Globalization has provoked changes in many facets of human life, particularly in diet. Trends in the development of dental caries in population have traditionally followed developmental patterns where, as economies grow and populations have access to a wider variety of food products as a result of more income and trade, the rate of tooth decay begins to increase. As countries become wealthier, there is a trend to greater preference for a more "western" diet, high in carbohydrates and refined sugars. Rapid globalization of many economies has accelerated this process [1
]. These dietary changes have a substantial impact on diseases such as diabetes and dental caries [2
]. The cariogenic potential of diet emerges in areas where fluoride supplementation is inadequate [4
]. Dental caries is a global health problem [5
] and has a significant negative impact on quality of life, economic productivity, adult and children's general health and development. Untreated dental caries in pre-school children is associated with poorer quality of life, discomfort, and difficulties in ingesting food that can result in failure to gain weight and impaired cognitive development [6
]. Since low-income countries cannot afford dental restorative treatment [7
] and in general the poor are most vulnerable to the impacts of illness, they should be afforded a greater degree of protection.
By WHO estimates one third of the world's population have inadequate access to needed medicines primarily because they cannot afford them [8
]. Despite the inclusion of sodium fluoride in the World Health Organization's Essential Medicines Model List [9
], the global availability and accessibility of fluoride for the prevention of dental caries remains a global problem. The optimal use of fluoride is an essential and basic public health strategy in the prevention and control of dental caries, the most common non-communicable disease on the planet. Although a whole range of fluoride vehicles are available for fluoride use (drinking water, salt, milk, varnish, etc.), the most widely used method for maintaining a constant low level of fluoride in the oral environment is fluoride toothpaste. As one of the key components of the WHO endorsed Basic Package of Oral Care
], the promotion of affordable and effective fluoride toothpaste is important for improving equity in oral health.
The promotion of brushing twice a day with fluoride toothpaste is based on strong scientific evidence [11
]. The widespread use of fluoride toothpaste has been recognised as the single most important reason for the decline of dental caries in developed countries during the 1970s and 1980s [13
]. An example is the United Kingdom where the only organized preventive program has been that of water fluoridation but that only about 9% of the UK population benefit from optimally fluoridated water [14
]. The introduction of fluoride toothpaste is the major most likely contributing factor to the decline in caries witnessed in the United Kingdom although other confounding factors inevitably play a role. More recently, the decline in dental caries amongst school children in Nepal, a low-income country, has been attributed to improved access to affordable fluoride toothpaste in Nepal [15
]. For many low-income nations, fluoride toothpaste is probably the only realistic population strategy for the control and prevention of dental caries since cheaper alternatives such as water or salt fluoridation are not feasible due to poor infrastructure and limited financial and technological resources. The use of topical fluoride e.g. in the form of varnish or gels for dental caries prevention is similarly impractical since it relies on repeated applications of fluoride by trained personnel on an individual basis and therefore in terms of cost cannot be considered as part of a population based preventive strategy.
Based on global estimates, about 500 million people utilize fluoride toothpaste, 210 million have access to fluoridated water, 40 million have access to fluoridated salt, and 60 million benefit from fluoride mouth rinses, tablets and clinically applied fluoride [5
]. Taking into account the global population for 2007 is estimated to be 6.6 billion it can be assumed that only about 12.5% of the world's population benefit from the caries preventive possibilities of fluoride toothpaste.
The use of an efficacious fluoride toothpaste is largely dependent upon its socio-cultural integration in personal oral hygiene habits, availability and the ability of individuals to purchase and use it on a regular basis. The price of fluoride toothpaste is believed to be too high in some developing countries [16
] and this might impede equitable access. In a survey conducted at a hospital dental clinic in Lagos, Nigeria 32.5% of the respondents reported that the cost of toothpaste influenced their choice of brands and 54% also reported that the availability of dentifrices influenced their choice [17
]. WHO endorses the development and use of affordable fluoride toothpaste and defines affordable
toothpaste as "one that is available at a price that allows people on low income to purchase it [18
]." To date there have not been any attempts to quantify affordability or to suggest a reasonable retail price which consumers might pay for fluoride toothpaste; nor has there been any research to evaluate the effects of affordability, purchasing, and utilisation. The aim of this paper is to compare the cost and relative affordability of fluoride toothpaste in high-, middle- and low-income countries. The hypothesis is that fluoride toothpaste is not equally affordable in high-, middle- and low-income countries.