surveys, health information systems, and strategic health planning frameworks. Dedicated oral health budget lines and improved integration of oral health within broader public health and non-communicable disease (NCD) strategies may help increase institutional visibility and support more sustainable financing mechanisms. In addition, cross-sector collaboration involving education systems, nutrition programs, community organizations, and primary healthcare services may strengthen prevention-oriented oral health policies and improve population-level oral health outcomes in LMIC settings. 6.3 Health System Level At the health system level, improving the distribution and capacity of the oral health workforce is essential for expanding equitable access to oral healthcare in LMIC settings. The expansion of mid-level oral health worker cadres, including dental therapists, oral health therapists, and community-based oral health workers, represents a potentially cost-effective strategy for addressing workforce shortages and extending preventive oral healthcare services to underserved populations. Targeted rural deployment incentives, workforce training reforms, and integration of oral health competencies within primary healthcare systems may further strengthen access to essential oral healthcare services in geographically marginalized communities (Singh et al., 2022). Integrating oral health promotion, screening, and preventive services within primary healthcare and community health worker programs may also improve early detection and population-level prevention efforts. School-based oral health programs, community fluoride interventions where feasible, and public oral health education initiatives can support prevention-oriented approaches that reduce dependence on costly curative dental services. Importantly, these interventions should be adapted to local social, cultural, and health system contexts to improve sustainability, community engagement, and long-term effectiveness in LMIC settings (Elwell et al., 2021; Stennett et al., 2026). VII. CONCLUSION This scoping review demonstrates that the persistent marginalization of oral health within LMIC public health systems is driven by interconnected governance failures, financing exclusions, workforce inequities, weak surveillance systems, and broader structural and political economy dynamics that limit the integration of oral health into national health agendas. Despite the substantial global burden of oral diseases and their well-established associations with social inequality, oral health continues to receive comparatively limited attention within universal health coverage (UHC) reforms, national public health planning, and international health financing frameworks. The findings suggest that oral health neglect is not primarily the result of insufficient epidemiological evidence, but rather the consequence of institutional and policy structures that systematically deprioritize oral health within broader health systems. Addressing these challenges requires multisectoral and equity-oriented approaches that integrate oral health within primary healthcare, non-communicable disease (NCD) prevention strategies, surveillance systems, and publicly financed health services. Strengthening oral health governance, improving workforce distribution, expanding preventive services, and increasing political visibility within national and global health agendas are critical for achieving more equitable oral health outcomes in LMIC settings. The review further highlights the importance of shifting oral health advocacy beyond narrow disease-specific approaches toward broader collaborations with health equity, child development, NCD prevention, and UHC reform initiatives. Positioning oral health as an essential component of public health and social development may strengthen its integration within national policy agendas and improve long-term sustainability of oral health reforms. Future research should continue to examine the political economy of oral health policy integration, evaluate cost-effective workforce and prevention strategies, and explore how social determinants and structural inequalities shape oral health outcomes across diverse LMIC contexts. Declarations Conflict of Interest: The author declares no conflicts of interest. Funding: This research received no specific funding from public, commercial, or not-for-profit funding agencies. Ethical Approval: Not applicable. This study involved no primary data collection from human participants. Data Availability: All data reviewed are available in the published literature cited in the reference list. References Aida J, Ando Y, Oosaka M, Niimi K, Morita M (2008) Contributions of social context to inequality in dental caries: A multilevel analysis of Japanese 3-year-old children. Commun Dent Oral Epidemiol 36(2):149–156 Amaral O, Fagundes M, Hugo F, Kassebaum N, Giordani J (2025) Structural determinants of inequalities in untreated dental caries in the Global Burden of Disease Study. PLoS ONE 20(5):e0325138. https://doi.org/10.1371/journal.pone.0325138 Arksey H, O’Malley L (2005) Scoping studies: Towards a methodological framework. Int J Soc Res Methodol 8(1):19–32 Bambra C, Fox D, Scott-Samuel A (2011) A politics of health glossary. J Epidemiol Community Health 59(1):67–70 Elwell K, Camplain C, Kirby C, Sanderson K, Grover G, Morrison G, Gelatt A, Baldwin J (2021) A formative assessment of social determinants of health related to early childhood caries in two American Indian communities. Int J Environ Res Public Health 18(18):9838. https://doi.org/10.3390/ijerph18189838 El-Yousfi S, Jones K, White S, Marshman Z (2019) A rapid review of barriers to oral healthcare for vulnerable people. Br Dent J 227:143–151 Foláyan MO, De Barros Coelho E, Feldens CA, Gaffar B, Virtanen JI, Abodunrin O et al (2025) A scoping review on early childhood caries and inequalities using the Sustainable Development Goal 10 framework. BMC Oral Health 25:5587. https://doi.org/10.1186/s12903-025-05587-1 Freeman R, Doughty J, Macdonald ME, Muirhead V (2020) Inclusion oral health: Advancing a theoretical framework for policy, research and practice. Commun Dent Oral Epidemiol 48(1):1–6 Freire dos Santos MC, Pereira JV, de Lima KC (2025) Systemic impacts of dental caries on the general health of adults: A literature review. Brazilian J Implantology Health Sci 7(1):88–101 GBD 2021 Oral Disorders Collaborators (2025) Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: A systematic analysis for the Global Burden of Disease Study 2021. Lancet 405(10482):897–910 Kassebaum NJ, Bernábe E, Dahiya M, Bhandari B, Murray CJL, Marcenes W (2015) Global burden of untreated caries. J Dent Res 94(5):650–658 Kingdon JW (1984) Agendas, alternatives, and public policies. Little, Brown and Company, Boston, MA Lai Y, Li Y, Liu X, Shi Y, Qu F, Zhang X, Shi B, Wang X, Sun T, Huang X, You D (2025) The impact of social and commercial determinants on the unequal increase of oral disorder disease burdens. BMC Oral Health 25 Article 6669. https://doi.org/10.1186/s12903-025-06669-w Levac D, Colquhoun H, O’Brien KK (2010) Scoping studies: Advancing the methodology. Implement Sci 5:69 National Academies of Sciences, Engineering, and Medicine (2021) The state of oral health in America: Advancing equity and well-being. National Academies, Washington, DC Northridge ME, Kumar A, Kaur R (2020) Disparities in access to oral health care. Annu Rev Public Health 41:513–535 Ogunbodede EO, Kida IA, Madjapa HS, Amedari M, Ehizele A, Mutave R, Sodipo B, Temilola S, Okoye L (2015) Oral health inequalities between rural and urban populations of the African and Middle East region. Adv Dent Res 27(1):18–25 Peres MA, Macpherson LMD, Weyant RJ, Daly B, Vaishampayan R, Mathur MR et al (2019) Oral diseases: A global public health challenge. Lancet 394(10194):249–260 Qin X, Zi H, Zeng X (2022) Changes in the global burden of untreated dental caries from 1990 to 2019. Heliyon 8:e10714 Reich MR (1994) The political economy of health transitions in the third world. In: Chen LC, Kleinman A, Ware NC (eds) Health and social change in international perspective. Harvard University Press, Cambridge, MA, pp 413–437 Schwendicke F, Dörfer CE, Schlattmann P, Foster Page L, Thomson WM, Paris S (2015) Socioeconomic inequality and caries: A systematic review and meta-analysis. J Dent Res 94(1):10–18 Singh A, Purohit BM, Masood M (2022) What makes inequality in the area of dental and oral health in developing countries? A scoping review. Int Dent J 72(4):437–448 Solar O, Irwin A (2010) A conceptual framework for action on the social determinants of health. World Health Organization, Geneva Stennett M, Dawson E, Hijryana M, Cannon P, Daly B, Macpherson L, Watt RG (2026) Upstream interventions to promote oral health and reduce oral health inequalities: A scoping review. Commun Dent Oral Epidemiol 54(2):146–162 Thomas J, Harden A (2008) Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 8:45 Tsakos G, Watt RG, Guarnizo-Herreño CC (2023) Reflections on oral health inequalities: Theories, pathways and next