Japan Oral Health Association — Oral Disaster Preparedness Project
Surviving the disaster is not the end of the danger. Pneumonia is among the leading causes of the deaths that follow.It can begin in the mouth — a risk that preparedness can address.
Japan, one of the world’s most disaster-prone and most aged societies, has learned this lesson repeatedly since 1995. This page presents the evidence, the model we are building, and an invitation to adapt it — in disaster response, and in humanitarian settings worldwide.
The Problem
The deaths that come after
Japan distinguishes between direct deaths — caused by the hazard itself — and disaster-related deaths (saigai kanren-shi): deaths caused by the deterioration of health during evacuation and shelter life. The trend across three decades is unambiguous.
- Great Hanshin-Awaji Earthquake (1995): 6,434 deaths in total, of which 919 were certified as disaster-related in Hyogo Prefecture. Pneumonia was the largest single cause of related deaths, at about 24%. Roughly 90% of related deaths were among people aged 60 and over, and about 80% occurred within two months of the disaster.
- Great East Japan Earthquake (2011): in Ishinomaki City, pneumonia reportedly accounted for 26.9% of certified disaster-related deaths.
- Kumamoto Earthquake (2016): 50 direct deaths; 225 disaster-related deaths certified as of April 2025. Deaths after the disaster exceeded deaths during it — by more than four to one.
- Noto Peninsula Earthquake (2024): 228 direct deaths; 516 disaster-related deaths certified as of July 2026 — more than double the direct toll, with screening still ongoing. Circulatory disease (roughly 34%) and respiratory disease (roughly 33%) are nearly tied as causes among the disclosed cases.
Why the mouth? In evacuation shelters, water is scarce, toothbrushes are missing from relief supplies, dentures are lost or cannot be cleaned, and stress reduces saliva. Oral bacteria multiply; in older adults with weakened swallowing function, they are aspirated into the lungs. Among hospitalized pneumonia patients aged 70 and over, approximately 80% of cases have been reported to be aspiration pneumonia. After a disaster, poor oral hygiene, dehydration, undernutrition and declining swallowing function tend to overlap, and this is considered to raise the risk of pneumonia, including aspiration pneumonia. Everyday oral care is one of the measures to reduce that risk.
The Evidence
Oral care and pneumonia: what the evidence shows
The founding trial
In a two-year randomized controlled trial among residents of Japanese nursing homes, professional oral care was reported to reduce the incidence of pneumonia by 39% and pneumonia mortality by 53%. (Yoneyama T. et al., “Oral care and pneumonia,” The Lancet, 1999;354:515.) This study examined professional oral care involving dental professionals; it did not directly examine the effect of everyday toothbrushing on its own.
The mechanism
Among hospitalized pneumonia patients aged 70 and over, approximately 80% of cases have been reported to be aspiration pneumonia — caused by oral and pharyngeal bacteria entering the lungs. For older adults, keeping the mouth clean is therefore considered one way to lower the risk of aspiration pneumonia. (Teramoto S. et al., J Am Geriatr Soc, 2008;56:577-579.)
The field data
After the 2011 Great East Japan Earthquake, pneumonia reportedly accounted for 26.9% of certified disaster-related deaths in Ishinomaki City. These are cause-of-death records, not an intervention study; on their own, they do not show the effect of oral care.
The project’s statistical citations, educational materials, and official positions are managed under a structure in which our Chief Academic Officer, Dr. Koichi Nakakuki, DDS, PhD (Specially Appointed Lecturer, Center for Disaster and Environmental Dentistry, Tohoku University Graduate School of Dentistry; principal investigator of a national research program on dental health crisis management in large-scale disasters, Health and Labour Sciences Research Grants, 2007–2009; co-editor of Disaster Dental Medicine, 2018), holds final academic responsibility. Under our governance rules, the accuracy of statistics and citations is subject to an annual full review by the Chief Academic Officer, independent of any sponsor. Many of the practical materials and Q&As currently published on the Japanese-language site are drafts that have not yet been academically reviewed; they will be updated after review.
The Japanese Model
Not a campaign. A system.
The Oral Disaster Preparedness Project, operated by the Japan Oral Health Association, is building a replicable social implementation model — turning oral care from an act of individual goodwill into institutional infrastructure. It rests on five pillars:
01
EDUCATION
A structured curriculum in disaster oral care, for both citizens and health professionals, to be delivered through e-learning and in-person training. (In preparation.)
02
CERTIFICATION
A three-tier certification scheme (basic / professional / instructor) to build a distributed workforce of local advisers. (Under development.)
03
STOCKPILING
Standardized oral care kits for households and evacuation shelters, with quantity standards by shelter size, so that “what to stockpile” is no longer left to guesswork.
04
GOVERNMENT ADOPTION
Support for municipalities to embed oral care into local disaster management plans, shelter operation manuals, drills, and registries of persons requiring special care.
05
EVIDENCE
Continuous outcome measurement and publication, so that every element of the model remains open to scrutiny and improvement.
A methodology tested in the field: stay, hand over, institutionalize
- Niigata Chuetsu Earthquake (2004): from day 5, a 25-day rotation across 115 shelters delivered oral care to 1,226 evacuees — early proof that shelter-based oral care can be organized at scale.
- Onagawa, after the 2011 tsunami: eight years of continuing involvement in rebuilding local dental public health.
- Minami-Aso, after the 2016 Kumamoto Earthquake: three years of continuing involvement in rebuilding local dental public health.
