Long Term Dental Work Force Build-Up and DMFT-12 Improvement in the European Region

Abstract

Introduction As Mikiko Hayashi noticed in an amazingly poetic way, dentistry remains in majority of national health systems across the globe: “the Cinderella of health care.” Regardless of undisputed progress of scientific knowledge there is a growing gap in service utilization patterns among the world's rich and poor citizens. The first tend to consume much of a rather cosmetic expensive treatments without essential health added value. At the same time almost three billion of people belonging to the low income households, lack access to basic dental services or do not pay a visit to a dentist for years (Hayashi et al., 2014). Although the issue of affordability is high at stakes in these countries, uneven distribution between rural and urban areas adds to the challenge. Prime example is definitely India whose giant population was served by 117,825 registered dentists out of whom almost 90,000 were concentrated in only four out of thirty Indian federal states (Vundavalli, 2014). Another case is Australia with its huge geographic area and recently reported ratio of almost 40,000% differential between dentist density in the suburbs of core coastline cities and desert Aboriginal communities (Tennant et al., 2013). Due to international efforts addressing global oral health deficiencies national capacities worldwide have increased sharply over past few decades (Petersen, 2003). Important part of this capacity build-up was grounds laid down by establishment of “WHO Oral Health Country/Area Profile Programme” (or “CAPP”) by the World Health Organization (WHO) back in 1990s. Its cause was the fact that evidence based policy needed reliable and internationally comparable field data. The two main WHO Collaborating Centers whom we own existence and maintenance of these public registries are the Niigata University, Japan and Faculty of Odontology, Malmö, Sweden. The first is in charge of Periodontal Country Profiles and the latter pursues the uneasy task of providing broader Country Oral Health Profiles. Nevertheless other comprehensive sources of evidence on oral health status across regions and nations developed independently. FDI World Dental Federation provides access to the its own Data Hub which consists of fusioned national data sources originating from WHO and World Bank (WB) and Globocan official registries. The European Health for All database (HFA-DB) created and updated by the WHO Office for the European Region and refers to a total of 53 countries located in the European continent. Some of the aforementioned investments allowed for revelation of hidden long term national patterns in oral health care and identification of core weaknesses that might serve as appropriate policy targets in future. So far there is scarcity of published evidence comparing efficiency of all European countries in dental workforce build-up and its relationship to the dental health status of school children in a several decades long time horizon. Methodology Measurements we relied on in this study were averaged over country populations in an observed year. Source used was official release of European Health for All Database (HFA-DB). Targeted 53 countries were all located entirely or partially within the WHO geographical boundaries of the European region. Indicators of health care professional personnel capacity (dentist density and graduate dentist annual outputs) and DMFT-12 (Decayed/Missing/Filled Teeth at 12 year olds) as the core indicator of juvenile oral health were observed. Selected indicators are presented in Tables 1, 2. Total decrease of DMFT-12 and total increase in dentist density per 100,000 population were observed as entire span between the first and the last available value reported to WHO by the national authorities. These historical indicator differentials were used to sort out countries through a top-down approach from most successful to the less efficient ones. Table 1 Oral health indicator DMFT-12 in the European region according to national values reported to WHO HFA-DB. Countries First available DMFT-12 index Last available DMFT-12 index Time span between two observations (Years) Total DMFT—12 decrease Annual DMFT—12 decrease Sweden 7.81975 0.82011 36 7.00 0.194 Norway 8.4 1973 1.62006 33 6.80 0.206 Finland 