steps for research priorities. Community Dentistry and Oral Epidemiology Vaishampayan P, Beniwal JS, Wilk P, McLean S, Jessani A (2025) Unmet oral health needs and barriers to dental services among socially marginalized youth: A scoping review. Front Oral Health 6:1521753 Venturelli R, Blokland A, Tsakos G, Stennett M, Makhani S, Jones K, Watt R, Heilmann A (2025) Oral health inequalities concerning socially vulnerable population groups in the United Kingdom: A scoping review. Br Dent J. https://doi.org/10.1038/s41415-025-8916-8 Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R, Listl S et al (2019) Ending the neglect of global oral health: Time for radical action. Lancet 394(10194):261–272 Winkelmann J, Listl S, van Ginneken E, Vassallo P, Benzian H (2023) Universal health coverage cannot be universal without oral health. Lancet Public Health 8(1):e8–e10 World Health Organization (2024) Oral health fact sheet. World Health Organization, Geneva Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9671286","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":637697230,"identity":"d3d3e015-3200-4089-8add-0d86efa82ed2","order_by":0,"name":"Jema Kiazolu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3OvQrCMBDA8SsHZol0bRH7DCeOBX2VSsEuDoKLg0NBaEfXgk8hvkAhoEvBWVwEV4c8gXhaxK3NKJg/5GPIjwuAzfaDefja54AgUqcEPkEYEeKnsoSaYBuBmvAtMiR+jjetSQnXv1MJy3CSYvfaSHrYoUFBCv3tjEmVMBHUSAIEiiUTujBxMsWk0/yxAIVWLzI+V0weBqSHcrB+T/Ekk9SA+Gu5cApK0Kum8zI6JMOsjXin417rZRi7udpd9Srsb0TWTD7F7z3i1TLj28j0oc1ms/1hTwUUO9/7aKGcAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0004-9603-7111","institution":"Hasanuddin University","correspondingAuthor":true,"prefix":"","firstName":"Jema","middleName":"","lastName":"Kiazolu","suffix":""}],"badges":[],"createdAt":"2026-05-10 15:35:47","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9671286/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9671286/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109067230,"identity":"467a994c-329e-491d-a4b5-8c65344ad162","added_by":"auto","created_at":"2026-05-12 09:29:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53582,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA Flow Diagram of Study Selection Process\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSource: Adapted from PRISMA-ScR reporting guidelines.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9671286/v1/53d2f9b66a46a015f321f2b5.png"},{"id":109069368,"identity":"4d90a6d4-2b01-4a28-8481-8f617dd10551","added_by":"auto","created_at":"2026-05-12 10:22:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":343349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9671286/v1/f9a1d2aa-d487-4195-a43b-25c1fb9055e7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOral Health as a Neglected Public Health Priority: A Scoping Review of Systemic Barriers to Oral Health Integration in Low- and Middle-Income Countries\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"I. INTRODUCTION","content":"\u003cp\u003eOral diseases affect an estimated 3.5\u0026nbsp;billion people globally, making them among the most prevalent health conditions affecting humanity (GBD 2021 Oral Disorders Collaborators, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). Untreated dental caries alone affects approximately 2.5\u0026nbsp;billion individuals with permanent dentition and over 530\u0026nbsp;million children with primary dentition worldwide (World Health Organization, \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). Periodontal disease, edentulism, and oral cancers add further to this substantial burden, which is concentrated in populations experiencing socioeconomic disadvantage and, critically, in low- and middle-income countries (LMICs) where health system capacities are most constrained (Peres et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Qin et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eYet despite this epidemiological reality, oral health occupies a peculiar position within global and national public health: extensively documented in clinical and research literature, yet systematically absent from the policy decisions, financing allocations, and health system designs that determine who receives care and when. Across most LMICs, oral health is excluded from universal health coverage benefit packages, omitted from national NCD strategies, absent from health information systems, and marginalized within global health financing architectures (Winkelmann et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Watt et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). The result is a self-reinforcing cycle of neglect in which absence of data justifies absence of policy, which perpetuates absence of investment, which sustains absence of care.\u003c/p\u003e\u003cp\u003eThis constitutes a profound public health governance failure. The consequences are not merely clinical but social and economic: untreated oral disease reduces workforce productivity, impairs child learning and development, generates catastrophic out-of-pocket health expenditure for low-income households, and contributes to systemic health complications that burden broader health systems (National Academies of Sciences, Engineering, and Medicine, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Freire dos Santos et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). The failure to integrate oral health into public health agendas is, therefore, not a technical oversight but a political and structural choice that perpetuates preventable suffering with measurable societal costs.\u003c/p\u003e\u003cp\u003eImportantly, this gap has been identified but inadequately analyzed. The existing literature robustly documents oral health inequalities and social determinants, yet research specifically examining why oral health remains deprioritized at the policy and governance level — and what structural changes are required to reverse this neglect — is sparse. This policy analysis scoping review addresses this gap by mapping the barriers to oral health integration in LMIC national public health agendas, synthesizing available policy evidence, and proposing a multilevel framework for systemic change.\u003c/p\u003e"},{"header":"II. THEORETICAL BACKGROUND","content":"\u003cp\u003eThis review is grounded in political economy frameworks applied to global health, health systems science, and the social determinants of health paradigm. Understanding why oral health is deprioritized in LMIC public health agendas requires engagement with theories of health policy formation, governance, and institutional change that go beyond epidemiological framing.\u003c/p\u003e\u003cp\u003eThe World Health Organization’s Commission on Social Determinants of Health (Solar \u0026amp; Irwin, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e) positions health outcomes as products of political, economic, and social structures that determine how resources, power, and opportunities are distributed within societies. Applied to oral health policy, this framework directs attention to the structural conditions — governance arrangements, financing mechanisms, professional power distributions, and political economy forces — that determine whether oral health receives policy attention and public investment. From this perspective, the neglect of oral health in LMIC national agendas is not a technical knowledge problem but a governance and power problem.\u003c/p\u003e\u003cp\u003eBambra et al.’s (\u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e) political economy of health framework further illuminates how ideological commitments to cost-containment, market-based healthcare, and disease-specific vertical programming systematically disadvantage oral health, which is perceived as a ‘discretionary’ or ‘elective’ health need rather than an essential public health priority. This perception is reinforced by the historical development of dentistry as a market-oriented private profession operating outside public health systems in most countries, creating institutional path dependencies that resist integration (Freeman et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe concept of ‘issue salience’ in health policy analysis (Reich, \u003cspan class=\"CitationRef\"\u003e1994\u003c/span\u003e) is particularly relevant for understanding oral health neglect. Policy issues gain traction when they possess high political visibility, organized advocacy constituencies, measurable outcome indicators linked to political accountability, and alignment with dominant policy paradigms. Oral health lacks all of these features in most LMIC contexts: it has low political visibility, a fragmented professional advocacy constituency with limited public health orientation, absent from routine surveillance systems and SDG monitoring, and disconnected from the disease-specific vertical programs that dominate global health financing (Watt et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Winkelmann et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eKingdon’s (\u003cspan class=\"CitationRef\"\u003e1984\u003c/span\u003e) multiple streams framework — which posits that policy change occurs when problem, policy, and political streams converge to create a ‘window of opportunity’ — provides a useful heuristic for understanding both the persistence of oral health neglect and the conditions under which change may be possible. This review analyses the barriers that keep these streams from converging for oral health in LMIC contexts and examines what policy entrepreneurs and institutional actors would need to do to open such a window.