The healthcare system and the provision of oral healthcare in EU Member States: France

Differences in the Ratios of General and Dental Specialists in Europe

BACKGROUND

The European Economic Area (EEA) is composed of member states with a multitude of different regions. This study aimed to analyse the ratios of general dentists and dental specialists to the total population and the proportion of dental specialists to general dentists in 24 European countries and to explore specific intranational differences within 2 countries: France and Germany.

METHODS

Available official documents and webpages from the United Kingdom and 23 of the 30 countries comprising the EEA were analysed. Data were expressed as absolute values, ratios of general dentists and dental specialists in the total of population, and percentages of dental specialists/dentists. The Mann-Whitney U test was used to clarify the main ratios that distinguish France from Germany, and cluster analysis was employed to determine similar areas.

RESULTS

Significant differences were found between countries, with Ireland and Austria having the lowest ratio of dentists and Romania and Greece having the highest. The Czech Republic, the Netherlands, France, and Denmark had the lowest ratios of dental specialists to the total population. Lithuania, Sweden, and Germany had the highest number of dental specialists. Orthodontists were the most numerous specialists (5.0% of dentists), followed by oral surgeons (2.7%). In France, differences between departments were pronounced and associated with the presence of dental schools and per capita income. In Germany, only the correlation between per capita income and the density of oral surgeons was significant.

CONCLUSIONS

Diverse ratios of general dentists and dental specialists to the total population and the proportion of dental specialists to general dentists were discovered within the examined countries, and their maximum values were 2.5, 5.7, and 4.1 times the minimum values, respectively. Differences were even found within the same country, as was the case in France and, to a lesser extent, in Germany.

Identifying Persons with Special Healthcare Needs in Dentistry-Development and Validation of the French Case Mix Tool

Providing dental care for certain patient groups is complicated due to difficulties with cooperation, communication, health conditions, and social context, amongst others. The majority of dentists in France work within a public fee-per-item system. A new measure has been introduced providing a financial supplement to dentists for each episode of care for a patient with a severe disability. This supplement is justified by completion of the French Case Mix tool (FCM), a new measure designed to retrospectively identify episodes of dental care that have required adaptation and additional time or expertise. The aim of this study was to investigate the validity and psychometric properties of the FCM. The content validity of the tool was improved at each round of pilot development, involving 392 patient encounters. Test-retest data at 2 weeks for 12 fictional patient treatment episodes were collected from 51 dentists. This phase confirmed inter- and intra-dentist reproducibility, criterion validity, and interpretability. Retrospective analysis of 4814 treatment episodes nationally demonstrated high reliability, internal consistency, and construct validity. Overall, the FCM showed high validity and good psychometric properties. However, the impact of providing a financial supplement on improving access to care for persons with special needs has yet to be evaluated.

Oral Care Needs Amongst Disadvantaged Migrants in France

Background

Disadvantaged migrant populations face risk factors that can affect their oral health amongst other health issues. The purpose of this study was to explore the oral care needs of these populations and to identify the obstacles they might encounter in accessing dental care.

Methods

A cross-sectional study using secondary data was carried out in the Centre Médical Louis Guilloux in Rennes, France, a health centre offering dental consults to migrants. The data were obtained by clinical oral examination and analysed according to various criteria: reason for consultation, diagnosis, treatment plan, drug prescriptions, and referrals to other practitioners.

Results

A high prevalence of decay was observed amongst the patients (72.3%). Fifty-nine patients were identified as needing major oral health care amongst the 130 files that were analysed. The lack of proficiency in the host country's language was associated with a major need for oral care (P < .02).

Conclusions

This study highlights that disadvantaged migrants face important oral care needs in France. It suggests alternative actions that should be carried out to improve their access to dental care, including access to interpreting.