6.91975 0.72009 34 6.20 0.182 Netherlands 7.31974 1.12005 31 6.20 0.2 Switzerland 6.11975 0.822009 34 5.28 0.155 Slovenia 6.91984 1.82000 16 5.10 0.319 Denmark 5.21975 0.62012 37 4.60 0.124 Italy 5.51978 1.12004 26 4.40 0.169 Ireland 5.41970 1.12002 32 4.30 0.134 United Kingdom 4.71973 0.72009 36 4.00 0.111 Hungary 6.11976 2.42008 32 3.70 0.116 EU members before May 2004 4.741980 1.372000 20 3.37 0.168 Slovakia 5.7 1975 2.42006 31 3.30 0.106 Germany 3.91992 0.72009 17 3.20 0.188 Latvia 6.61985 3.42004 19 3.20 0.168 Portugal 4.61975 1.482005 30 3.12 0.104 Czech Republic 5.7 1975 2.62006 31 3.10 0.1 Luxembourg 3.91985 0.82006 21 3.10 0.148 Croatia 7.61986 4.82010 24 2.80 0.117 Greece 3.81975 1.352007 32 2.45 0.076 France 3.51975 1.22006 31 2.30 0.074 EU 4.11985 1.862000 15 2.24 0.149 Belgium 3.11972 0.92010 38 2.20 0.058 Albania 5.91983 3.82007 24 2.10 0.087 Bosnia and Herzegovina 6.21997 4.22004 7 2.00 0.286 Kyrgyzstan 3.11973 1.11993 20 2.00 0.1 Uzbekistan 2.81988 0.92001 13 1.90 0.146 Estonia 4.11988 2.42000 12 1.70 0.142 European Region 3.811985 2.222000 15 1.59 0.106 Cyprus 2.5 1990 1.32010 20 1.20 0.06 Bulgaria 4.21979 3.12008 29 1.10 0.038 Malta 2.31975 1.42004 29 0.90 0.031 Spain 1.91975 1.12010 35 0.80 0.023 Turkey 2.71987 1.92007 20 0.80 0.04 Israel 2.41975 1.66 2002 27 0.74 0.027 EU members since May 2004 4.221985 3.552000 15 0.67 0.045 Russian Federation 3.51975 2.92008 33 0.60 0.018 Commonwealth of Independent States (CIS) 3.491986 3.461990 4 0.03 0.007 Armenia 2.41985 2.41990 5 0.00 0 Georgia 2.41985 2.41990 5 0.00 0 Kazakhstan 2.11985 2.11990 5 0.00 0 Montenegro 3.42006 3.42006 0 0.00 0 San Marino 3.71987 3.71990 3 0.00 0 Tajikistan 1.21973 1.21990 17 0.00 0 Turkmenistan 2.61985 2.61990 5 0.00 0 Lithuania 3.61985 3.72005 20 −0.10 −0.005 Ukraine 2.51983 2.82008 25 −0.30 −0.012 TFYR Macedonia 6.51986 6.92007 21 −0.40 −0.019 Romania 1.71975 2.192009 34 −0.49 −0.014 Republic of Moldova 2.31986 3.52008 22 −1.20 −0.054 Andorra N/A N/A N/A N/A N/A Austria N/A 1.42007 N/A N/A N/A Azerbaijan N/A N/A N/A N/A N/A Belarus N/A 2.12009 N/A N/A N/A Iceland N/A 1.42005 N/A N/A N/A Monaco N/A N/A N/A N/A N/A Poland N/A 3.22010 N/A N/A N/A Serbia N/A N/A N/A N/A N/A *DMFT-12 index—Decayed, missing or filled teeth at age 12. Table 2 Dentist density and graduate dentist output in the European region according to the national values reported to WHO HFA-DB. Countries Dentists density (PP) per 100 000 (First available/Last available) Time span between two observations (Years) Total increase in Dentist Density (PP) per 100 000 Annual increase in Dentist Density (PP) per 100 000 Dentists graduated per 100 000 (First/Last available value) Number of Dentists (PP) national level (First/Last available value) Number of dentists graduated in a given year (First/Last available value) Portugal 11.01980/76.82011 31 65.8 2.12 0.51985/6.92011 10831980/81082011 501985/7232011 Cyprus 35.81980/91.52011 31 55.7 1.80 N/A 1821980/7832011 N/A TFYR Macedonia 23.61980/78.62011 31 55 1.77 3.81980/7.62010 4461980/16222011 721980/1562010 Spain 10.51980/63.02011 31 52.5 1.69 1.01991/3.02011 39461980/290702011 3691991/13792011 Greece 79.31980/128.52011 31 49.2 1.59 4.31980/3.22007 76461980/145182011 4121980/3552007 Luxembourg 36.01980/83.12012 32 47.1 1.47 N/A 1311980/4412012 N/A Estonia 46.21980/88.02011 31 41.8 1.35 1.61980/2.32011 6821980/11792011 231980/312011 Bulgaria 54.61980/90.92011 31 36.3 1.17 2.61985/4.02011 48391980/66822011 2311985/2902011 Belarus 17.91980/54.12011 31 36.2 1.17 1.81990/2.62011 17241980/51232011 1871990/2452011 Austria 21.61980/56.92012 32 35.3 1.10 0.01998/1.62010 16221980/47972012 31998/1312010 Croatia 37.41980/71.82011 31 34.4 1.11 3,71980/3.52003 17151980/31622011 1691980/1562003 Latvia 37.01992/70.72011 19 33.7 1.77 2.51980/1.82012 9661992/14562011 621980/372012 Romania 31.71999/62.12011 12 30.4 2.53 1.91991/5.92011 71081999/133242011 4461991/12632011 Ireland 30.41980/58.02012 32 27.6 0.86 2.11980/1.52011 10331980/26612012 711980/702011 Lithuania 55.21992/82.12011 19 26.9 1.41 1.51985/4.72011 20441992/24862011 541985/1412011 Hungary 26.41985/52.52011 26 26.1 1.00 1.31985/2.82011 28081985/52362011 1341985/2792011 Czech Republic 45.91980/70.82011 31 24.9 0.80 4,31980/2.92011 47431980/74292011 4401980/3002011 Ukraine 45.42000/67.62012 12 22.2 1.85 2.82000/4.52012 223722000/306882012 14012000/20452012 Armenia 