\u003c/p\u003e"},{"header":"III. METHODOLOGY","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study employed a scoping review design with a policy analysis orientation to examine the systemic barriers preventing the integration of oral health into national public health agendas in low- and middle-income countries (LMICs). The review followed the methodological framework developed by Hilary Arksey and Lisa O’Malley and further refined by Danielle Levac et al., while reporting was guided by the PRISMA Extension for Scoping Reviews checklist.\u003c/p\u003e\u003cp\u003eA scoping review methodology was considered appropriate because the research question spans multiple interdisciplinary domains, including oral health policy, health systems governance, public health financing, universal health coverage (UHC), and non-communicable disease (NCD) integration. The review aimed to map and synthesize the breadth of available evidence regarding structural and institutional barriers to oral health policy integration rather than evaluate the effectiveness of a single intervention or generate pooled quantitative estimates.\u003c/p\u003e\u003cp\u003eIn addition to evidence mapping, the review incorporated a policy analysis perspective to examine how governance structures, political economy dynamics, financing arrangements, and institutional priorities contribute to the persistent marginalization of oral health within LMIC public health systems.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSearch Strategy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA comprehensive literature search was conducted across four electronic databases: PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar. The search was performed between January and March 2026 to identify literature examining oral health policy integration, health systems governance, financing, and public health prioritization in low- and middle-income country (LMIC) contexts. Search terms were developed iteratively based on the study objectives and relevant conceptual frameworks in oral health policy and global health governance. Keywords and Boolean operators included combinations of “oral health policy,” “oral health governance,” “oral health integration,” “oral health LMIC,” “oral health and universal health coverage,” “oral health and non-communicable diseases,” “health financing dentistry,” “oral health surveillance,” “primary healthcare oral health,” “oral health inequalities,” “oral health neglect developing countries,” and “health system barriers oral health.” Boolean operators (“AND,” “OR”) and database-specific search adaptations were applied to optimize retrieval sensitivity and relevance. In addition, reference lists of included studies, major review articles, and relevant global policy documents from the World Health Organization and other international organizations were manually screened to identify additional eligible sources not captured through the initial database search. The search strategy prioritized literature addressing governance, financing, workforce, surveillance, equity, and policy integration dimensions of oral health within public health systems, particularly in LMIC settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion and Exclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudies and policy documents were included if they examined oral health policy, governance, financing, workforce development, surveillance systems, or health system integration within low- and middle-income country (LMIC) or global public health contexts. Eligible sources included peer-reviewed original studies, systematic reviews, scoping reviews, policy analyses, conceptual papers, and authoritative reports published by major international health organizations. To ensure contemporary policy relevance, only literature published in English between 2004 and 2026 was considered. Studies were also required to address barriers, determinants, inequalities, or policy frameworks related to the integration of oral health into public health agendas, universal health coverage (UHC) systems, primary healthcare, or non-communicable disease (NCD) strategies.\u003c/p\u003e\u003cp\u003eStudies were excluded if they focused exclusively on clinical treatment outcomes, laboratory-based dental research, or individual-level behavioral interventions without broader policy or health systems relevance. Literature limited solely to high-income country settings without transferable implications for LMIC health systems was also excluded. Editorials, opinion pieces lacking analytical or empirical grounding, conference abstracts, duplicate publications, and non-English sources were excluded from the final synthesis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Selection and Data Synthesis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll retrieved records were exported and screened for duplication prior to the review process. Title and abstract screening was conducted to assess relevance based on the predefined inclusion and exclusion criteria. Articles considered potentially eligible underwent full-text review to determine final inclusion. Sources that did not sufficiently address oral health policy integration, governance, financing, workforce, surveillance, or public health system barriers were excluded during the eligibility assessment stage.\u003c/p\u003e\u003cp\u003eFollowing full-text screening, 32 sources met the inclusion criteria and were included in the final synthesis. Data from included studies were extracted using a standardized data extraction framework capturing key study characteristics, including author, year of publication, geographic setting, study design, policy domains examined, major barriers identified, and proposed recommendations for oral health integration. The extraction process also documented themes related to governance structures, political economy dynamics, universal health coverage (UHC), health financing, workforce distribution, surveillance systems, and institutional integration.\u003c/p\u003e\u003cp\u003eA thematic narrative synthesis approach, informed by the methods described by James Thomas and Angela Harden, was used to organize findings into major structural and policy domains. Given the heterogeneity of the included literature, quantitative meta-analysis was not appropriate. Instead, findings were synthesized descriptively to identify recurring patterns, systemic barriers, and policy implications related to the integration of oral health into LMIC public health agendas.\u003c/p\u003e\u003cp\u003eThe study selection process was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Records identified through database searching and additional sources underwent screening, eligibility assessment, and final inclusion based on the predefined criteria. A PRISMA flow diagram summarizing the study selection process is presented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval was not required for this study because it involved the review and synthesis of publicly available literature and did not include primary data collection involving human participants. All included sources were appropriately cited and referenced in accordance with academic standards for scholarly reporting.\u003c/p\u003e"},{"header":"IV. RESULTS","content":"\u003cp\u003eThe literature search identified studies and policy documents examining the governance, financing, workforce, surveillance, and institutional dimensions of oral health integration within public health systems. Following screening and eligibility assessment, 32 sources were included in the final synthesis. The included literature comprised systematic reviews, scoping reviews, policy analyses, conceptual papers, burden of disease studies, and global health reports addressing oral health inequalities, universal health coverage (UHC), health system governance, and non-communicable disease (NCD) integration in low- and middle-income country (LMIC) contexts. The findings were synthesized thematically into major domains reflecting the structural and policy barriers contributing to the persistent marginalization of oral health within national public health agendas.