Patients' Perspective on Their Experience of Dental Treatments Covered by Public Health Insurance in Romania-A Pilot Study

Although the aims of any public health coverage are prevention, diagnosis, treatment, rehabilitation, and maintenance, dental services are hardly ever included in services. The goal of our pilot study is to assess the perspective of a group of adult patients on their covered dental treatments. The present cross-sectional study was conducted on 140 patients who reported their perception by filling in a questionnaire. All the collected data were statistically analyzed using IBM SPSS Statistics 25. Most of the subjects (40.7%, n = 57) were treatment oriented, visiting the dentist only in an emergency situation. A total of 40.7% (n = 57) of the participants stated that all the dental treatments had coverage and 22.8% (n = 13) had to split their treatment plan because of the insurance budget limit. The subjects who had chosen covered dental services because they considered it was a right they should benefit from (53.7%, n = 22) and those who had chosen covered dental services because of financial reasons (29.3%, n = 12) were more frequently unsatisfied with the types of covered dental services. The reduced level of satisfaction was associated mainly with the list of dental procedures accepted for coverage and also with younger and highly educated patients. For a more accurate description, the present study should be completed by future studies not only on a representative population at national level, but also by assessing the perspective of dental professionals.

Inequalities in utilization and provision of dental services: a scoping review

BACKGROUND

There are many determinants that can affect inequality in oral and dental health. This study is aimed to explore the main determinants of inequality in both utilization and provision of dental services in Organization for Economic Co-operation and Development (OECD) countries.

METHODS

Four databases including PubMed, ISI WOS, Scopus, and ProQuest were searched up to 8 Aug 2020, applying the relevant keywords. Thematic analysis was used for synthesizing and extracting data. Trend analysis was applied to determine the trends of the inequality determinants.

RESULTS

Thematic analysis led to 6 main themes, 13 sub-themes, and 53 sub-sub-themes. The main themes represent the main inequality determinants for both utilization and provision of dental services. The streamgraph illustrated that fewer studies have been conducted on social and cultural determinants, and for almost all determinants the trend of published articles has been increasing since 2007, with the exception of health policies.

CONCLUSIONS

Inequality in the utilization and provision of dental services is addressed by various factors including individual, social, cultural and economic determinants, health policies, and availability of services. The first four determinants are related to utilization and the last two are related to the provision of services. All these aspects must be considered to reduce inequality in dental services.

Self-reported periodontal health and incident hypertension: longitudinal evidence from the NutriNet-Santé e-cohort

OBJECTIVE

An association between periodontitis and arterial hypertension has been suggested recently. This study aimed at investigating the hypothesis that periodontal health is linked to incident arterial hypertension.

METHODS

We analyzed data from the French population-based e-cohort NutriNet-Santé, selecting participants who had completed two oral health questionnaires in 2011-2012. Pregnant women, participants with diabetes, cancer, arterial hypertension and cardiovascular diseases at inclusion were excluded. Incident cases of arterial hypertension were self-reported and/or based on the use of antihypertensive therapy. Periodontal health was evaluated by estimating the modified and validated PEriodontal Screening Score (mPESS), with mPESS at least 5 corresponding to a high probability of severe periodontitis. Descriptive statistics and Cox proportional hazards regression models, taking into account sociodemographic and lifestyle confounders, were used.

RESULTS

The study population consisted of 32 285 participants (mean age: 45.79 ± 13.87 years); 78.5% were women. Two thousand one hundred and sixteen incident cases of arterial hypertension were identified during a median follow-up of 8 years (April 2012--December 2019). In the fully adjusted model, an mPESS at least 5 [hazard ratio: 1.84; 95% confidence interval (CI): 1.66-2.03] and the presence of nonreplaced missing teeth (hazard ratio: 1.13; 95% CI: 1.03-1.23) were significantly associated with a greater risk of incident arterial hypertension, whereas a regular annual visit to the dentist was associated with a lower risk (hazard ratio: 0.88; 95% CI: 0.80-0.97).

CONCLUSION

Self-reported assessed periodontitis was associated with incident arterial hypertension over an 8-year period. The present results highlight the importance of considering periodontal health when assessing an individual's risk of arterial hypertension.