23.02000/42.72012 12 19.7 1.64 0.71980/20.22012 7422000/12902012 221980/6102012 EU 48.21985/67.02011 26 18.8 0.72 2.31980/2.72011 N/A N/A EU members before May 2004 53.61992/71.32011 19 17.7 0.93 2.31985/2.42011 N/A N/A Italy 42.21993/59.32011 18 17.1 0.95 0.71985/2.22011 240001993/351832011 4101985/13092011 Germany 65.11992/80.12011 19 15 0.79 3.11991/2.72011 524561992/655022011 24441991/21872011 European Region 28.61980/42.52011 31 13.9 0.45 2.01985/2.32011 N/A N/A Republic of Moldova 33.71980/46.92012 32 13.2 0.41 1.81980/3.42011 13531980/16702012 701980/1222012 Turkey 15.91980/28.42011 31 12.5 0.40 0.71980/1.32011 70771980/210992011 3191980/9502011 Andorra 48.41995/60.52009 14 12.1 0.86 2.92003/0.02009 311995/512009 22003/02009 Iceland 73.71980/84.22012 32 10.5 0.33 3.11980/1.92010 1681980/2702012 71980/62010 Kazakhstan 30.91980/41.22012 32 10.3 0.32 1.81990/2.42009 46231980/69202012 3061990/3742009 Netherlands 41.01995/50.22010 15 9.2 0.61 3.11985/1.72011 63441995/83452010 4531985/2782011 Switzerland 45.01980/53.62011 31 8.6 0.28 2.11980/1.42011 28411980/41232011 1301980/1042011 Albania 24.91980/32.92006 26 8 0.31 1.01990/1.32010 6651980/10352006 331990/422010 EU members since May 2004 44.21980/51.42011 31 7.2 0.23 2.31980/3.32011 N/A N/A Belgium 63.61985/70.42011 26 6.8 0.26 1.41993/1.32011 62731985/77772011 1391993/1462011 Commonwealth of Independent States (CIS) 24.81980/30.82012 32 6 0.19 2.01990/2.52012 N/A N/A Slovakia 44.12000/50.02007 7 5.9 0.84 2.61980/1.02009 23842000/26972007 1301980/532009 United Kingdom 48.32007/53.62012 5 5.3 1.06 N/A 294512007/336532012 N/A Tajikistan 11.81985/15.92011 26 4.1 0.16 1.01990/0.72006 5391985/12442011 551990/432006 Russian Federation 28.51990/32.02006 16 3.5 0.22 2.01990/1.82004 421021990/456282006 29301990/25672004 Uzbekistan 13.81980/17.32012 32 3.5 0.11 1.31990/1.32010 21951980/51512012 2551990/3772010 Slovenia 59.11998/62.42011 13 3.3 0.25 0.81980/1.92011 11711998/12802011 161980/382011 Norway 82.21985/85.22011 26 3 0.11 2.51980/2.72011 34141985/42182011 1011980/1352011 Kyrgyzstan 15.31980/17.82012 32 2.5 0.08 1.11980/4.82012 5541980/9732012 381980/2622012 Malta 43.22009/45.32012 3 2.1 0.7 2.81990/1.42012 1792009/1902012 101990/62012 Bosnia and Herzegovina 19.51980/20.72010 30 1.2 0.04 1.81980/3.42010 7991980/7972010 741980/1322010 Georgia 33.21996/33.62012 16 0.4 0.02 1.01990/7.62011 15341996/15092012 551990/3402011 France 65.62011/65.32012 1 −0.3 −0.3 3.41980/1.42007 415072011/417402012 18491980/8362007 Azerbaijan 28.91980/26.72012 32 −2.2 −0.07 1.31990/1.22012 17771980/24612012 891990/1132012 Turkmenistan 16.71998/11.92012 14 −4.8 −0.34 1.61985/0.32012 7881998/6142012 511985/142012 Finland 85.22000/78.92010 10 −6.3 −0.63 3.51980/3.32012 44102000/42342010 1661980/1772012 Sweden 91.21995/84.92010 15 −6.3 −0.42 4.41980/2.32010 80481995/79592010 3621980/2172010 Denmark 84.61992/77.92009 17 −6.7 −0.39 3.21980/2.52011 43731992/42972009 1661980/1412011 Israel 85.61996/75.62011 15 −10 −0.66 1.41990/1.22011 48671996/58672011 671990/902011 Serbia 47.02003/34.12012 9 −12.9 −1.43 2.92002/7.62011 35162003/24582012 2162002/5502011 Monaco 115.41980/102.42012 32 −13 −0.41 0.02011/0.02011 301980/372012 02011/02011 Poland 47.31980/33.82011 31 −13.5 −0.43 2.11980/2.52011 168341980/130332011 7401980/9582011 Montenegro 26.21980/4.52011 31 −21.7 −0.7 N/A 1521980/282011 N/A San Marino N/A N/A N/A N/A N/A N/A N/A *Ranking was based on average annual improvement to eliminate bias arising from different reporting periods. Results Combined insight into the national professional capacity data reveals few interesting patterns (Table 1). Over the past three decades, dentist density per 100,000 resident population increased sharply across Europe. The list is topped by mostly Mediterranean countries (Portugal, Cyprus, Spain, Greece), continental high-income economies (Luxemburg and Austria) while the remaining ones among top 10 performers belong to Eastern European formerly planned economies (TFYR Macedonia, Estonia, Bulgaria, Belarus). Surprisingly, the upper half of ranked dental health systems is actually dominated by Eastern European countries out of which some are post-2004 EU members (Croatia, Latvia, Romania, Lithuania, Hungary, Czech Republic) others belonged to the Commonwealth of Independent States (CIS) for the most of post Cold War period (Ukraine, Armenia, Republic of