\u003c/p\u003e\n\u003cp\u003e4.1 Global Policy Frameworks and Oral Health: Persistent Gaps\u003c/p\u003e\n\u003cp\u003eThe global policy architecture for health provides the institutional environment within which national oral health priorities are shaped and implemented. Analysis of major international health frameworks demonstrates that oral health has historically received limited operational integration despite increasing recognition of its public health significance. Although oral health is referenced within several global health strategies, its inclusion has often remained largely rhetorical, with limited incorporation into financing structures, accountability systems, universal health coverage (UHC) packages, and national implementation frameworks in many low- and middle-income countries (LMICs). Table 1 summarizes the relationship between major global health policy frameworks and oral health integration.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1. Global Health Policy Frameworks and Their Relationship to Oral Health Integration\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003ePolicy Framework\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003eCore Principles\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003eRelevance to Oral Health Integration\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003ePrimary Health Care (PHC) Approach (Alma-Ata, 1978)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eUniversal, equitable, community-based essential healthcare\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eOral health historically remained peripheral to PHC implementation and service delivery\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eWHO Action Plan for Oral Health 2016\u0026ndash;2025\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003ePrevention-oriented and equity-focused oral health integration\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eLimited implementation in LMICs due to financing, governance, and workforce constraints\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eUniversal Health Coverage (UHC) Framework\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eFinancial protection and equitable access to essential services\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eDental services frequently excluded from national UHC benefit packages\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eWHO Global Action Plan for NCDs 2013\u0026ndash;2030\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eIntegrated prevention using shared risk factor approaches\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eOral diseases acknowledged conceptually but weakly integrated into national NCD strategies\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eSustainable Development Goals (SDGs) 2030\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eHealth equity, well-being, and reduced inequalities\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eOral health lacks dedicated indicators within SDG monitoring systems\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe World Health Organization Action Plan for Oral Health 2016\u0026ndash;2025 acknowledged the need for integrated, prevention-oriented oral health systems and emphasized stronger intersectoral collaboration. However, implementation across many low- and middle-income countries (LMICs) has remained constrained by insufficient financing, weak accountability mechanisms, limited political prioritization, and inadequate institutional capacity for integration within broader health system reforms. The inclusion of oral health within the WHO Global Action Plan for Non-Communicable Diseases (NCDs) 2013\u0026ndash;2030 represented an important conceptual shift by positioning oral diseases within the shared risk factor framework alongside cardiovascular disease, diabetes, chronic respiratory diseases, and other NCDs. Nevertheless, evidence suggests that this recognition has rarely translated into substantial budget allocations, service integration, or sustained national-level implementation in many LMIC settings (Peres et al., 2019).\u003c/p\u003e\n\u003cp\u003eA particularly significant limitation within global health governance is the absence of dedicated oral health indicators within the Sustainable Development Goals (SDGs) monitoring framework. This omission contributes to the institutional invisibility of oral health within national reporting and accountability systems that guide health priority-setting and financing decisions. Without measurable SDG-linked indicators, oral health lacks the political leverage and international reporting obligations that have facilitated the integration of other global health priorities into LMIC national health agendas (Fol\u0026aacute;yan et al., 2025).\u003c/p\u003e\n\u003cp\u003e4.2 Health Financing Exclusions and Fiscal Invisibility\u003c/p\u003e\n\u003cp\u003eThe exclusion of oral healthcare from publicly funded health financing systems represents one of the most significant structural barriers to oral health integration in LMIC public health systems. In many low- and middle-income countries, dental services remain heavily dependent on out-of-pocket expenditure, making oral healthcare financially inaccessible for large segments of the population, particularly low-income and rural communities that experience the highest burden of untreated oral disease (Winkelmann et al., 2023; Proano et al., 2024). As a result, oral health inequalities are reinforced through financing arrangements that prioritize acute and curative medical services while marginalizing preventive and essential oral healthcare within national health budgets and universal health coverage (UHC) benefit packages.\u003c/p\u003e\n\u003cp\u003eThe political economy of health financing further compounds this exclusion. Ministries of health in resource-constrained settings frequently face competing priorities and limited fiscal space, requiring difficult decisions regarding which services are included within publicly financed healthcare systems. Oral health often receives low prioritization because it is commonly perceived as a specialized or elective service rather than an essential component of public health and primary healthcare. The absence of robust oral health surveillance data, limited advocacy capacity, and the historical separation of dentistry from mainstream public health systems further weaken the ability of oral health programs to compete for national funding allocations (Watt et al., 2019; Singh et al., 2022).\u003c/p\u003e\n\u003cp\u003eAmaral et al. (2025) demonstrated through analyses from the Global Burden of Disease Study that national variations in untreated dental caries are strongly associated with broader structural and socioeconomic indicators, including the Human Development Index, income inequality, and access to essential health services. These findings suggest that the unequal distribution of oral disease is shaped not only by individual behaviors or biological factors, but also by systemic inequities embedded within national health financing and social protection systems. Evidence from countries that have incorporated oral health services into publicly funded primary healthcare and universal health coverage (UHC) frameworks further indicates that financing integration can contribute to improved access, earlier prevention, and reductions in oral health inequalities.\u003c/p\u003e\n\u003cp\u003e4.3 The Evidence Base and Included Studies\u003c/p\u003e\n\u003cp\u003eThe studies included in this review reflect a multidisciplinary evidence base spanning global health policy, oral epidemiology, public health governance, health systems research, and health equity analysis. The literature consisted of systematic reviews, scoping reviews, conceptual papers, burden of disease analyses, and policy-oriented studies examining the structural determinants of oral health inequalities and the barriers to integrating oral health within national public health systems. Collectively, these studies provide evidence that oral health neglect in LMICs is closely linked to governance failures, financing exclusions, workforce inequities, weak surveillance systems, and the broader marginalization of oral health within global health architecture. Table 2 summarizes the key evidence sources included in the review and their relevance to oral health policy integration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2. Summary of Key Evidence Sources and Policy Relevance\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\u003cstrong\u003eAuthor/Year\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\u003cstrong\u003eGeographic Scope\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\u003cstrong\u003eStudy Type\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\u003cstrong\u003eKey Policy-Relevant Findings\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eGBD Oral Disorders Collaborators (2025)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eSystematic burden analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eOral diseases remain among the world\u0026rsquo;s most prevalent conditions, with disproportionately high burden in LMICs\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003ePeres et al. (2019)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eReview article\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eOral diseases represent a major public health challenge requiring structural policy