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

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.