The State of

Oral Health in Europe

Report Commissioned by the Platform
for Better Oral Health in Europe
Dr. Reena Patel, Dental Advisor
September 2012
3
Foreword
The news on Europes oral health is both good and bad: the good news is that we have witnessed incred-
lble progress ln Lhe lasL decades ln Lhe prevenuon of carles ln chlldren. 1he bad news ls LhaL havlng dam-
aged, mlsslng or lled LeeLh ls sull Lhe norm raLher Lhan Lhe excepuon ln Lurope, and oral dlseases remaln
amongsL Lhe mosL lmporLanL healLh burdens. Moreover, we sull fall Lo reallse LhaL oral healLh ls abouL
much more Lhan havlng good LeeLh. lL ls an lnLegral parL of our general healLh, and lL lmpacLs noL only our
quallLy of llfe, buL also on socleLy and healLh sysLems Lhrough Lhe assoclaLed economlc cosLs.
ln a ume of ausLerlLy measures and growlng pressure on healLhcare budgeLs, Lhls reporL ls a umely re-
mlnder LhaL we have Lo Lackle Lhe perslsung dlsparlues ln oral healLh across and wlLhln Lu counLrles, wlLh
regards Lo socloeconomlc sLaLus, age, gender, or lndeed general healLh sLaLus.
ln order Lo do so and Lo ensure LhaL Luropean cluzens can all have healLhler smlles ln Lhe fuLure lL ls my
bellef LhaL Lhe Lu can, and musL, play a sLronger role ln Lhe ghL for beuer oral healLh.
1hls reporL clearly underllnes Lhe challenges LhaL cluzens and pollcymakers are confronLed wlLh when Lry-
lng Lo lmprove oral healLh:
1radluonal curauve denLal care has a slgnlcanL economlc burden for many lndusLrlallzed coun-
Lrles: Lhe currenL Lu 27 spendlng on all aspecLs of care and LreaLmenL ls close Lo t79 bllllon, and lf
Lhe Lrends conunue, Lhls gure could be as hlgh as t93 bllllon ln 2020.
uemographlc change presenLs a formldable challenge for oral healLh, slnce decreaslng loss of
LeeLh wlLhln Lhe elderly populauon ls expecLed Lo lncrease LreaLmenL needs slgnlcanLly ln Lhe
comlng years.
1here are rlslng lnequallues across Member SLaLes ln Lerms of access Lo approprlaLe oral care, as
low-lncome populauons mosL ln need of denLal care face hlgher hurdles compared Lo hlgh-lncome
groups.
AL Lhe same ume, Lhls reporL also ouLllnes a number of successful lnluauves LhaL can help reduce Lhe soclal
and lndlvldual burden of oral dlseases Lhrough a number of measures such as: communlLy-based preven-
uon lnluauves, reducuon of Lhe socloeconomlc and envlronmenLal rlsk facLors of chronlc dlseases, Lhe
promouon of rouune oral hyglene pracuces and oral healLh awareness and Lhe provlslon of beuer access
Lo denLal care.
Applylng Lhese successful models and sharlng good pracuces across Lhe Lu can play a vlLal
role ln lmprovlng Lhe oral healLh of Luropean cluzens. ln LhaL sense, Lhls reporL provldes
Lhe evldence-base for good pollcymaklng. l encourage everyone Lo help ln pumng Lhe re-
porL's recommendauons lnLo acuon.
Ms. karln kadenbach, Member of Lhe Luropean arllamenL
4
Foreword
1he SLaLe of Cral PealLh ln Lurope" reporL has been commlssloned by Lhe lauorm for 8euer Cral PealLh
ln Lurope, a forum whlch brlngs LogeLher Luropean organlsauons LhaL work Lowards Lhe promouon of oral
healLh and lmprovlng Lhe prevenuon of oral dlseases ln Lurope.
uesplLe slgnlcanL achlevemenLs ln Lhe prevenuon of carles ln Lurope, a loL remalns Lo be done ln a num-
ber of areas lncludlng: oral healLh awareness, Lackllng oral healLh lnequallues and addresslng common rlsk
facLors. ln addluon, Lhe developmenL of hlgh quallLy, comparable oral healLh daLa ln Lurope and beuer
cosL-eecuveness sLudles, Lo assess Lhe lmpacL of prevenuon lnluauves, are lndlspensable Lools ln Lhe ghL
for beuer oral healLh ln Lurope.