responses\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eWatt et al. (2019)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003ePolicy review\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eOral health neglect reflects governance failures, financing gaps, and institutional silos\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eWinkelmann et al. (2023)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003ePolicy analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eUniversal health coverage cannot be fully achieved without oral health inclusion\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eSchwendicke et al. (2015)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eMultiple countries\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eSystematic review and meta-analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eSocioeconomic inequalities strongly influence untreated dental caries burden\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eNorthridge et al. (2020)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eUnited States\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eReview article\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eStructural barriers to oral healthcare persist despite insurance expansion\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eAmaral et al. (2025)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eBurden analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eStructural socioeconomic indicators predict inequalities in untreated dental caries\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eQin et al. (2022)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eSystematic analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eAbsolute burden of untreated dental caries continues to rise in many LMICs\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eStennett et al. (2026)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eScoping review\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eUpstream oral health interventions remain underimplemented due to policy neglect\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eFreeman et al. (2020)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eConceptual paper\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eExisting oral health systems structurally exclude vulnerable populations\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eFol\u0026aacute;yan et al. (2025)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eScoping review\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eOral health inequalities intersect with broader SDG equity and development challenges\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eLai et al. (2025)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eGlobal\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003ePublic health analysis\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eCommercial and social determinants contribute to unequal oral disease burdens\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003eSingh et al. (2022)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eDeveloping countries\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eScoping review\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003eOral health inequalities in developing countries are driven by governance and workforce barriers\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e4.4 Structural Barriers to Oral Health Policy Integration\u003c/p\u003e\n\u003cp\u003eBeyond financing exclusions, the findings of this review demonstrate that the marginalization of oral health within LMIC public health systems is driven by multiple interconnected structural barriers operating across governance, workforce, surveillance, institutional, and community levels. These barriers interact in ways that reinforce the continued exclusion of oral health from national policy priorities, universal health coverage (UHC) frameworks, and public health system planning. Table 3 summarizes the major structural barrier domains, their manifestations within LMIC settings, and the supporting evidence identified in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3. Structural Barriers to Oral Health Integration in LMIC Public Health Agendas\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003eBarrier Domain\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003eManifestations in LMIC Contexts\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cstrong\u003eKey Supporting Evidence\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eGovernance and Political Economy\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eLimited policy prioritization, weak advocacy capacity, and exclusion of oral health from national strategic plans\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eWatt et al. (2019); Peres et al. (2019)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eHealth Financing\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eDependence on out-of-pocket payments and exclusion of dental services from publicly funded benefit packages\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eWinkelmann et al. (2023); Proano et al. (2024)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eWorkforce Maldistribution\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eConcentration of dental professionals in urban private sectors and shortages in rural areas\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eOgunbodede et al. (2015); Singh et al. (2022)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eHealth Information Systems\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eLimited oral health surveillance data and weak integration into national health information systems\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eAmaral et al. (2025); GBD Oral Disorders Collaborators (2025)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eProfessional and Institutional Silos\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eSeparation of dentistry from primary healthcare and public health systems\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eFreeman et al. (2020); Tsakos et al. (2023)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eGlobal Health Architecture\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eLimited inclusion of oral health within major global health financing and development initiatives\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eWatt et al. (2019); Winkelmann et al. (2023)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003eCommunity and Demand-Side Barriers\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eLow oral health literacy, financial constraints, stigma, and competing social priorities\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003eEl-Yousfi et al. (2019); Vaishampayan et al. (2025)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGovernance and Political Economy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOral health governance in many low- and middle-income countries (LMICs) is characterized by limited political prioritization, fragmented institutional leadership, and weak advocacy capacity within national health systems. Where oral health programs exist, they are often positioned within small dental divisions of ministries of health with limited authority, staffing, and financial resources. This institutional marginalization reduces the ability of oral health programs to influence broader national health planning, financing decisions, and universal health coverage (UHC) reforms. In addition, the historical organization of dentistry as a predominantly curative and privately oriented profession has limited its integration within public health systems and population-based prevention strategies (Freeman et al., 2020; Watt et al., 2019).\u003c/p\u003e\n\u003cp\u003eThe shared risk factor framework provides an important policy opportunity for improving oral health integration within broader non-communicable disease (NCD) strategies. Oral diseases share several upstream determinants with other major NCDs, including tobacco use, excessive sugar consumption, alcohol use, and socioeconomic disadvantage. Evidence demonstrating consistent socioeconomic gradients in untreated dental caries and periodontal disease supports the argument that oral health inequalities are structurally linked to broader social and economic inequities rather than solely to individual behaviors. Despite this alignment, oral health remains insufficiently incorporated into many national NCD prevention and health promotion programs in LMIC settings (Schwendicke et al., 2015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth Information Systems and Surveillance Deficits\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWeak oral health surveillance systems represent a major structural barrier to evidence-informed policymaking and resource allocation in many LMICs. Oral health indicators are frequently absent from national health information systems, routine health surveys, and disease surveillance platforms, resulting in limited availability of reliable population-level data on oral disease burden, treatment access, and oral health inequalities. In many countries, dental conditions are inconsistently recorded within hospital and primary healthcare reporting systems, further contributing to the underrepresentation of oral health within national health statistics and planning processes (GBD Oral Disorders Collaborators, 2025; Qin et al., 2022).