One Health and Oral Health: A Scoping Review to Inform Research and Present Challenges

Abstract

Background:

“One health” is an integrated, unifying approach that recognizes the interconnectedness between the health of people, animals, and the environment. Oral diseases are the most common diseases to affect humankind, and it is increasingly acknowledged that key determinants of oral heath are social and environmental. However, there is a dearth of information on the relationship between oral health and one health.

Aims:

A scoping review was conducted to examine how animal and environmental health affects human oral health and vice versa, to examine the interest in the field overtime, and to provide a synthesis of the literature concerning one health in the oral health context to date.

Methods:

A broad standardized search strategy was employed across 5 electronic databases. Screening of publications with defined inclusion and exclusion criteria followed PRISMA-ScR (the Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

Results:

The initial search yielded 345 articles; 163 remained after removal of duplicates. Nineteen articles were identified as “potentially effective studies,” and after consideration of the full text, 13 articles were identified as “effective studies” to inform this review. Most studies were published since 2020 (60.5%, 8/13), and there were reports from 5 of the 6 World Health Organization regions (except the Eastern Mediterranean region). Most studies were observation in nature and mostly of cross-sectional study design (84.7%, 11/13 studies). More than half of the studies (53.8%, 7/13) were concerned with how environmental factors such as chemical exposures affect human oral health. Studies involving animals (46.2%, 6/13) highlighted the risk of zoonotic infections from horses and livestock to humans.

Conclusions:

There is a recent and growing interest in “one health” in the oral health context. Qualitative synthesis of data highlighted the interconnectedness between the health of animals and environment with human health with implications for consideration and action by dentistry.

Knowledge Transfer Statement:

The results of this scoping review address the importance of dentistry in the “one health” concept. This scoping review will allow other researchers to be aware of and fill literature gaps with respect to the impact of animal health and environment on oral health and contribute to future research.

Keywords

human health environment animal health dentistry zoonoses

Introduction

The term “one health” and its related concept is reported to have originated from the Wildlife Conservation Society and the Manhattan Principles, arising from a symposium titled “Health in a Globalized World” in 2004 (Evans and Leighton 2014). The principles consider the need for interdisciplinary actions as a global community to holistically examine the interplay of animal health and the environmental ecosystem to human health, as often complex health issues cannot be solved by a single discipline or sector. In operationalizing one health, the World Health Organization for Animal Health, the Food and Agriculture Organizations of the United Nations, and the World Health Organization (WHO) identified 7 key activities to advance the one health agenda (Centers for Disease Control and Prevention [CDC] 2010). The activities focused on (1) cataloging and developing one health trainings and curricula, (2) establishing a global network, (3) developing a country-level needs assessment, (4) building capacity at the country level, (5) developing a business case to promote donor support, and (6) gathering evidence for proof of concept through literature reviews and prospective studies (CDC 2010). The updated Berlin principles of one health 15 y on reiterated the importance of comprehensively considering the health of humans, nonhumans, and ecosystems in bridging global health and conservation and urgently called for action in the wake of COVID-19 (Gruetzmacher et al. 2021).

The increasing world population and massive changes in land use (including intensive farming practice), coupled with urbanization, have led to growing concerns about the environment and ecosystems globally and particularly in developing countries (Cumming et al. 2014). Of ongoing concern has been the effects of climate change, rising temperatures, changes in precipitation patterns (droughts and flooding), and loss of biodiversity. Evidence continues to emerge about the potential effects of climate change on human health. Studies have shown increased mortality and morbidity rates associated with climate change, and in many cases, the effects of climate change have been shown to affect the more vulnerable in society: young children and older people (Tome et al. 2022). Climate change has been shown have potential implications for cardiovascular health and neurodegenerative diseases and exacerbates social disparities and inequalities in health. Other environmental issues of concern are food security and food safety; the former refers to availability and access to meet the dietary needs of individuals/communities, and the latter refers the conditions of handling and preparing food so that it is safe to consume. Food insecurity has been shown to be associated with suboptimal child development, risk of cardiovascular diseases and other diseases, and health inequities (Weiler et al. 2015). Food safety is critical to prevent foodborne illness such as salmonella, hepatitis, and botulism; the consequences can range from mild upset, to gastrointestinal upset, to poisoning and death (Gallo et al. 2020). Environmental contamination and exposures include air pollution, water contamination, soil contamination, and chemical and radiation exposures, among others. Air pollution can trigger allergies and asthma attacks, increase the risk of chronic obstructive pulmonary diseases and lung cancers, and contribute to premature deaths (Orru et al. 2017). Environmental exposures/contamination have been shown to be associated with a host of diseases, including liver diseases and liver failure (Barouki et al. 2023), neurologic degradation, neuropathies, and Alzheimer’s disease (Vasefi et al. 2020). The type, severity, and progression of diseases depend on the type of environmental exposure, the associated level (amount of exposure), and length of time of exposure (Kripke et al. 2020).