1he SLaLe of Cral PealLh ln Lurope" reporL was born from Lhe deslre of Lhe lauorm Lo promoLe Lhe evl-
dence base and seek opporLunlues Lo deepen cooperauon wlLh Luropean declslon-makers Lo lmprove oral
healLh pollcles ln Lurope and acceleraLe Lhe sharlng of good pracuce. 1he reporL has gaLhered Lhe mosL
rellable daLa avallable on Lhe prevalence of oral dlseases ln Lurope and presenLs new evldence of Lhe
economlc and soclal lmpacL of oral healLh. 1he reporL also alms Lo conLrasL and benchmark good pracuce
lnluauves ln oral healLh across Lurope, ln order Lo ldenufy prlorlues and dene a seL of key recommenda-
uons Lo lmprove oral healLh ln Lurope.
1he reporL ls publlshed ahead of Lhe 1sL an-Luropean Cral PealLh SummlL, Lo be held on 3
th
SepLember
2012, aL Lhe Luropean arllamenL, wlLh Lhe klnd supporL of Ms. karln kadenbach ML and ur. Crlsuan Sllvlu
8u;ol ML and under Lhe paLronage of Lhe CyprloL resldency of Lhe Luropean unlon. 1he SummlL brlngs
LogeLher pollcymakers and speclallsLs ln 8russels, aL Lhe occaslon of World Cral PealLh uay, Lo dlscuss Lhe
currenL slLuauon and engage pollcymakers Lo commlL Lo developlng and fundlng pollcles LhaL wlll lmprove
Lhe prevenuon of oral dlseases prevenuon and Lhelr LreaLmenL.
lL ls somewhaL surprlslng and regreuable LhaL - for years - Lhere has been no concerLed eorL aL an Lu
level Lo brlng denLal publlc healLh Lo Lhe auenuon of Lhe Luropean lnsuLuuons, and Lo glve pollcymakers
a deeper undersLandlng of whaL can and needs Lo be done abouL oral healLh ln Lurope, parucularly lLs
lnLegral role for general healLh and well-belng. 1he sLakes on Lhls lssue are hlgh and Lhe ume for change
ls now. WlLh Lhe lauorm, Lhe 8eporL and Lhe 1
st
an-Luropean Cral PealLh SummlL l hope
and belleve we nally have Lhe adequaLe Lools and procedures ln place Lo work eecuvely
LogeLher and fosLer pollcy declslons whlch wlll beneL Lhe oral healLh of everyone ln Lurope
ln Lhe years Lo come.
rofessor kenneLh LaLon, Chalr of Lhe lauorm for 8euer Cral PealLh ln Lurope
5
Acknowledgements
1he lauorm wlshes Lo dlrecL lLs mosL slncere Lhanks Lo Lhe auLhor of Lhe reporL, ur. 8eena aLel, and Lo
Lhe pan-Luropean Leam of conLrlbuLors:
- rof. kenneLh LaLon, Chalr of Lhe lauorm for 8euer Cral PealLh ln Lurope
- ur. Lduardo Chlmenos kusLner, rofessor of Cral Medlclne,
laculLy of CdonLology, unlverslLy of 8arcelona
- rof. Pelkkl MurLomaa, rofessor and Pead, ueparLmenL of
Cral ubllc PealLh, lnsuLuLe of uenusLry, unlverslLy of Pelslnkl
- rof. Leva WldsLrm, SpeclallsL ln Cllnlcal uenusLry, nauonal
8esearch and uevelopmenL CenLre of Welfare and PealLh, Pelslnkl
- rof. ur. SLefan Zlmmer, Pead of uenLal School, Sclenuc ulrecLor of
Lhe unlverslLy, Wluen/Perdecke unlverslLy
1he lauorm ls graLeful Lo Lhe Chlef uenLal Cm cers for Lhelr supporL ln Lhe collecuon of nauonal daLa ln-
cluded ln Lhe reporL and Lhelr conLrlbuuon Lo lLs developmenL.
1he reporL was supporLed by an unresLrlcLed granL from Lhe Wrlgley Cral PealLhcare rogram and
ClaxoSmlLhkllne Consumer PealLhcare.
1he oplnlons and vlews expressed ln Lhls reporL are Lhe sole responslblllLy of lLs auLhor.