TRIAL REGISTRATION

# NCT03335644.

Oral Health System in Myanmar: A Review

Objectives:

The study aims at reviewing Myanmar’s current situation to consider an improved oral health system and at promoting the oral health status of the Myanmar population.

Materials and Methods:

This review was conducted using the World Health Organization’s (WHO’s) six building blocks of the health system: oral health-care service delivery, dental workforce, oral health information system, essential medicine, health financing, and leadership and governance. The review was established on scientific articles and documents and information from reliable government and nongovernment organizations’ websites.

Results:

According to the National Oral Health Survey (2016–2017), the prevalence rate of untreated caries in six-year-old Myanmar children (84.1%), and in the 35–44 and 65–74 age group (above 40%) is high, which reflects a low utilization of oral health-care services. The dentist to population ratio is approximately 1:16,000: There are around 5,000 dentists and 400 trained dental nurses in Myanmar, and only about 1,000 dentists serve in government sectors. The inequalities in dental health care are compounded by a limited dental workforce and inequality of dentists between the public and private sectors in Myanmar. In the last National Health Plan (NHP, 2006–2011), the Myanmar government’s funding for required dental equipment and materials in each dental unit (around 5726 USD) has been considered inadequate. The current expenditure is not transparent. The other challenges are an insufficient supply of dental materials and instruments to all public dental sectors and a lack of oral health-care infrastructure.

Conclusions:

Such findings suggest a pressing need to address the effective oral health-care system and decree the specific goals for the Myanmar population’s oral health.

Does the Registered Dentists' Program Alleviate the Socioeconomic Gap in the Use of Dental Sealants?

Many countries provide preventive dental care for children to reduce inequalities. In Korea, the registered dentists' program was implemented to promote oral health and prevent oral diseases in primary school students. This study aimed to evaluate the registered dentist program through the sealant utilization rate using national cohort data and to compare the socioeconomic gap of the cohorts by participation. The sample cohort data were obtained from the National Health Insurance Sharing Service (NHISS) in South Korea. The utilization of dental sealants was analyzed using the chi-square test according to the independent variables of each year. To identify the independent effects of participation in the registered dentists' program, a panel logistic regression analysis of the utilization of dental sealants was performed. The participants were 1.35 times more likely to have dental sealants than non-participants. The significance of income quintiles disappeared in the case groups. The gap became more obvious in the employees of the control group even after adjusting for all variables. Implementing oral health programs can alleviate inequality with a relative increase in utilization in vulnerable populations.

Design and Development of Virtual Medical System Interface Based on VR-AR Hybrid Technology

With the continuous development of information technology and digital medicine, computer-assisted virtual medicine has become the development trend of a new generation of clinical surgery, which aims to improve the accuracy of surgery, reduce the risk of surgery, and achieve precise and minimally invasive treatment. The interface design in the computer-aided virtual medical system is a medium for transmitting and exchanging information between humans and machines. This article uses virtual reality technology and augmented reality technology to develop a virtual medical system interface, which aims to solve the interaction problem between users and virtual medical systems and satisfy users. The multidemand psychology is an effective way of interaction. It provides users with a multichannel and comprehensive communication method, which truly meets the design goals that meet the user's psychological needs. It also expands applications for virtual reality technology and augmented reality technology.

Developing leadership in dentists and schoolteachers to improve oral health inequalities

With oral diseases affecting people of all ages in every country of the world, new approaches are necessary to remove inequalities in oral health and increase access to oral health education. With over 1 billion children attending school, developing dental leadership skills not only in dental professionals but also in schoolteachers will help to spread oral health prevention messages effectively, implement healthy habits at a young age and impact a greater proportion of the global population to improve their oral health.

Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions

Oral health is an important component of general health, yet there is limited financial protection for the costs of oral health care in many countries. This study compares public dental care coverage in a selection of jurisdictions: Australia (New South Wales), Canada (Alberta), England, France, Germany, Italy, Sweden, and the United States. Drawing on the WHO Universal Coverage Cube, we compare breadth (who is covered), depth (share of total costs covered), and scope (services covered), with a focus on adults aged 65 and older. We worked with local experts to populate templates to provide detailed and comparable descriptions of dental care coverage in their jurisdictions. Overall most jurisdictions offer public dental coverage for basic services (exams, x-rays, simple fillings) within four general types of coverage models: 1) deep public coverage for a subset of the older adult population based on strict eligibility criteria: Canada (Alberta), Australia (New South Wales) and Italy; 2) universal but shallow coverage of the older adult population: England, France, Sweden; 3) universal, and predominantly deep coverage for older adults: Germany; and 4) shallow coverage available only to some subgroups of older adults in the United States. Due to the limited availability of comparable data within and across jurisdictions, further research would benefit from standardized data collection initiatives for oral health measures.

Implementation and impact of a dental preventive intervention conducted within a health promotion program on health inequalities: A retrospective study

Background

The objective of this retrospective survey was to evaluate after one year, the conditions and impacts of a dental sealant intervention conducted in New Caledonia, within a health promotion program. A greater or at least equivalent quality and impact of the intervention was expected for children living in socially deprived regions with the greatest health needs.

Methods

The study population was the schoolchildren, aged 6 years in 2016, who benefited from the dental sealant program (n = 2532). The study sample was randomly selected in 2017 from that population (n = 550). The children's dental status was evaluated at school in 2017 and compared with that recorded in 2016 during the sealant intervention allowing the calculation of the retention rates and one-year carious increment on first permanent molars. Socio-demographic variables (gender, public/private school) and conditions of sealant placement (school/dental office, presence of a dental assistant) were recorded. The carious increment was explained using a mixed multiple random-effects regression. A mediation analysis was conducted to assess the respective contributions of the retention rates and the region of origin on caries increment.

Results

The participation rate was very high (89%) and on average, children had 83% of their dental sealants present after one year, 31% fully and 52% partially present. Caries increment varied depending on the sealant retention rate as well as on the region (North, South, Islands). The mediation analysis showed that living in a deprived area (The Islands) was a strong determinant for high caries increment particularly when the retention rates were low.

Conclusions

This study showed a high participation rate and acceptable effectiveness as measured with the one-year retention rates, for a fissure sealant intervention conducted in real-life conditions and integrated in a large health promotion program. Nevertheless, the intervention was not effective enough to totally balance the influence of health determinants, especially in socially deprived sectors characterized by greater dental needs.

Sociodemographic Determinants and Common Reasons for Visiting the Emergency Dental Service in the City of Zagreb

Objective

The objective of the study was to determine the sociodemographic and clinical parameters of patients who visit the emergency dental service and their most common diagnoses.

Materials and Methods

The data were collected on the basis of a survey filled out by patients. A total of 1730 out of 6732 patients (26%) were surveyed using a questionnaire to analyze sociodemographic status, dental visits, the description and dynamics of the symptoms. After the data collection, methods of descriptive data presentation and of inferential statistics were made in SPSS.

Results

Survey results show that most subjects (60.4%) came during the weekends and holidays. The subjects, 73.1% of them, stated that they had already used this type of service, and 65.8% did not visit their dentist beforehand. The largest number of subjects (62.2%) reported that they needed emergency service within a week after their problems had begun. The most common diagnoses included face and jaw abscesses (27.3%). There is a statistically significant difference between the number of patients who went to the emergency dental service and completed the questionnaire over the course of several months contrary to patients who were there in May and June (59.7%) compared to July and August (40.3%).

Conclusions

Most subjects had clear indications for being referred to an emergency dental service. Most of the emergency conditions were mainly due to irregular visits to the dentist. Patient education and preventive programs would probably have reduced the number of visits.

