While dental decay remains the most common form of oral disease, untreated, it can lead to life-threatening complications. (Photo: Bekky Bekks/Unsplash)Comment & Analysis
25th September 2025 | Bulela Vava
We need to confront the racialised and class-based structures that still dictate society’s oral health outcomes, argues Dr Bulela Vava as we head toward the end of this year’s National Oral Health Month.
September’s National Oral Health Month arrived as a bittersweet milestone for a nation still grappling with the unshakable legacy of apartheid. Despite significant strides made over the past three decades, for many in South Africa, oral disease is not simply a matter of cavities and gum pain – it is a mirror reflecting the structural inequities of race, gender, disability and class that persist three decades into democracy.
Data from the World Health Organisation reveals that 41% of South African children aged 1 to 9 years have untreated tooth decay, and nearly 28% of people over five have cavities in their permanent teeth. Nearly a quarter of adults suffer from severe periodontal disease, and edentulism (the complete loss of natural teeth) affects over 8% of people aged 20 and older.
Dentists make up a significant majority of the oral health workforce, and with less than 7 000 registered dentists in South Africa, roughly 1.1 for every 10 000 people, the workforce is far too small to meet the needs of a population of over 60 million. For context, the WHO Global Oral Health Status Report reported a global average density for dentists of 3.28 per 10 000. Access to care is uneven, with most dentists concentrated in urban centres and wealthier provinces, further marginalising rural and financially vulnerable persons.
Deeper divides
These numbers mask deeper divides. Apartheid’s spatial and economic segregation still shapes who can afford dental care. In 2018, more than 70% of white South Africans had private health insurance compared with just 10% of Black South Africans. Overall, black Africans comprised just over 50% of all medical aid members, a low percentage given the country’s demographics – black Africans make up over 80% of the general population.
Private insurance typically covers dental services, although comprehensive cover has seen a steady decline over the years. Without it, people are forced to rely on an overstretched public system or to pay out of pocket.
Many people living in South Africa discover chronic illnesses only when complications send them to the hospital. The same pattern holds for oral health: routine check-ups and preventive care are luxuries for those living from hand to mouth, with care largely accessed when it impedes social function.
Despite mounting challenges in the system, South Africa’s oral health sector is a house divided. The private sector, employing the majority of the country’s oral health workforce, is preoccupied with survival and profit. Boardroom debates revolve around return on investment in a volatile and difficult economy, while the true well-being of the clients who sustain the industry is treated as a secondary concern, or merely a tedious exercise to maintain profitability.
As the country battles a healthcare worker unemployment crisis, with oral health professionals equally impacted, young professionals, many mired in student debt, accept meagre salaries in the private oral healthcare sector. The cost of replacing talent is getting lower with an influx of unemployed and desperate professionals with little hope of opening their own practices. The cost of starting a practice runs into millions, with scant access to loans or grants. Professional associations charge high fees, effectively keeping many early-career professionals outside their ranks. These associations are an invaluable resource for mentoring and professional development.
The public sector, meanwhile, has slipped into complacency, sailing with dysfunctional rudders toward the abyss, resistant to change and incapable of letting go of outdated approaches to care. The New South Institute has warned that South Africa’s public workforce is ageing – the public oral health sector is no exception. Staffing shortages (perpetuated by increasing vacancy rates for oral health professionals) leave queues growing ever longer. Leadership positions rotate among the same small circle of practitioners, and there is little investment in mentoring or developing the next generation of oral healthcare leaders.
Universities, once celebrated for their forward thinking and innovation, have, in their desperation to steady dilapidated ships, resorted to bringing back leaders from bygone eras instead of cultivating new talent – despite the clear need for fresh crews, updated rudders and stronger sails. Universities are blinded by their obsession with research outputs without sufficient emphasis on whether it actually leads to any material change in society through implementation. The broader political economy for oral health requires political intelligence and discernment, not expert knowledge alone, to drive meaningful impact.
This fractured system is at odds with itself. Each component is consumed by its own struggle: private practices fight for profitability and survival, public clinics battle to meet an overwhelming need for care, and universities play musical chairs with leadership. In the process, they lose sight of the bigger picture, advancing oral health for all.
We cannot continue to operate in siloed fiefdoms. Our mandate must be held by capable, willing hands across sectors, not by a privileged few who treat oral health as a personal enterprise. The private sector must look beyond matters of survival and economic prosperity for some and take its rightful place in championing universal access for all. The public sector must move past autopilot and actively lead, investing in mentorship, modernising care and developing leadership capacity to meet today’s mounting challenges.
Agents of change
Communities, too, must be partners in this effort. Engaging residents not as passive recipients but as agents of change can unlock a powerful force for health equity. Grassroots mobilisation can drive accountability and community-centred and driven approaches to oral healthcare.
With the ever-rising costs and inequitable distribution of oral healthcare access, turning to promoting self-care, brushing twice a day, limiting sugar consumption and, where available, visiting oral health clinics for regular check-ups, should be promoted not as a luxury but as a necessity. Prevention is cheaper than cure, and fostering self-reliance, within a broader supportive framework, reduces the burden on clinics and empowers people to take control of their health.
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The World Health Organization’s regional framework, together with the UN’s draft Political Declaration on the prevention and control of non-communicable diseases and the promotion of mental health, tabled at the UN High-Level Meeting, calls for stronger political commitment, resource investment and innovative workforce models to address oral diseases. Those words must become reality here. Integrating oral care into primary health packages (including cover for a dignified basic oral health package as part of National Health Insurance), expanding the training of dental therapists and hygienists, and ensuring fair remuneration are essential steps. But systemic change requires more: it demands that we confront the racialised and class-based structures that still dictate society’s oral health outcomes.
National Oral Health Month should not be a marketing exercise; it should be a rallying cry. We need leaders who recognise that oral health is inseparable from social justice and broader struggles for inclusive and equitable healthcare. We need a private sector that sees beyond profit margins, and its survival and a public sector that refuses to accept mediocrity. Most of all, we need communities to believe that their voices matter and that their actions, however small, can help heal our nation’s health and oral health problems.
*Vava is an Atlantic Fellow for Health Equity based at Tekano and the founding president of the Public Oral Health Forum, a volunteer-driven network committed to advancing oral health equity in South Africa and beyond.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