This methodology was developed through two decades of field work by Japan’s disaster dental community, in which our Chief Academic Officer has played a central role. Its lessons were institutionalized in 2022 as JDAT — the Japan Dental Alliance Team — a nationwide disaster dental support system referenced in Japan’s Basic Disaster Management Plan, whose training program our Chief Academic Officer helped design and lead. In the 2024 Noto Peninsula Earthquake, 127 JDAT teams were deployed.
What Japan can offer is not equipment. It is a tested sequence: educate, stockpile, embed in government plans, stay after the cameras leave, and hand over to the community.
Beyond Japan
Wherever people are displaced, the same chain of risk follows them
The conditions that make oral care in shelters both harder and more important — crowded shelters, scarce water, interrupted routines, lost dentures, exhausted and grieving people — are not unique to earthquakes, and not unique to Japan.
Disasters
Earthquakes, floods, cyclones. Any country with an ageing population may face the pattern Japan documented: survival of the event, followed by disaster-related deaths during evacuation, in which respiratory diseases, including pneumonia, are among the leading causes. The model’s shelter protocols, stockpile standards, and training curricula are designed to be adapted, not copied.
Conflict and displacement
People displaced by armed conflict often live in collective shelters for months or years — far longer than most natural-disaster evacuations. Older people, people with disabilities, and people who have lost caregivers carry the highest risk. We believe that keeping one’s mouth clean, being able to eat, and being able to speak are quiet but fundamental parts of human dignity in displacement. We seek partners with humanitarian field experience to adapt this model responsibly; we do not claim expertise we do not yet have.
Ageing societies
Japan is the world’s most aged society; many countries are one or two decades behind on the same curve. Building oral care into emergency preparedness now is less costly than discovering its absence after the next crisis.
International humanitarian and health frameworks already acknowledge this territory. The Sphere Handbook’s guidance on hygiene items lists toothbrushes and toothpaste as additional items — beyond the first-phase essentials — to be provided to affected populations. The World Health Assembly’s 2021 resolution on oral health (WHA74.5) and the WHO Global Oral Health Action Plan 2023–2030 call for oral health to be included in national emergency preparedness and response plans. What remains globally underdeveloped — as it was in Japan — is operational implementation in emergency settings: who acts, with what supplies, under which procedures. That is precisely the layer this model addresses.
Partner With Us
We are looking for the first partners outside Japan
This project is young, and we say so plainly: our track record is being built now, in the open, with every design document and data source published. What we offer partners is not a finished product but a tested methodology, a documented evidence base, and an academic governance structure — and the willingness to adapt all three to your context.
Government agencies and municipalities
We can share our municipal adoption toolkit — model wording for disaster management plans, shelter operation checklists, stockpile quantity standards, and drill formats — and discuss adaptation to your legal and administrative framework. We work with governments of any political composition; the Association is strictly non-partisan.
International organizations
We seek dialogue on how shelter-based oral care can be operationalized within existing humanitarian coordination structures and standards, and how Japan’s disaster-related death certification data can inform global guidance.
NGOs and humanitarian operators
If your teams work in displacement or post-disaster settings, we are interested in co-designing pilot adaptations of our training and kit standards — with your field expertise leading on context, protection, and delivery.
Researchers
Our evidence base, reference list, and outcome frameworks are public. We welcome collaboration on shelter-based oral health outcomes, implementation science, and comparative disaster epidemiology.
Write to us in English or Japanese via the contact form.
The form is in Japanese. As the inquiry type, choose “国際連携・海外導入（International）” if it is not already selected, then fill in your name, email address, and message.
Contact usJapan Oral Health Association (registered general incorporated association, corporate number 3010405019730), Tokyo, Japan.
Governance, funding independence, and conflict-of-interest policies: /about/governance
Sources and data notes
- Yoneyama T., Yoshida M., Matsui T., Sasaki H. "Oral care and pneumonia." The Lancet, 1999;354(9177):515.
- Teramoto S. et al. J Am Geriatr Soc, 2008;56:577-579.
- Adachi R. An Official Journal of the Japan Primary Care Association, 2011;34:245-248 (Great Hanshin-Awaji Earthquake related-death analysis).
- Ishinomaki City, analysis of disaster-related deaths after the Great East Japan Earthquake (2011): pneumonia share of certified disaster-related deaths.
- Official disaster-related death certifications: Fire and Disaster Management Agency; Reconstruction Agency; Kumamoto Prefecture (Kumamoto figures as of April 2025); Ishikawa Prefecture damage report No. 230 and press tallies (Noto figures as of July 2026; the Noto total covers Ishikawa, Niigata and Toyama prefectures). Causes among the disclosed Noto cases: Cabinet Office, White Paper on Disaster Management 2025. Certified totals are revised over time; the Hanshin-Awaji total of 6,434 includes disaster-related deaths.
- Nakakuki K. (principal investigator). National research program on dental health crisis management in large-scale disasters, Health and Labour Sciences Research Grants, 2007–2009.
- Sphere Association. The Sphere Handbook, 2018 edition (hygiene items guidance; toothbrushes and toothpaste are listed among additional items).
- WHO. Resolution WHA74.5 on oral health (2021); Global Oral Health Action Plan 2023–2030 (who.int).
Japanese-language primary sources and the full reference list: /evidence. Disaster-related death figures are official certified counts and change as certifications proceed; this page states the as-of date wherever figures are cited.
The Association is non-partisan and does not endorse or affiliate with any political party, in Japan or elsewhere. Partnerships are governed by written agreements approved by the Association’s board.