Animal health is closely interconnected to human health and those include both positive health effects associated with emotional well-being and detrimental effects associated with zoonotic infections and animal foodborne disease risks. Zoonotic infections refer to infection with pathogens such as bacteria, viruses, or parasites transmitted from nonhuman animal to humans via direct contact or through a food/environment source (WHO 2020). There are several hundred types of zoonoses, including a long history of rabies and toxoplasmosis from household pets (Fooks et al. 2017). Animal vaccines have been highly effective in controlling zoonotic infection, such as rabies, in industrialized countries, but this infection remains a problem in many developing countries (Zhu and Guo 2016). From livestock, the risk of brucellosis through direct contact on consumption of unpasteurized dairy products posed a considerable risk in the mid-20th century in Europe and the Americas, which remains endemic in parts of the world today (Khurana et al. 2021). Wildlife, too, poses considerable risks for zoonotic infection, and this is becoming an increasing problem with encroachment and destruction of wildlife habitats (Cunningham et al. 2017). In recent decades, the concern has been emerging contagious or pathogenic zoonotic diseases given the oral cavity may support pathogenic viromes (Baroni de Carvalho et al. 2023), especially viral diseases with recurring life-threatening disease outbreaks of Ebola, Zika, and Nipah (Tambo et al. 2020). The emergence of SARS-CoV-2 and the global pandemic related to COVID-19 has brought to the fore the importance of one health and specifically zoonotic infections (Jacob et al. 2020). Furthermore, adaptive evolutional mutation of SARS-CoV-2 virus against the host by suppressing the innate immune response has resulted in various distinct variants (Alpha [B.1.1.7], Delta [B.1.617.2], and Omicron [B.1.1.529]) that in themselves poses distinct and different risks (Thorne et al. 2022).

There has been considerable interest in one health with respect to health in general, but there is a lack of studies on the potential link between one health and oral health, which this scoping review aims to address. A scoping review was conducted to examine how animal and environmental health affects human oral health and potentially vice versa. In addition, to examine the interest in the field over time, we examine the key aspects of one health in the oral health context and provide a synthesis of the scientific evidence to date.

Methods

Scoping Review Protocol and Research Question

This scoping review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al. 2018). This scoping review addressed the research question, “What is the impact of animal health and environmental health on the oral health?” The scoping review process is shown in the Figure (Page et al. 2021).

Figure.

The data extraction process following the PRISMA-ScR guideline.

Searching Strategy and Screening

A standardized search strategy was developed based on the keywords and MeSH terms relating to “one health” and “oral health” and across 5 electronic databases to identify potential sources of evidence: PubMed, Embase, Web of Science, Scopus, and Global Health were applied. An example of the searching strategy for PubMed is presented in Table 1, and other search strategies are presented in Appendix 1. The title of articles across the 5 databases were combined in EndNote (version X9, Clarivate Analytics), and duplicate citation of articles were identified and removed. In selecting relevant studies, a 2-phase screening process was adopted. The initial screening was conducted based on the title and abstract for studies relating to association/impact of “animal health or environment on human oral health” or impact of “human oral health on animal health or environment.” Eligibility criteria for inclusion were (1) full-length, peer-reviewed original research articles published in English or (2) observational (cross sectional and longitudinal) and intervention (quasi-experimental, case-control intervention studies or clinical trials). Exclusion criteria were (1) review articles (i.e., narrative reviews), (2) outcomes or exposures not related to animal health or environment, or (3) outcomes of exposure not related to human oral health. Screening was conducted by 2 independent raters (H.S. and L.J.W.), and the level of agreement between raters was determined. Where disagreement occurred, a third rater (C.Mc.G.) resolved whether to include or exclude the abstract through discussion. Full text of all potentially effective studies following initial screening were obtained and reviewed by the independent rates for inclusion based on methods and results of the downloaded publications. Confirmed eligibility for inclusion was determined based (1) study type (in vitro or in vivo studies, observational and intervention studies), (2) confirmed outcomes or exposures related to animal health or environment, and (3) confirmed outcomes of exposure related to human oral health. The level of agreement between raters (H.S. and L.J.W.) in their assessment of the eligibility of studies to inform the review (i.e., “effective studies”) was determined. Where disagreement occurred as to whether to include or exclude a study, a third rater (C.Mc.G.) made the final decision.