The author: Dr. Reena Patel, Dental Advisor
8eena graduaLed as a denusL from Lhe unlverslLy of Wales, College of Medlclne. She
galned her ulploma of Membershlp of Lhe laculLy of uenLal Surgery aL Lhe 8oyal College
of Surgeons of Lngland, and Lhen wenL on Lo compleLe an MSc ln lnLernauonal PealLh
managemenL aL lmperlal College, London.
8eena has worked ln a varleLy of cllnlcal roles wlLhln Lhe nauonal PealLh Servlce ln Lhe uk, and ln volunLary
placemenLs abroad, ln lndla and nepal. ln recenL years, she has expanded her knowledge and corporaLe
experlence by worklng as a ManagemenL ConsulLanL aL uelolue, ln Lhe PealLhcare and Llfesclences ulvl-
slon. 8eena has underLaken several lndependenL commlsslons for a varleLy of organlsauons. She has also
presenLed Lhe ndlngs of her work aL nauonal and Luropean sclenuc conferences, and publlshed ln Lhe
8rlush uenLal !ournal and Cral PealLh and uenLal Medlclne.
6
Table of Contents
Lxecunve Summary ............................................................................................................................... 7
Secnon 1: AbouL oral healLh..........................................14
Secnon 2: 1he prevalence and Lrends of oral dlseases ln Lu Member SLaLes ..................................... 19
Secnon 3: Lconomlc lmpacL of oral dlseases ln Lurope ....................................................................... 24
Secnon 4: lnequallues relaung Lo Lhe LreaLmenL of oral dlseases ln Lurope ....................................... 30
Secnon S: Cral healLh pollcles, Lhe promouon of oral healLh and
Lhe prevenuon of oral dlseases ln Lurope ............................................................................................ 37
Secnon 6: Concluslons: undersLandlng Lhe problems ......................................................................... 43
Secnon 7: 8ecommendauons for Luropean declslon-makers .............................................................. 49
keferences............................................................................................................................................ 36
7
Executive Summary
Introduction and context
Across Lurope, oral dlseases consuLuLe a ma[or publlc healLh burden, and slgnlcanL oral healLh lnequall-
ues exlsL boLh wlLhln and beLween lndlvldual Member SLaLes ln Lerms of severlLy and prevalence. 1he
burden ls aurlbuLable prlnclpally Lo denLal carles, perlodonLal dlseases, and oral cancer.
Cral dlseases noL only lmpacL on Lhe lndlvldual Lhrough paln and dlscomforL, and Lhe broader lmpacL on
Lhelr general healLh and quallLy of llfe, buL also on Lhe wlder communlLy, Lhrough Lhe healLh sysLem and
assoclaLed economlc cosLs.
LxpendlLure on LreaLmenL of oral condluons oen exceeds LhaL for oLher dlseases, lncludlng cancer, hearL
dlsease, sLroke, and demenua. 1hls ls dlsLurblng, glven LhaL much of Lhe oral dlsease burden ln hlgh-lncome
counLrles ls due Lo denLal carles and lLs compllcauons, and Lhls ls prevenLable Lhrough Lhe use of uorlde
and oLher cosL-eecuve measures.
1here ls a dlsuncL lack of pollcy emphasls placed on prevenuon wlLhln oral healLh ln Lurope. 1hls ls com-
pounded by Lhe dearLh of rouunely avallable and comparable epldemlologlcal and economlc daLa, whlch
descrlbe Lhe currenL slLuauon ln Lurope. 8obusL daLa ls of supreme lmporLance ln Lhe plannlng, lmplemen-
Lauon and evaluauon of communlLy prevenuve acuvlues and oral healLh promouon, and as a resulL Lhere
are Lhus challenges ln ldenufylng besL-pracuce lnluauves, and allocaung resources Lo where Lhey are mosL
needed.
ln llghL of Lhls slLuauon, Lhe lauorm for 8euer Cral PealLh ln Lurope commlssloned ur 8eena aLel, uenLal
Advlsor, Lo examlne some of Lhe key lssues relaung Lo oral healLh. 1hese lnclude:
revalence and Lrends of oral dlseases ln Lurope,
AssessmenL of Lhe economlc lmpacL of oral dlseases ln Lurope,
ldenucauon of besL pracuce lnluauves ln oral healLh promouon across Lurope,
uevelopmenL of a seL of key recommendauons for declslon-makers Lo lmprove oral healLh ln Lu-
rope.