Association of the Dietary Index Underpinning the Nutri-Score Label with Oral Health: Preliminary Evidence from a Large, Population-Based Sample

The 2017 implementation in France of the front-of-package nutrition label known as ‘Nutri-Score’ was intended as a public health strategy to help individuals make healthier food choices at the point of purchase and thus help reduce chronic disease on the population level. Nutri-Score and the associated individual-level dietary index are based on the British Food Standards Agency Nutrient Profiling System (FSAm-NPS-DI). Prior research has shed light on the relation between the dietary index and various physical health outcomes, yet no studies have explored the link with oral health. We analyzed the cross-sectional association of the dietary index with oral health in a population-based sample of 33,231 adults from the French NutriNet-Santé cohort. Oral health (main dependent variable) was assessed in 2016 with the General Oral Health Assessment Index; FSAm-NPS-DI (main independent variable) was calculated using ≥3 non-consecutive 24-h dietary records, following established methodology; lower scores corresponded to better diet quality. Age-specific associations were explored via multivariable linear regression. Fully-adjusted models showed modest yet significant associations between the dietary index and oral health in younger (18–59 years) and older (60+ years) participants, with the strength of the model being more pronounced in the former compared with the latter age group (F value: 28.5 versus 6.3, both p < 0.0001). Higher diet quality was associated with a somewhat lower risk of oral health problems. Albeit preliminary, the findings support the relevance of dietary indices underpinning nutrition labels such as the Nutri-Score. Future research is needed to confirm the associations.

Evaluation of a Care Coordination Initiative in Improving Access to Dental Care for Persons with Disability

In French law, the state is responsible for ensuring equal access to health care for people with disabilities. No system exists within dentistry to guarantee this-there are no salaried public service workers, over 85% of dentists work in general practice, and hospital dentistry is poorly developed. Public funding is available for care coordination initiatives termed "Health Networks". The objective of this study is to report on an internal evaluation of the Réseau Santé Bucco-Dentaire et Handicap de la région Rhône-Alpes (RSBDH), a Health Network coordinating dentistry for persons with disability in the Rhône-Alpes region, and to discuss the French model of Health Networks as a response to improve access to care. Existing governmental guidelines for the evaluation of Networks were adapted for the RSBDH. The RSBDH coordinated dentists to ensure screening, prevention, and treatment for 3219 persons with disability in 2015. Identified strengths included the identification of vulnerable persons, improved access to treatment and collaboration with primary care services. Weaknesses included training of professionals, continuity of care, information sharing, and stakeholder participation. In 2015, the cost was €501 per patient. This model raises major issues of cost, training, equity, and quality of care within special care dentistry. This discussion is relevant to many countries where models of service provision are currently being developed.

[Oral health inequalities: Determinants of access to prevention and care in France]

INTRODUCTION

Oral diseases are unequally distributed according to a social gradient, which now constitutes a major public health problem. Acting against oral health inequalities requires a better understanding of the underlying mechanisms in order to identify the appropriate solutions to improve access to oral health promotion and dental care for deprived populations.

METHODS

A patient-centered model of health care access, describing the ideal interactions between individuals and the health care system was applied to the field of oral health in the French context. This model defines access to health care as the result of interactions between individuals and the health care system, in which health needs are perceived, health care is sought, health care structures are accessed and effectively used. Analysis is based on quantitative and qualitative bibliographic data acquired through an explanatory sociological approach.

RESULTS

Socially deprived populations face many barriers preventing their access to dental care: the need for dental care is not necessarily perceived, and, when perceived, dental care is not immediately sought, accessibility to dental care structures is difficult and dental attendance is erratic.

CONCLUSION

This review provides information to decision-makers in order to support regional health policies and to help implement public health strategies according to the principle of proportionate universalism. Two axes for action were identified, namely to integrate oral health promotion interventions within health promotion programmes and to gradually reorganize the dental care system to make it more accessible to everyone.