Table 1.

Scoping Review Search Strategy for PubMed.

Database	Search Terms
PubMed	1. (“One Health”[Mesh]) 2. “one health”[Title/Abstract] OR “OneHealth”[Title/Abstract] OR “one-health”[Title/Abstract] OR “one health approach”[Title/Abstract] OR “one health concept”[Title/Abstract] OR “one health perspective”[Title/Abstract] OR “one health initiative”[Title/Abstract] OR “one medicine”[Title/Abstract] OR “one medicine initiative”[Title/Abstract] OR “conservation medicine”[Title/Abstract] OR “one science”[Title/Abstract] OR “one world”[Title/Abstract] OR “EcoHealth”[Title/Abstract] 3. #1 OR #2 4. (((((((“Oral Health”[Mesh]) OR “Mouth Diseases”[Mesh]) OR “Tooth Diseases”[Mesh]) OR “Oral Hygiene”[Mesh]) OR “Dentistry”[Mesh]) OR “Mouth Mucosa”[Mesh]) OR “Jaw diseases”[Mesh]) 5. “oral health”[Title/Abstract] OR “dental health”[Title/Abstract] OR “mouth disease”[Title/Abstract] OR “tooth disease”[Title/Abstract] OR “oral hygiene”[Title/Abstract] OR “dental caries”[Title/Abstract] OR “tooth decay”[Title/Abstract] OR “tooth loss”[Title/Abstract] OR “dental plaque”[Title/Abstract] OR “periodont”[Title/Abstract] OR “gingiv”[Title/Abstract] OR “orofacial trauma”[Title/Abstract] OR “mouth tumor”[Title/Abstract] OR “mouth neoplasm”[Title/Abstract] OR “oral cancer”[Title/Abstract] OR “dentistry”[Title/Abstract] OR “Tooth Extraction”[Title/Abstract] OR “oral mucosa*”[Title/Abstract] OR “oral manifestation”[Title/Abstract] #4 OR #5 6. #3 AND #6

Database

Search Terms

PubMed

1. (“One Health”[Mesh])
2. “one health”[Title/Abstract] OR “OneHealth”[Title/Abstract] OR “one-health”[Title/Abstract] OR “one health approach*”[Title/Abstract] OR “one health concept*”[Title/Abstract] OR “one health perspective*”[Title/Abstract] OR “one health initiative*”[Title/Abstract] OR “one medicine*”[Title/Abstract] OR “one medicine initiative*”[Title/Abstract] OR “conservation medicine*”[Title/Abstract] OR “one science”[Title/Abstract] OR “one world”[Title/Abstract] OR “EcoHealth”[Title/Abstract]
3. #1 OR #2
4. (((((((“Oral Health”[Mesh]) OR “Mouth Diseases”[Mesh]) OR “Tooth Diseases”[Mesh]) OR “Oral Hygiene”[Mesh]) OR “Dentistry”[Mesh]) OR “Mouth Mucosa”[Mesh]) OR “Jaw diseases”[Mesh])
5. “oral health”[Title/Abstract] OR “dental health”[Title/Abstract] OR “mouth disease*”[Title/Abstract] OR “tooth disease*”[Title/Abstract] OR “oral hygiene”[Title/Abstract] OR “dental caries”[Title/Abstract] OR “tooth decay”[Title/Abstract] OR “tooth loss”[Title/Abstract] OR “dental
plaque”[Title/Abstract] OR “periodont*”[Title/Abstract] OR “gingiv*”[Title/Abstract] OR “orofacial trauma”[Title/Abstract] OR “mouth tumor”[Title/Abstract] OR “mouth neoplasm*”[Title/Abstract] OR “oral cancer”[Title/Abstract] OR “dentistry”[Title/Abstract] OR “Tooth Extraction”[Title/Abstract] OR “oral mucosa*”[Title/Abstract] OR “oral manifestation”[Title/Abstract]
#4 OR #5
6. #3 AND #6