\u003c/p\u003e\n\u003cp\u003eThe absence of robust surveillance data creates a self-reinforcing cycle of policy neglect. Without reliable epidemiological and financing data, oral health is less likely to be incorporated into national burden of disease estimates, priority-setting frameworks, and health budget allocations. In turn, limited political attention and financing reduce investment in oral health surveillance infrastructure and research capacity. Strengthening the integration of oral health indicators into national health information systems, demographic health surveys, and universal health coverage (UHC) monitoring frameworks is therefore essential for improving visibility, accountability, and evidence-based policy development in LMIC settings (Amaral et al., 2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWorkforce Maldistribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe distribution of the oral health workforce in many low- and middle-income countries (LMICs) remains highly unequal, with dental professionals concentrated primarily in urban and privately operated healthcare settings. Rural, remote, and socioeconomically disadvantaged populations frequently experience severe shortages of oral health personnel, limiting access to preventive, diagnostic, and restorative dental services. In several regions, particularly sub-Saharan Africa and parts of South and Southeast Asia, dentist-to-population ratios remain critically low relative to population needs, contributing to substantial geographic disparities in oral healthcare access (Ogunbodede et al., 2015; Singh et al., 2022).\u003c/p\u003e\n\u003cp\u003eThe dominance of dentist-centered service delivery models further constrains the scalability of oral healthcare within resource-limited health systems. Evidence increasingly supports the expansion of mid-level oral health worker cadres, including dental therapists, oral health therapists, and community-based oral health workers, as cost-effective strategies for extending preventive and basic oral healthcare services to underserved populations. However, implementation of these workforce models has faced resistance in some settings due to regulatory limitations, professional protectionism, and inadequate policy support. Integrating oral health promotion, screening, and preventive education into existing community health worker and primary healthcare programs may provide a more feasible pathway for improving population-level access to essential oral healthcare services in LMIC contexts.\u003c/p\u003e\n\u003cp\u003e4.5 Oral Health in Global Health Architecture: Financing Marginalization\u003c/p\u003e\n\u003cp\u003eA critical yet frequently underexamined dimension of oral health policy neglect is its limited integration within the broader global health financing and development architecture that shapes health system priorities in many LMICs. Major international health financing mechanisms and development initiatives have historically prioritized communicable diseases, maternal and child health, immunization, and other high-visibility global health concerns, while oral health has remained comparatively marginalized within funding agendas, technical assistance programs, and international health partnerships. Large global financing initiatives, including programs focused on HIV/AIDS, tuberculosis, malaria, and immunization, have provided limited direct support for oral health system strengthening or preventive dental services in LMIC settings (Watt et al., 2019).\u003c/p\u003e\n\u003cp\u003eThis marginalization within global health architecture has important downstream consequences for LMIC health systems. Limited international financing and technical support reduce the visibility of oral health within national policy agendas and constrain opportunities for workforce development, implementation research, surveillance strengthening, and integration into primary healthcare reforms. In addition, the commercial determinants of oral health, including the influence of sugar industries, unhealthy food marketing, and broader economic interests linked to dietary transitions, further complicate efforts to advance prevention-oriented oral health policies. These structural dynamics contribute to the continued under prioritization of oral health within both global and national public health systems (Lai et al., 2025).\u003c/p\u003e"},{"header":"V. DISCUSSION","content":"\u003cp\u003eThis policy-oriented scoping review demonstrates that the persistent marginalization of oral health within LMIC public health systems is driven less by a lack of epidemiological evidence than by structural governance failures, financing exclusions, institutional fragmentation, and broader political economy dynamics that limit the integration of oral health into national health priorities. The findings reveal that oral health neglect is reinforced through interconnected barriers operating across financing systems, workforce distribution, surveillance infrastructure, policy governance, and global health architecture. Collectively, these barriers contribute to the continued exclusion of oral health from universal health coverage (UHC) reforms, national non-communicable disease (NCD) strategies, and broader public health planning processes.\u003c/p\u003e\n\u003cp\u003eThe review further highlights that oral health policy neglect functions as a self-reinforcing cycle. Weak surveillance systems limit the visibility of oral disease burden within national health data, reducing policy attention and financing allocations. Limited financing and institutional prioritization subsequently constrain workforce expansion, preventive programming, and research investment, which further perpetuates weak integration within health systems. Addressing these structural dynamics therefore requires coordinated multisectoral reforms rather than isolated technical interventions focused solely on clinical service delivery.\u003c/p\u003e\n\u003cp\u003eThe governance analysis also suggests that oral health experiences what may be described as a \u0026ldquo;multiple invisibilities\u0026rdquo; problem within many LMIC health systems. Oral health is frequently underrepresented in national health accounts, surveillance systems, NCD strategic plans, UHC benefit packages, and SDG monitoring frameworks. These overlapping forms of institutional invisibility reinforce one another and contribute to a cycle in which the absence of data limits policy prioritization, while limited policy attention reduces investment in oral health systems and surveillance infrastructure.\u003c/p\u003e\n\u003cp\u003eThe political economy dimensions of oral health neglect are equally important. The historical development of dentistry as a predominantly private and curative profession, rather than a population-based public health service, has contributed to institutional arrangements that limit integration within publicly funded primary healthcare systems. Similar challenges have been observed in other historically marginalized areas of healthcare, including mental health, where institutional separation, financing constraints, and limited political salience have historically impeded integration into primary healthcare reforms (Freeman et al., 2020; Tsakos et al., 2023).\u003c/p\u003e\n\u003cp\u003eThe shared risk factor framework provides an important opportunity for strengthening oral health integration within broader NCD prevention strategies. Oral diseases share common upstream determinants with several major NCDs, including tobacco use, unhealthy diets, excessive sugar consumption, alcohol use, and socioeconomic disadvantage. Positioning oral health within integrated NCD prevention frameworks may therefore provide stronger political and institutional pathways for policy integration than isolated disease-specific advocacy approaches (Watt et al., 2019).\u003c/p\u003e\n\u003cp\u003eFinally, the findings underscore the importance of adopting a life-course and equity-oriented perspective in oral health policymaking. Evidence linking early childhood oral disease with impaired child development, educational outcomes, and long-term health trajectories suggests that oral health should be understood not only as a clinical issue but also as a broader social and developmental concern. Framing oral health within child development, human capital, and health equity agendas may strengthen its policy relevance within LMIC public health systems and development planning processes (Stennett et al., 2026; Fol\u0026aacute;yan et al., 2025).