1hls Secuon conLalns a summary of Lhe key ndlngs of Lhe reporL, whlch assesses Lhe burden caused by
oral dlseases ln Lurope, and ldenues pollcy orlenLauons Lo address lL.
ln order Lo provlde a represenLauve vlew of Lhe slLuauon across Lurope, whlle reecung Lhe mosL rellable
daLa avallable, Lhe auLhor focused on Lhe followlng counLrles: AusLrla, Cyprus, uenmark, lrance, Cermany,
lreland, lLaly, LlLhuanla, oland, 8omanla, Spaln and Lhe uk.
8
Prevalence and trends of oral diseases in EU Member States
Chronlc non-communlcable dlseases and condluons such as obeslLy, hearL dlsease, sLroke, cancer, dlabe-
Les, and oral dlseases all share a seL of common rlsk facLors whlch lnclude dleL, smoklng and alcohol use.
uesplLe belng largely prevenLable, oral dlseases and lnequallues, consuLuLe a slgnlcanL publlc healLh
problem alongslde Lhe lnequallues ln Lhe prevalence of Lhe ma[or dlseases of Lhe 21sL cenLury.
A range of healLh condluons are assoclaLed wlLh oral dlsease. oorly conLrolled dlabeLes ls a well-esLab-
llshed rlsk facLor for developlng perlodonLal breakdown and recenL research shows how chronlc gum dls-
eases can lncrease dlabeuc compllcauons. Cum dlseases are also assoclaLed wlLh rheumaLold arLhrlus,
adverse pregnancy ouLcomes, and coronary hearL dlsease.
Key points
- uesplte o qlobol Jeclloe lo cotles, tbe Jlseose sull temolos o ptoblem fot mooy qtoops of people
lo osteto otope, ooJ fot tbose ftom soclo-ecooomlcolly JeptlveJ qtoops lo oll otopeoo uoloo
Membet 5totes.
- Ovet 50X of tbe otopeoo popolouoo moy so[et ftom some fotm of petloJoouus ooJ ovet 10X
bove sevete Jlseose, wltb ptevoleoce locteosloq to 70-85X of tbe popolouoo oqeJ 60-65 yeots of
oqe. letloJootol beoltb moy be Jetetlotouoq wltblo tbe popolouoo of tbe u. 1bls ls ptloclpolly Joe
to o lotqet oombet of people tbot ote tetololoq some of tbelt teetb loto olJ oqe, ooJ oo locteose lo
tbe ptevoleoce of Jlobetes. plJemloloqlc Joto oo petloJootol Jlseoses ote of vety poot poollty.
- Otol coocet ls tbe elqbtb most commoo coocet wotlJwlJe. lo tbe u, llp ooJ otol covlty coocet ls tbe
12tb most commoo coocet lo meo. lo 2008, tbete wete opptoxlmotely 1J2,000 coses of beoJ ooJ
oeck coocet octoss otope, tesoluoq lo 62,800 Jeotbs. nlqbest ptevoleoce totes ote foooJ lo 5polo
ooJ nooqoty. 1teoJs lo otol coocet ote oow sbowloq oo locteosloq loclJeoce lo womeo, ooJ yoooq
oJolts. Mottollty totes bove coouooeJ to locteose lo sevetol osteto otopeoo Membet 5totes.
Economic impact of oral diseases in Europe
uenLal dlsease and lLs compllcauons can lmpose a slgnlcanL nanclal burden Lo Lhe lndlvldual and socleLy.
1hls ls dlsLurblng, glven LhaL much of Lhe oral dlsease burden ln hlgh-lncome counLrles ls due Lo denLal carles
and lLs compllcauons, and Lhls ls prevenLable Lhrough Lhe use of uorlde and oLher cosL-eecuve measures.
Powever, Lhere are challenges ln esumaung Lhe expendlLure on Lhe provlslon of oral healLhcare due Lo a
lack of daLa, and dlmculues ln quanufylng ouL-of-pockeL expendlLure and lndlrecL cosLs arlslng from Lhe
soclal burdens of poor oral healLh, and lLs lnLeracuon wlLh sysLemlc dlseases.
CuL-of-pockeL expendlLure ls an lmporLanL, and oen underesumaLed, aspecL of oral healLhcare dellvery.
ln Member SLaLes where oral healLh servlces are malnly provlded by prlvaLe pracuuoners, Lhere may be a
slgnlcanL lmpacL on low lncome groups, whlch may noL be capLured by declslon-makers.