Data Extraction and Synthesis of Evidence

From the effective studies, the following data were extracted from full-text articles: (1) publication details based on (i) journal type (dental or nondental), (ii) period of publication (year), (iii) geographical region of the study (based on corresponding author details), (iv) study type (in vivo or in vitro) and study design (observational or interventional), (v) study subjects (animals or humans) and sample size. (vi) Key outcomes and classifications: (i) animal health related: (a) animal health with human health, (b) animal health with environment, (c) animal health with human health and environment. (ii) Environment related: (a) environment with human health, (b) environment with animal health, (c) environment with human health and animal. (vii) Key findings of association and impact with implication for one health. Qualitative syntheses of the evidence were produced. Key findings were reviewed based on outcomes to determine feasibility for quantitative synthesis of the evidence.

Results

Search Strategy and Screening Outcomes

The initial screening identified 345 articles across the 5 databases: PubMed (69 articles), Embase (60 articles), Web of Science (84 articles), Scopus (99 articles), and Global Health (33 articles); after removal of duplicates, 163 articles remained and underwent initial screening. Following the initial screening of titles and abstracts, 19 articles remained. Reasons for exclusion in the initial round of screening was abstracts not available or not in English (n = 14), (2) study type nonobservational/nonintervention studies (n = 0), (3) narrative reviews (n = 30), (4) outcomes or exposures not related to animal health or environment (n = 28), and (5) outcomes of exposure not related to human oral health (n = 72). The Kappa value of the level of agreement between raters of initial screening was 0.87. Disagreement on 17 articles occurred, and the reviewers agreed that 7 articles be included for full-text review (potentially effective studies). Details of the search and screening outcomes process are presented in the Figure, Prisma Flow Diagram.

Among the 19 potentially effective studies, 6 articles were excluded based on full-text ratings. The reasons for exclusion were (1) article type (4 articles: reviews [3 articles] and conferences abstracts [1 article]), (2) outcomes or exposures not related to animal health or environment (1 article), and (3) full-text article not retrievable (1 article). There was full agreement between raters with respect to secondary screening (K = 1.00).

Characteristics of Effective Studies

Profile of effective articles: time period and WHO region

Among the 13 effective studies, none of the articles were published in dental-specific journals. The period of publication ranged from 2007 to 2023, with more than half published since 2020 (60.5%, 8/13). Studies were conducted across 5 of the 6 WHO regions, except for the Eastern Mediterranean region. Most studies were conducted in the Western Pacific region (30.8%, 4/13: China [2 studies], Cambodia/Loas, Mongolia) and in the European region (30.8%, 4/13: Turkey, Portugal [2 studies], Austria). Approximately a quarter of the studies (23.1%, 3/13) were published in the regions of the Americas (United States [2 studies] and Canada). One study was conducted in the Southeast Asian region (7.7%, 1/13: India) and 1 study in the African region (7.7%, 1/13: Rwanda).

Study design and key aspects of one health covered

Most studies were cross-sectional studies (84.69%, 11/13), 1 was a retrospective observational study (Airikkala-Otter et al. 2022), and 1 was a case-control interventional study (Browar et al. 2018). More than half of the studies (53.8%, 7/13) involved a study of environmental factors, mostly relating to environmental exposures (57.1%, 4/7): cadmium levels (2 studies; Browar et al. 2018; Browar et al. 2019), fluoride exposure (1 study; Habiyakare et al. 2021), and wood dust exposure (1 study; Wultsch et al. 2015). The other environmental studies involved climate change (2 studies; Fang et al. 2011; Bajalan et al. 2022) and urbanization effect (1 study; Yang et al. 2007). The impact of environmental exposures on human health was assessed in 1 cadaver study (cadmium levels; Browar et al. 2018), a study among factory workers (occupational health; Hancock et al. 2015), fluorosis levels among children (Habiyakare et al. 2021), infectious disease cases at a county level (Fang et al. 2011), child diseases identified at school entry level (Yang et al. 2007), and attitudes of dental students (Bajalan et al. 2022).