\u003c/p\u003e\n\u003ch2\u003e5.1 Limitations\u003c/h2\u003e\n\u003cp\u003eSeveral limitations should be considered when interpreting the findings of this review. First, the review included only English-language literature, which may have excluded relevant studies and policy documents published in other languages, particularly from non-English-speaking LMIC contexts. Second, the included sources were heterogeneous in design and scope, encompassing systematic reviews, scoping reviews, conceptual papers, policy analyses, and global health reports. While this diversity was appropriate for a scoping review, it limited direct comparability across studies and precluded quantitative synthesis.\u003c/p\u003e\n\u003cp\u003eThird, because this study employed a scoping review methodology, formal critical appraisal and risk-of-bias assessment of included studies were not conducted. The objective of the review was to map and synthesize the breadth of evidence related to oral health policy integration rather than evaluate intervention effectiveness or establish causal relationships. Fourth, the review relied primarily on published and accessible literature, which may not fully capture informal political dynamics, unpublished policy processes, or context-specific governance challenges influencing oral health prioritization in LMIC settings.\u003c/p\u003e\n\u003cp\u003eFinally, the rapidly evolving nature of global health policy and universal health coverage (UHC) reforms means that some country-level developments may not yet be fully represented in the available literature. Despite these limitations, the review provides a comprehensive synthesis of the major structural and policy barriers contributing to the continued marginalization of oral health within LMIC public health systems.\u003c/p\u003e"},{"header":"VI. POLICY RECOMMENDATIONS","content":"\u003cp\u003eThe findings of this review indicate that addressing the persistent neglect of oral health within LMIC public health systems requires coordinated reforms across multiple levels of governance, financing, workforce development, surveillance, and service delivery. Because the barriers identified are interconnected and structurally embedded within health systems, isolated interventions are unlikely to achieve sustainable integration of oral health into national public health agendas. Instead, comprehensive and multisectoral approaches are needed to strengthen policy visibility, expand financial protection, improve workforce distribution, enhance surveillance systems, and integrate oral health within broader universal health coverage (UHC) and non-communicable disease (NCD) frameworks. Table 4 summarizes the major policy recommendations identified through the review and their expected public health implications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4. Multilevel Policy Recommendations for Oral Health Integration in LMIC Public Health Agendas\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommended Action\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTarget Barrier\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpected Public Health Impact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eGlobal Governance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eIncorporate oral health indicators into SDG and UHC monitoring frameworks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003ePolicy invisibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eIncreased accountability and policy prioritization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eGlobal Governance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eExpand inclusion of oral health within global health financing initiatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eFinancing constraints\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eImproved resource mobilization for LMIC oral health systems\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eNational Policy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eInclude essential oral healthcare services within UHC benefit packages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eCoverage exclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eReduced financial barriers and improved access to care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eNational Policy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eEstablish dedicated oral health budget lines within national health accounts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eFiscal invisibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eMore sustainable oral health financing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eHealth Systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eExpand mid-level oral health workforce cadres and rural deployment incentives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eWorkforce maldistribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eImproved geographic access to preventive oral healthcare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eHealth Systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eIntegrate oral health into primary healthcare and community health worker programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eInstitutional silos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eGreater service integration and prevention coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eSurveillance Systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eIncorporate oral health indicators into national health information systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eData limitations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eStronger evidence base for policy planning and monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eCommunity-Level Interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eImplement school-based prevention programs and population-level oral health promotion strategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eDemand-side barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003eReduced oral disease burden and improved oral health literacy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ch2\u003e6.1 Global Governance Level\u003c/h2\u003e\n\u003cp\u003eAt the global governance level, strengthening the visibility of oral health within international monitoring and accountability frameworks is essential for improving policy prioritization in LMICs. The absence of dedicated oral health indicators within Sustainable Development Goal (SDG) and universal health coverage (UHC) monitoring systems contributes to the continued institutional marginalization of oral health within national and global health agendas. Establishing measurable oral health indicators linked to international reporting mechanisms could improve accountability, strengthen advocacy efforts, and increase the integration of oral health within broader health system reforms and development planning processes (Fol\u0026aacute;yan et al., 2025).\u003c/p\u003e\n\u003cp\u003eGreater integration of oral health within global health financing mechanisms and international development initiatives is also necessary. External financing and technical support have played major roles in advancing health system strengthening efforts for communicable diseases, maternal and child health, and immunization programs in many LMICs. Expanding support for oral health system strengthening preventive services, workforce development, and surveillance infrastructure within international health financing initiatives could help reduce longstanding resource and implementation gaps affecting oral healthcare delivery in LMIC settings (Winkelmann et al., 2023).\u003c/p\u003e\n\u003ch2\u003e6.2 National Policy Level\u003c/h2\u003e\n\u003cp\u003eAt the national policy level, integrating essential oral healthcare services within universal health coverage (UHC) benefit packages represents a critical step toward reducing financial barriers and improving equitable access to oral healthcare. In many LMICs, reliance on out-of-pocket expenditure continues to limit access to preventive and restorative dental services, particularly among low-income and rural populations. Expanding publicly financed oral healthcare services within national health systems may contribute to earlier disease prevention, reduced treatment delays, and lower long-term health and economic burdens associated with untreated oral disease. Countries that have incorporated oral health services within publicly funded healthcare systems, including Thailand and Brazil, demonstrate that greater oral health integration within national health reforms is both feasible and potentially effective in improving access and equity (Watt et al., 2019).\u003c/p\u003e\n\u003cp\u003eStrengthening national oral health governance also requires the inclusion of oral health indicators within national health surveys, health information systems, and strategic health planning frameworks. Dedicated oral health budget lines and improved integration of oral health within broader public health and non-communicable disease (NCD) strategies may help increase institutional visibility and support more sustainable financing mechanisms. In addition, cross-sector collaboration involving education systems, nutrition programs, community organizations, and primary healthcare services may strengthen prevention-oriented oral health policies and improve population-level oral health outcomes in LMIC settings.