A call for a paradigm shift to community-embedded, home-based primary preventive oral health care in Africa

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Oral diseases constitute a global public health crisis, affecting nearly 3.5 billion people worldwide [1]. They cause pain, disability, and economic loss, with their highest burden falling on vulnerable and marginalized populations [1,2]. This crisis is exacerbated by a widespread systemic failure: c [3]. This exclusion frames oral health as a discretionary rather than an essential service, rendering cost a primary barrier to access [4]. Africa exemplifies the severe consequences of this global neglect. The continent is projected to experience the largest relative increase in oral diseases by 2030, driven by urbanization, dietary changes, and the persistent low prioritization of oral health [3,5,6]. The prevailing clinic-centric, curative model is not only misaligned with regional demographics, resource constraints, and cultural contexts [7] but also replicates a global paradigm that uses high cost as a rationale for exclusion rather than as an impetus for innovating equitable, preventive solutions. Therefore, the challenge in Africa is a pressing demonstration of the need for a paradigm shift in how oral health is valued and delivered.The persistent inadequacy of oral health care in Africa is a deeply entrenched structural problem, rooted in systemic and self-perpetuating deficiencies that are more than a simple shortfall of resources or logistics. This structural failing is evident in the severe maldistribution and shortage of the oral health workforce, where the low dentist-to-population ratio, frequently reaching 1:100,000, stands in stark contrast to ratios around 1:2,000 in high-income countries [2,6]. This scarcity is exacerbated by a maldistribution of care providers, with most dental facilities concentrated in urban centers [8]. Consequently, rural populations, which constitute the majority in many African countries [9], face geographic barriers to accessing care [10]. Compounding this is the policy and financing neglect, as oral health remains excluded from most UHC schemes and primary care policies [11], resulting in catastrophic out-of-pocket expenditures for many households [12]. In the absence of political will and dedicated preventive funding, the oral health burden is normalized for marginalized populations due to a lack of [11][12][13].In the absence of accessible and affordable professional care, populations often resort to traditional or complementary remedies [14]. While these remedies are often effective for basic hygiene, they lack an evidence base for managing acute conditions, potentially leading to delayed presentation and health complications [15]. Yet, the prevailing clinic-centric model, derived from Western biomedical frameworks, creates a systemic cultural and institutional disconnect by overlooking and not strengthening indigenous health practices and community-based oral health care traditions, thereby widening the access gap [15,16]. The cumulative effect is a situation where a preventable condition like dental caries can progress to a life-threatening infection and chronic oral pain [17]. This disconnect is exacerbated by infrastructural and technological inequities, where limited preventive public health infrastructure and uneven digital access reinforce disparities rather than resolve them [18]. The cycle is perpetuated by dental education curricula that remain focused on curative, clinical care, offering minimal training in community-based prevention, cultural competence, or the integration of traditional knowledge systems [16]. Collectively, these intertwined factors create a system in which oral diseases are treated late [19][20][21], and late access to treatment is systematically sustained by the very structures designed to combat them.While it is known that prevention remains the most viable option to address oral disease [1] and a strategic necessity to achieve health equity, reduce healthcare costs, and improve overall quality of life [22]. The critical question is how to implement it effectively within the African socio-economic and cultural landscape. Mitigating the oral health crisis in Africa requires fundamental structural reorientation toward community-embedded, preventive, and culturally intelligent models of care. The aim of the study is to advocate for a shift away from the current prevailing model of oral healthcare in Africa, and to propose a new, community-embedded, home-based primary preventive model.The conventional oral healthcare model, which relies on encouraging clinic attendance for preventive check-ups and education, is rooted in a Western biomedical framework and fails to account for the geographic, financial, and cultural barriers that limit clinic access, thereby exacerbating health inequities. It is ill-suited to the infrastructure, economic realities, and cultural practices of many lowresource settings in Africa as it inherently places the onus of cost, time, and travel on the individual, thereby disproportionately disadvantaging rural and low-income communities. This raises a pivotal question: in settings where transportation costs are significant considerations, and where cultural beliefs often prioritize home-based and community-advocated remedies [15,16], is a clinic-based model for prevention justifiable?For Africa, where a more equitable, efficient, and culturally intelligent model of delivering oral health care is needed, alternative(s) must be explored. A viable path forward is a reorientation towards home-based and community-driven primary prevention. This is a call to re-engineer the ecosystem, positioning the household as the primary locus of prevention, supported by a strengthened public health infrastructure that actively incorporates indigenous knowledge and hands the responsibility of prevention to empowered communities. This model aligns with the WHO's building blocks approach by focusing on community ownership and integrating oral health into broader health initiatives [23].Advocating for a home-based, community-embedded model of oral health prevention does not diminish the fundamental responsibility of governments and health systems to ensure population health. Rather, this paradigm shift represents a strategic reorientation toward primary prevention, anchored by robust public health infrastructure, targeted professional development, and equitable distribution of tools and knowledge. The model's success wholly depends on this systemic support; without it, responsibility is devolved onto individuals and communities, exacerbating the very inequities it seeks to address. The proposed model, therefore, envisions a synergistic partnership, positioning the household and community as the frontline of daily prevention-actively fortified by the state through funded preventive programs, subsidized access to essentials like fluoride toothpaste, and culturally sensitive training curricula [24]. Ultimately, the goal is to avoid making people responsible for outcomes beyond their control due to inadequate support. Instead, the model empowers them within a framework of shared responsibility, where public health infrastructure enables effective self-care and community action, thereby transforming the locus of care without abandoning the population.This proposed model offers several distinct advantages, with an emphasis on cultural leverage. First, a preventive approach is economically prudent. Evidence indicates that population-based preventive programs yield a high return on investment: for every USD invested in community-based oral disease prevention, up to USD 50 in treatment costs can be saved [25]. Empowering individuals, households, and communities with the knowledge and tools for effective self-care, including the use of affordable fluoride toothpaste, sugar consumption limitation, and other dietary strategies, can prevent a significant proportion of oral diseases, thereby alleviating financial pressure on both households and the overstretched public health systems.Second,

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