Approximately half of the studies involved animals (46.2%, 6/13); 2 studies involved horses (da Costa Pimenta 2021; Pimenta et al. 2023), 1 study involved dogs (Airikkala-Otter et al. 2022), 1 study was on rats in the laboratory setting (Browar et al. 2018), 1 study was on cattle and buffalo (Siengsanan-Lamont and Blacksell 2021), and 1 study involved cattle and goats (Habiyakare et al. 2021). Among the animal studies, 1 study reported on an association between animal health and human health in terms of dental fluorosis levels in children and livestock (goats), that is, environmental exposure rather than animal-to-human transmission (Habiyakare et al. 2021). Sample sizes varied among studies: in the animal studies, samples ranged from 8 (horses; da Costa Pimenta 2021) to more than 6,000 livestock (cattle and buffalo; Siengsanan-Lamont and Blacksell 2021). Among the human studies, the sample sizes ranged from 12 (human cadaver) to more than 50,000 (first-grade children; Yang et al. 2007; Browar et al. 2019).

Qualitative synthesis of the evidence

A qualitative syntheses of study findings is presented in Table 2. In terms of attitudes relating to one health, there was a survey among dental students and dentists (Bajalan et al. 2022; Eroğlu Çakmakoğlu 2022). Dental students (562) perceived antibiotic resistance (mean 8.9 ± 1/10) and climate change (mean 8.7 ± 1/10) to be considerable challenges (Bajalan et al. 2022). A survey among Turkish dentists (603) identified that most (99.2%, 598/603) were aware that diseases can be transmitted from animals to human, and approximately two-thirds perceived that dentists had a role in treating zoonotic infections (Eroğlu Çakmakoğlu 2022). Variations in knowledge about zoonotic infections was associated with dental specialty (Barouki et al. 2023). A qualitative study among nomadic herders (104) identified that they had an adept understanding of the concept of “one health,” the relationship between climate change and landscape degradation (environmental factors) leading to declining animal health, and human socioeconomic consequences (DiPietro 2023).

Table 2.

Qualitative Synthesis Characteristic of Selected Bibliography.