Variations in the provision and cost of oral healthcare in 11 European countries: a case study

Aim: To compare the provision and costs at the point of delivery of dental treatments in a sample of European Union (EU) Member States. Materials and methods: A questionnaire with open-ended questions was sent to oral health policy-makers in Denmark, England, France, Germany, Hungary, Ireland, Italy, the Netherlands, Poland, Romania, Scotland and Spain. They were asked to answer questions on the probable costs and provision of treatment in their country for a vignette presented as a pre-defined case. Results: All respondents returned answers to all questions. Wide variations were reported in: who would deliver care, cost of items of care and total cost. For example, in France, only a dentist would provide the treatment. In Denmark, England, Germany, Ireland, Italy, the Netherlands and Scotland, it was likely that the treatment would be provided by a combination of dentist, dental hygienist and dental nurse. Fees ranged from €72 in England (if treated within the NHS) to €603 in Denmark. In Italy, Spain and for most patients in Romania, all treatment costs were paid by the patient. In the other nine countries, some subsidy from public funds was available. In terms of percentage of per capita Gross National Income, the cost to the patient ranged from 0.12% in France to 1.57% in Spain. Conclusions: It was apparent that there are wide variations between EU Member States in the manner in which oral healthcare is delivered, its cost and the extent to which the cost of treatment is subsidised from state funds or through private insurance.

Adherence to National Dietary Guidelines in Association with Oral Health Impact on Quality of Life

We aimed to assess the association between oral health, in terms of its impact on quality of life, and diet quality expressed as adherence to dietary guidelines. We analyzed cross-sectional data from the French NutriNet-Santé general population-based e-cohort (N = 18,263 adults; mean age = 56.5 ± 13.8 years). The main independent variable, oral health-related quality of life, was assessed in 2016 with the GOHAI instrument (maximum score = 60). The main dependent variable, diet’s nutritional quality, was assessed with the mPNNS-GS score (maximum score = 13.5) measuring adherence to French dietary guidelines and computed on the basis of repeated 24-h dietary records. Multivariable linear regression models were fit. Mean GOHAI score was 54.5 ± 4.3 and mean mPNNS-GS score was 7.7 ± 1.6. Among participants aged 18–64 years, those scoring ≤50 on GOHAI (poor oral health with a detrimental impact on quality of life) were less likely to adhere to dietary guidelines than participants scoring 57–60 points (good oral health) (beta = −0.18, 95% CI: −0.26, −0.09; p < 0.0001). Among participants aged 65+ years, those scoring 51–56 points on GOHAI (average oral health with some negative impact on quality of life) were less likely to adhere to dietary guidelines than were participants scoring in the range 57–60 (beta = −0.23, 95% CI: −0.33, −0.13; p < 0.0001). The findings suggested modest age-dependent associations between oral health-related quality of life and diet quality. Confirmation is needed longitudinally with representative samples and accounting for diet quality evolution.

Which factors most influence referral for restorative dental treatment under sedation and general anaesthesia in children with complex disabilities: caries severity, child functioning, or dental service organisation?

BACKGROUND

The UN Convention on the Rights of the Child gives all children right to the highest standard of services for treatment and rehabilitation. For children with disabilities, sedation and general anaesthesia (GA) are often indicated for dental treatment; however, accessibility to this varies. The International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) enables a biopsychosocial description of children undergoing dental treatment.

AIM

To investigate conscious sedation and GA in children with complex disabilities and manifest caries and analyse how caries, child functioning, and dental service organisation relate to dental GA (DGA), comparing Argentina, France, and Sweden using the ICF-CY.

DESIGN

Quantitative, cross-sectional; data collected through structured interviews, observation, and dental records.

RESULTS

Sedation and DGA were common. Children with limitations in interpersonal interactions and relationships were more likely to have had DGA (OR: 5.3, P = 0.015). Level of caries experience was strongly correlated with experience of DGA. There were significant differences between countries regarding caries prevalence, sedation, DGA, and functional and environmental factors.

CONCLUSIONS

Although caries experience and child functioning are important, dental health service organisation had the most impact on the incidence of DGA, and for the use of conscious sedation, for children with complex disabilities.