Moldova, Kazakhstan). Few regions in Europe actually recorded fall in professional staff density. This was either the case due to satisfactory health system performance such as the Nordic model applied in Finland, Sweden and Denmark. Other countries with significant negative trend noticed where two Western Balkan countries (Serbia and Montenegro), Poland and CIS members Turkmenistan and Azerbaijan. Among these there are few traditional mature market economies of France, Israel and Monaco. Observation of European historical evolution on DMFT-12 since the middle of 1970s has shown substantially different landscape (Table 2). The list is topped by Scandinavian countries (Sweden, Norway, Finland and Denmark). All other top ten nations marked by high childhood dental health improvements belong to traditional high income societies (Netherlands, Switzerland, Italy, Ireland, and United Kingdom) or recent ones like Slovenia. The remaining part of upper half of the rank list is dominated by diverse Eastern European countries (Hungary, Slovakia, Latvia, Croatia, Czech Republic, Albania, Bosnia and Herzegovina, Kyrgyzstan, Uzbekistan, Estonia) with quite few OECD members prior to 2000s (Germany, Luxembourg, Greece, France, Belgium, Portugal). Large amount of missing DMFT-12 data in certain years or geographical territories or rather short intervals observed placed significant part of bottom ranked countries into the “no-progress” group (equal values reported at baseline and last point in seven countries) with eight countries with non-applicable DMFT-12 calculation. Five nations confirmed worsening of childhood dental health at age 12 and these were Lithuania, Ukraine, TFYR Macedonia, Romania, Republic of Moldova. Vast majority of the entire aforementioned group of non-classified or poor performing health systems are located within Eastern Europe and the Balkans region. Discussion With regards to core oral health indicators such as the index of serious tooth decay (DMFT) most of broad European Region recorded significant achievements since very concerning dental health landscape of the 1970s. Deep Russian recession of 1990s dragging surrounding nations and transitional health reforms taking place throughout Central and Eastern Europe took their toll (Jakovljevic and Getzen, 2016). Nevertheless since the late 1990s things got substantially better in many of these countries, availability of resources became bigger while management of both in- and outpatient dental services was getting more efficient and cost-effective toward the 2000s (Jakovljevic, 2013). These developments affected both the old public and newly evolving, private dental sector. Over several decades improvements in school children were huge. Such advances mostly assumed decreasing frequency of tooth extractions substituted with fillings as well as longer preservation of natural teeth in adults alongside life span. Although there is an evident converging trend in oral health within the European Union (EU) member states few core weaknesses remain. Some of the most prominent are: inter country and inter regional diversity of dental health status indicators among the elderly, lower affordability of dental care to minority groups and the poor and concerning signs of possible worsening of oral health among the European children since the 2000s (Bourgeois et al., 2003). Blossoming of private dental schools in less regulated markets, oversupply and underemployment of graduate dentists are present but more characteristic of Post-Semashko, Eastern European national systems. Some policy makers across the region suspected falling quality of medical services. This might be partially attributable to the growing competitiveness of the private dental sector in Europe and financial incentives to gain larger profit margins. Previous literature records suspect direct causal link between DMFT-12 and dentist density. Furthermore there is reliable evidence that pediatric dental health is less linked to the local accessibility of dental practitioners and more dependent upon gross national income level, dental expenditure and expected years of education (Pinilla and González, 2009). Nevertheless availability of these data over long term time horizon allows assessment of independent progress in both issues in Europe. Oversight of significant inter-country differences in dental