Author, Year	Journal	Country/Region	Study Design	Subjects (Sample Size)	Subclassification	Key Findings
Animal-to-human studies
Airikkala-Otter et al., 2022	Indian Journal of Community Medicine	India	Retrospective study	Dogs (1,334/1,699)	Rabies	Vaccination campaign against rabies in a rural India setting was successful through collaboration between an animal husbandry department and a village public health department; the vaccination rates of dogs was 78.5% (1,334/1,699) within 15 working days.
Eroğlu Çakmakoğlu et al., 2022	Bezmialem Science	Turkey	Cross-sectional study	Dental team (603)	Zoonotic infections	Survey among Turkish dentists (specialists and nonspecialists) identified less than 1/20 had heard of the concept “one health.” Most (99.2%, 598/603) identified that diseases can be transmitted from animals to humans. Approximately two-thirds (62.4%, 376/603) perceived dentists had a role in treating zoonotic infections. Variations in knowledge about zoonotic infections was associated with dental specialty type (P < 0.05).
Pimenta et al., 2021	Open Veterinary Journal	Portugal	Animal study (equine)	Horse (8)	Zoonotic infections	1. Gram-negative microbiota was isolated from the gingiva of healthy horses. 2. The microbiota were potentially zoonotic and were multidrug resistant.
Pimenta et al., 2023	Antibiotic	Portugal	Cross-sectional (equine)	Horses (30)	Zoonotic infections	Fifty-five gram-negative isolates were identified, with 89.5% being zoonotic and 62% affecting humans, which were also found commonly in the environment. Forty-eight isolates (96%) were multidrug resistant.
Siengsanan-Lamont and Blacksell, 2021	Microbiology Australia	Thailand and United Kingdom	Cross-sectional	6,031 animals (4,421 cattle, 1,610 buffalo)	Zoonotic infections	Foot and mouth disease antibodies derived from natural infection rather than vaccination were noted in greater than 40% of the animals sampled at abattoirs in Laos and Cambodia, suggesting significant underreporting of outbreak events, and risk of zoonotic infections.
Environment-to-human studies
Bajalan et al., 2022	Antimicrobial Resistance & Infection Control	Norway, Canada, and Brazil	Cross-sectional	562	Antibiotic resistance	Survey among dental students at 6 universities in 3 countries (Norway, Canada, and Brazil) identified that approximately 1 in 10 had heard of the concept of “one health.” Perceived greatest challenges were “antibiotic resistance” (mean 8.9 ± 1/10) and “climate change” (mean 8.7 ± 1/10).
Browar et al., 2018	Toxics	United States	Intervention study	10 rats (5 experiments, 5 control)	Cadmium exposure	Cadmium exposure (0.6 mg/kg/d) for up to 12 wk resulted in significant periodontal bone loss compared with no cadmium exposure in rats (P < 0.0001). Cadmium’s effects on periodontal bone loss were time dependent.
Browar et al., 2019	Toxics	United States	Cross-sectional study	12	Cadmium exposure	1. Cadmium (Cd) levels in mandibular alveolar bone were significantly greater than in basal bone (mean 0.06 ± 0.02 versus 0.02 ± 0.01, P = 0.01) (P<0.01). 2. Human cadaver periodontal scores were correlated with basal mandible bone Cd content (r² = 0.890, P < 0.05).
Fang et al., 2012	EcoHealth	China	Cross-sectional (human)	Organizations, farmer, households (4,188,363)	Climate change	Water management challenges were identified water shortages, water pollution, and excessive levels of fluoride water due to environment/climate change and with impact on depletion of ground water resources, increased water pollution, and increased risk of fluorosis.
Wultsch et al., 2015	Mutagenesis	Vienna, Austria	Cross-sectional survey (human)	Woodworkers (89 with wood dust exposure) and control (65)	Wood dust exposure	Exposure to low levels of wood dust was not associated with the formation of micronuclei (i.e., genomic damage); cancer risks of the workers were found not to be increased as a consequence of genetic damage.
Yang et al., 2007	BMC Public Health	China (Taiwan)	Cross-sectional survey (human)	School children younger than 8 y (53,053)	Urbanization	1. Approximately 4 in 5 (79.5%) first graders had at least 1 health problem. 2. There were significant differences in the prevalence of dental caries, myopia, and obesity in relation to levels of urbanization.
Environment-to-animal and -human studies
DiPietro et al., 2023	Journal of Climate Change and Health	Mongolia	Cross-sectional survey (qualitative)	Nomadic herders (104)	Climate change	1. The nomadic herders displayed adept understanding of one health concepts. 2. They perceived that climate change contributes to landscape degradation, leading to declining animal health and human socioeconomic consequences.
Habiyakare et al., 2021	One Health Outlook	Rwanda	Cross-sectional (human)	Children (186) and animals (85)	Fluoride exposure	Dental fluorosis was highly prevalent among children (90.7%) and livestock (76.0%) on Gihaya Island with various food and water sources contributing a cumulative exposure to fluoride causing fluorosis.

In terms of environment, 3 studies were related to environmental exposure/contamination, exploring the relationship between environment with animal health and environment with human health. With respect to cadmium levels, a case-control intervention study among rats identified significant differences in periodontal bone loss with respect to length of time exposed, with potential implications for human health (Browar et al. 2018). A human cadaver study identified an association between cadmium levels in bone and periodontal bone loss (Browar et al. 2018). A study of fluoride levels in the environment (water samples) was associated with fluorosis levels in children and livestock (i.e., environment affects animal health, environment affects human health; Habiyakare et al. 2021). One study examining occupation environmental exposure of wood dust identified no significant genotoxicity in the buccal and nasal mucosae of workers (Jacobsen et al. 2021). One study explored the link between climate change and water management challenges and claimed a plausible link to infectious diseases data from county-level statistics (Fang et al. 2011). A study of environment urbanization levels identified a significant association between morbidly levels (prevalence rate of health problems) among first graders and the degree of urbanization (Yang et al. 2007).