\u003c/p\u003e\n\u003ch2\u003e6.3 Health System Level\u003c/h2\u003e\n\u003cp\u003eAt the health system level, improving the distribution and capacity of the oral health workforce is essential for expanding equitable access to oral healthcare in LMIC settings. The expansion of mid-level oral health worker cadres, including dental therapists, oral health therapists, and community-based oral health workers, represents a potentially cost-effective strategy for addressing workforce shortages and extending preventive oral healthcare services to underserved populations. Targeted rural deployment incentives, workforce training reforms, and integration of oral health competencies within primary healthcare systems may further strengthen access to essential oral healthcare services in geographically marginalized communities (Singh et al., 2022).\u003c/p\u003e\n\u003cp\u003eIntegrating oral health promotion, screening, and preventive services within primary healthcare and community health worker programs may also improve early detection and population-level prevention efforts. School-based oral health programs, community fluoride interventions where feasible, and public oral health education initiatives can support prevention-oriented approaches that reduce dependence on costly curative dental services. Importantly, these interventions should be adapted to local social, cultural, and health system contexts to improve sustainability, community engagement, and long-term effectiveness in LMIC settings (Elwell et al., 2021; Stennett et al., 2026).\u003c/p\u003e"},{"header":"VII. CONCLUSION","content":"\u003cp\u003eThis scoping review demonstrates that the persistent marginalization of oral health within LMIC public health systems is driven by interconnected governance failures, financing exclusions, workforce inequities, weak surveillance systems, and broader structural and political economy dynamics that limit the integration of oral health into national health agendas. Despite the substantial global burden of oral diseases and their well-established associations with social inequality, oral health continues to receive comparatively limited attention within universal health coverage (UHC) reforms, national public health planning, and international health financing frameworks.\u003c/p\u003e\n\u003cp\u003eThe findings suggest that oral health neglect is not primarily the result of insufficient epidemiological evidence, but rather the consequence of institutional and policy structures that systematically deprioritize oral health within broader health systems. Addressing these challenges requires multisectoral and equity-oriented approaches that integrate oral health within primary healthcare, non-communicable disease (NCD) prevention strategies, surveillance systems, and publicly financed health services. Strengthening oral health governance, improving workforce distribution, expanding preventive services, and increasing political visibility within national and global health agendas are critical for achieving more equitable oral health outcomes in LMIC settings.\u003c/p\u003e\n\u003cp\u003eThe review further highlights the importance of shifting oral health advocacy beyond narrow disease-specific approaches toward broader collaborations with health equity, child development, NCD prevention, and UHC reform initiatives. Positioning oral health as an essential component of public health and social development may strengthen its integration within national policy agendas and improve long-term sustainability of oral health reforms. Future research should continue to examine the political economy of oral health policy integration, evaluate cost-effective workforce and prevention strategies, and explore how social determinants and structural inequalities shape oral health outcomes across diverse LMIC contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of Interest: The author declares no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eFunding: This research received no specific funding from public, commercial, or not-for-profit funding agencies.\u003c/p\u003e\n\u003cp\u003eEthical Approval: Not applicable. This study involved no primary data collection from human participants.\u003c/p\u003e\n\u003cp\u003eData Availability: All data reviewed are available in the published literature cited in the reference list.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAida J, Ando Y, Oosaka M, Niimi K, Morita M (2008) Contributions of social context to inequality in dental caries: A multilevel analysis of Japanese 3-year-old children. Commun Dent Oral Epidemiol 36(2):149\u0026ndash;156\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmaral O, Fagundes M, Hugo F, Kassebaum N, Giordani J (2025) Structural determinants of inequalities in untreated dental caries in the Global Burden of Disease Study. 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World Health Organization, Geneva\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Hasanuddin University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"oral health policy, universal health coverage, public health systems, low- and middle-income countries, health governance, oral health inequalities, scoping review, non-communicable diseases","lastPublishedDoi":"10.21203/rs.3.rs-9671286/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9671286/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOral diseases constitute one of the most prevalent yet persistently neglected non-communicable disease (NCD) burdens globally, disproportionately affecting populations in low- and middle-income countries (LMICs). Despite substantial epidemiological evidence demonstrating their public health significance, oral health remains insufficiently integrated within national health strategies, universal health coverage (UHC) benefit packages, and global health financing frameworks in many LMICs.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis scoping review examined the structural, governance, financing, and institutional barriers contributing to the marginalization of oral health within LMIC public health agendas and explored policy approaches for improving integration within primary healthcare and UHC systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study employed a scoping review methodology guided by the Arksey and O\u0026rsquo;Malley framework and reported in accordance with PRISMA-ScR guidelines. Literature searches were conducted across PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar for studies published between 2004 and 2026. Eligible sources included peer-reviewed studies, policy analyses, reviews, and global health reports addressing oral health governance, financing, workforce, surveillance, and policy integration in LMIC contexts. A thematic narrative synthesis approach was used to analyze the findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirty-two sources met the inclusion criteria. The review identified several interconnected barriers contributing to oral health neglect, including weak governance and political prioritization, exclusion of oral healthcare from publicly financed health systems, workforce maldistribution, inadequate surveillance systems, institutional separation of dentistry from public health, limited integration within global health financing architecture, and persistent social and structural inequalities affecting access to care. These barriers collectively reinforce the continued marginalization of oral health within LMIC health systems.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe persistent neglect of oral health in LMICs reflects broader structural and policy failures rather than a lack of epidemiological evidence. Strengthening oral health integration requires coordinated reforms involving UHC inclusion, financing expansion, workforce development, surveillance strengthening, and integration within broader NCD and public health frameworks. Greater political commitment and multisectoral collaboration are essential for advancing oral health equity in LMIC settings.\u003c/p\u003e","manuscriptTitle":"Oral Health as a Neglected Public Health Priority: A Scoping Review of Systemic Barriers to Oral Health Integration in Low- and Middle-Income Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 09:26:34","doi":"10.21203/rs.3.rs-9671286/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7aac6eb-2b4c-4559-8eb8-b63c467cd965","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67873116,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-05-12T09:26:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 09:26:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9671286","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9671286","identity":"rs-9671286","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}