workforce capacities across the continent to some extent masks huge regional intra-country diversity mostly driven by socioeconomic inequalities (Tchicaya and Lorentz, 2014). Contribution of European Commission's agenda in oral public health is development of strategies aimed at closing major gaps in population dental status within the EU and converging national health policy targets (Widström and Van Den Heuvel, 2005). Recent FDI effort actually reveals hidden patterns of dental work force migration and market incentives affecting service provision and unmet demand (Yamalik et al., 2014). Output of dental graduates follows country size as a general rule (Table 1) and it is dominated by Russian Federation, Germany and other large European countries. Some others like Turkey exhibit so far weaker overall dentist practitioner capacity (21,099 in total in 2011 compared to its large population size). Some of similar time lags of the emerging economies compared to mature ones might be explained by the fact that oral health is frequently neglected policy priority in most national health systems (Kandelman et al., 2000). Study limitations Unique data set exploited for this study consisted of national level records reported to WHO HFA-DB. Unlike many other public health indicators present in major international publicly accessible registries, the best available oral health and dentist density data are presented with wide gaps in both individual countries as well as time periods. These missing data gaps are present in many years or entire regions. Therefore all calculations made here are based upon the best available evidence. Conclusions arising from presented facts are therefore based on differentials between the first and the last available data. In order to improve methodological soundness and applicability we presented individual country advances in community oral health in terms of annual rates and total differentials. Although these calculations might serve as an approximate success ratio they are not fully comparable among countries. This is the case because reported annual national values frequently refer to slightly different time horizons. Nevertheless majority of observed historical data belong to the middle of 1970s or early 1980s while most of the last available data belong to the early 2010s. Conclusion The long term trends observed relate to the period of three to four decades. Such insight points out to the broad changes of the landscape of major challenges in the European dentistry. Obvious successes in liquidating great oral health crisis of the 1970s are reflected in a decent dental status of European school children. Serious efforts to build up dental work force capacities are only partially responsible for that success story (Velickovic et al., 2015). Large part of the improvements is actually attributable to the growing living standards, oral health literacy of general population and policy efforts to improve affordability of dental care to the ordinary citizens (Rančić et al., 2015). Nevertheless major upcoming challenges are population aging associated with extended life expectancy and blossoming of prosperity diseases and increased demand for medical care by the elderly. How the European region will cope with these issues remains unclear (Ogura and Jakovljevic, 2014; Jakovljevic, 2015, 2016; Jakovljevic and Milovanovic, 2015). This study points out to the significant regional differences within the continent (Jakovljevic and Getzen, 2016). Eastern EU members as well as Commonwealth of Independent States members were driving the large part of staff density increase due to their intensive transitional health reforms (Jakovljevic et al., 2015). Regardless of such promising changes these countries will remain substantially more vulnerable to the upcoming challenges compared to the traditional market economies of Western Europe (Jakovljevic et al., 2016a,b). Author contributions MJ and TK designed the research questions and concept of this Opinion article. ML and RV acquired selected published data from the public registry European Health for All Database issued by WHO. All four authors interpreted jointly the findings stated in the article and contributed to the final manuscript in important intellectual content. Conflict of interest statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.