In terms of the 4 animal studies, 1 study reported on the effectives of the collaboration between agricultural and public health services to achieve high vaccination rates (78.5%; Airikkala-Otter et al. 2022). An animal disease surveillance study identified higher levels of foot-and-mouth antibodies from natural infections as opposed to from vaccinations, suggesting underreporting of infection outbreaks with implications for animal and human health (Siengsanan-Lamont and Blacksell 2021). Two animal studies identified the carriage of specific gram-negative microbiota from the horse-gingivae samples that could potentially be transmitted to humans including drug-resistant microbiota (da Costa Pimenta 2021; Pimenta et al. 2023).

Discussion

A scoping review was undertaken given the broad and exploratory nature of identifying literature relating to animal health, environment and oral health. A scoping review is particularly useful when exploring novel concept such as “one health,” in which working definitions and conceptual boundaries are somewhat ambiguous (Peters et al. 2015). The search terms used in this scoping review were broad MeSH terms and keywords used in reviews of one health and systemic health to maximize the likelihood of identifying any potential article in the field. Furthermore, a broad search was used across 5 electronic databases for comprehensiveness and included, in addition to the conventional databases of PubMed, Embase, Scopus, and Web of Science, the database of “Global Health,” which provides access to research articles in the broader field of public health, covering topics such as infectious diseases and environmental health for comprehensiveness (Falagas et al. 2008).

The scoping review process benefited from using the PRISMA extension for Scoping Reviews as guidance in terms of providing checklist and explanations to identify and screen articles (Tricco et al. 2018). Despite the broad search terms used and multiple databases, the initial search identified a modest number of articles across the databases (~350) compared with the much larger number identified in scoping reviews relating to systematic health reviews. Of note, there was considerable overlap and duplication of articles among the database (almost half), but nonetheless, each database contributed to identifying articles, and this highlights the value of searches across multiple databases and databases with differing focuses/audiences (Gasparyan et al. 2013). Following initial and secondary screening, most articles (~90%) were excluded as they were not specific to the health of animals and/or the environment in relation to oral health. There was substantial/excellent agreement between raters, and where disagreement occurred, this was resolved by the supervisor.

Of the 19 effective articles/studies that informed this scoping review, all were published since 2007 and most since 2020. This mirrors the development of the concept of one health and the growing recognition of the interdependent nature of the health of animals and/or environment with human health in the new millennium (CDC 2022). A large proportion of publications since 2020 in dental research is likely to reflect the world’s realization of the risk associated with zoonotic infections such as SARS-CoV-2 virus and COVID-19 disease of the mouth (Iranmanesh et al. 2021; Farid et al. 2022). Studies/articles were from across the globe, covering 5 of the 6 World Health Organization regions, highlighting the global importance of the concept in general and how infections in one region can rapidly become endemic and a pandemic worldwide (Tang et al. 2022). More than half of the studies were related to the effects/potential effects of environment and oral health such as water shortages, water contamination, and other environmental exposures. There is a growing acknowledgment of the effects of environment (and specifically climate change) on health (Campbell-Lendrum et al. 2023), and this scoping review provides evidence of the growing emergence of environment and oral health literature (de Abreu et al. 2021). Interestingly, all studies of the scoping review were published in nondental journals, and although this has merits in raising the oral health implications to medical colleagues, it does hamper more widespread awareness and knowledge of the one health concept in the dental arena, as has been observed in a survey administered to dental students and dentists (Bajalan et al. 2022; Eroğlu Çakmakoğlu 2022).

In terms of study design, the vast majority (more than 4 in 5 studies) were observational studies and of a cross-sectional nature, exploring the association between oral health effects/risk of oral health events with the health of animals and the environment. Observational studies with a cross-sectional design, although highlighting potential oral manifestations of oral health, are limited in providing evidence of causation: cross-species transmission, adaptive evolution, and pathogenesis (Primadharsini et al. 2021). Approximately half of the studies focused on evidence from animals and frequently with respect to potential carriage of zoonotic infections rather than specific evidence of cross-species transmissions per se (da Costa Pimenta et al. 2021; Pimenta et al. 2023). In some cases, the effect of environmental exposure on animal oral health was used as a model to depict the potential effects on humans (i.e., cadmium and periodontal bone loss; Browar et al. 2018).

Qualitative synthesis of studies identified a key concern that infections could potentially be transmitted from animals to humans. Studies among horses identified gram-negative microbiota from the oral cavity of horses that could potentially be transmitted to humans as a results of horse bites, contact with horse saliva, or aerosols of horse saliva (da Costa Pimenta et al. 2021; Pimenta et al. 2023). Also of concern was the potential for outbreaks of foot-and-mouth diseases given the high levels of antibodies from natural infections as opposed to from vaccinations (Airikkala-Otter et al. 2022). The outbreak of foot-and-mouth disease has been considered a worldwide epidemic threat among young children, especially in developing countries where the rates of enteroviruses are underestimated (Zhu et al. 2023). In addition, studies observed multidrug-resistant animal microbiota, highlighting the challenges of managing zoonotic infections if they were to arise, as has been reported in the case of Methicillin-resistant Staphylococcus aureus (Algammal et al. 2020). The transmission of rabies to humans is also of concern, and this can be effectively controlled through agricultural and public health vaccination programs (Airikkala-Otter et al. 2022). There is a much evidence of vaccination programs being the most cost-effective means of controlling rabies in endemic settings (Lavan et al. 2017).

In terms of environment factors, key issues were related to occupational environmental hazard (Wultsch et al. 2015) as well as broader environmental concerns of water supplies and environmental contamination (Fang et al. 2011). Occupation exposure to dust (wood dust) has been shown to cause cancer, and oral mucosae samples represent a readily accessible way to monitor potential dysplastic changes (Bonassi et al. 2016). Another issue is water being a key resource for human health and the climate change effects on water supplies have implications for oral health and systemic health (Fang et al. 2011). In terms of water, a key issue in the studies of a scoping review was fluoride levels and its associations with level of dental fluorosis (Habiyakare et al. 2021). There is a need to establish an optimum level of fluoride levels that brings the benefit of caries prevention with minimal levels of fluorosis that can be considered unesthetic.

Dental professionals’ responsibility extends beyond treating oral diseases and should include confronting emerging global diseases through understanding the effects of oral health and environment/animal health and vice versa. The lack of acknowledgment of the integral concept of one health may contribute to the transmission of infectious diseases, antimicrobial resistance, and unsustainable environmental impacts (Sinclair 2019).Urgent curriculum updates are required to prepare dental students and professionals for the complex health challenges of the future. By embracing one health principles, interdisciplinary collaboration with veterinary, medical, and environmental sciences should be encouraged for education, research, and clinical practice, as in the case of COVID-19 (Sharun et al. 2021).

In summary, this scoping review found evidence of a growing interest in one health and oral health globally and particularly so in recent years. Studies highlight the potential effects of animal health on oral health through zoonotic infection that warrant attention because of antimicrobial resistance levels. Furthermore, the environment effects on human health are recognized, notably climate change, water management, and environmental/occupational hazards. There is a need to raise awareness about one health and oral health among the dental community to determine the extent of the issues and to promote interdisciplinary collaboration so as to improve human and animal health and safeguard the environment.

Author Contributions

S. Huang, contributed to searching protocol design, data acquisition and analysis, drafted and critically revised the manuscript; J.W. Li, contributed to data acquisition and analysis, manuscript review, contributed to conceptualization, review, and editing the manuscript; L.W. Zheng, contributed to conceptualization, review, and editing the manuscript; W.W. Qiao, contributed to searching protocol design, manuscript review; C. McGrath, contributed to conception, design, data analysis, critically revised the manuscript. All authors have their final approval and agree to be accountable for all aspects of work.

Supplemental Material

sj-docx-1-jct-10.1177_23800844241273821 – Supplemental material for One Health and Oral Health: A Scoping Review to Inform Research and Present Challenges

Supplemental material, sj-docx-1-jct-10.1177_23800844241273821 for One Health and Oral Health: A Scoping Review to Inform Research and Present Challenges by Lisa J. Heaton, Tamanna Tiwari, Eric P. Tranby, S. Huang, J.W. Li, L.W. Zheng, W.W. Qiao and C. McGrath in JDR Clinical & Translational Research

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The scoping review was supported by the general research fund from the Research Grants Council of the Hong Kong Special Administrative Region, China (grant No. 17107621).

A supplemental appendix to this article is available online.

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