1he lack of robusL daLa on Lhe economlc burden of oral dlseases and Lhe cosL-emclency of prevenLauve
measures ls a ma[or publlc healLh lssue ln Lurope. 1hls may lead Lo an underesumauon of Lhe Lrue cosLs of
oral healLhcare provlslon, Lhus llmlung Lhe ablllLy Lo assess Lhe lmpacL of exlsung publlc healLh measures,
and lnvesL ln Lhe mosL eecuve lnluauves.
9
Key points
- uellvetloq otol beoltb setvlces ls costly, occooouoq fot 5X of totol beoltb expeoJltote ooJ 16X of
ptlvote beoltb expeoJltote octoss Ocu cooottles lo 2009.
- 1be cotteot u 27 speoJloq ls close to t79 blllloo, ooJ lf tbe tteoJs coouooe, tbls fqote coolJ be os
blqb os t9J blllloo lo 2020.
- 5toJles bove olso sbowo tbot tbe mootb ls tbe most expeoslve pott of tbe boJy to tteot. xpeoJltote
ls llkely to exceeJ tbot fot coocet, beott Jlseose, sttoke ot Jemeouo.
- 1bete ls sttooq evlJeoce tbot tbe beoefts of pteveouoq tootb Jecoy exceeJ tbe costs of tteotmeot.
1bls ls potucolotly evlJeot lo Membet 5totes socb os ueomotk ooJ 5weJeo, wblcb bove lovesteJ
beovlly lo tbe ptovlsloo of pteveotouve otol beoltb setvlces, wltb o slqolfcoot teJocuoo lo tbe ptev-
oleoce of otol Jlseose.
Inequalities relating to the treatment of oral diseases in Europe
lnequallues ln healLh beLween people ln hlgher and lower educauonal, occupauonal and lncome groups
have been found ln all Member SLaLes. Lower socloeconomlc groups are more suscepuble Lo poor nuLrluon
and Lo Lobacco and alcohol dependency, all of whlch are ma[or conLrlbuLory facLors ln many dlseases and
condluons. 1here are also profound oral healLh dlsparlues across Lu counLrles, relaLed Lo soclo-economlc
sLaLus, age, gender, and general healLh sLaLus.
Carles sull remaln a ma[or healLh problem for many groups of people ln LasLern Lurope, and ln all Luropean
Member SLaLes, for Lhose from soclo-economlcally deprlved or vulnerable groups. 1he lncldence of oral
cancer and perlodonLal dlseases ls also sLrongly relaLed Lo soclal and economlc deprlvauon.
A facLor whlch lmpacLs on denLal auendance ls Lhe sLrucLure for Lhe dellvery of oral healLhcare servlces,
whlch varles slgnlcanLly beLween lndlvldual Member SLaLes. A far lower percenLage of Lhe populauon ap-
pear Lo auend Lhe denusL ln soclally and economlcally less well developed Lu Member SLaLes, where Lhere
ls llule or no publlcally funded denusLry, Lhan ln Lhose whlch provlde publlcly subsldlsed oral healLh care.
Key points:
- osotloq occess to otol beoltbcote setvlces temolos o mojot beoltb ptoblem omooq voloetoble ooJ
low locome qtoops. 1bese loJlvlJools qeoetolly oueoJ setvlces less ftepoeotly tboo tbe qeoetol
popolouoo, fot ptlmoty cote ot emetqeocy tteotmeot wbeo lo polo, totbet tboo fot pteveouve loJl-
couoos.
- otobotometet sotvey Joto (2010) soqqest tbot of tbose wbo tespooJeJ to tbe sotvey, tbe tespoo-
Jeots most llkely to bove vlslteJ o Jeoust lo tbe lost twelve mootbs wete lobobltoots of Nottbeto u
Membet 5totes.
- 1be ossoclouoo betweeo eJocouoo ooJ oueoJooce ot tbe Jeoust votles slqolfcootly betweeo
Membet 5totes. otopeoos wbo ote lo foll ume eJocouoo tbe looqest oppeot to be mote llkely to
vlslt o Jeoust fot o cbeck-op, totbet tboo ooly oueoJloq wbeo lo polo.
10
Oral health policies, the promotion of oral health and the prevention of oral
diseases in Europe
lrequenL exposure Lo uorlde, regular brushlng, a healLhy dleL and rouune oral care all conLrlbuLe Lo lm-
proved oral healLh ouLcomes and a reducuon ln oral healLh lnequallues.
MosL of Lhe evldence ln oral healLh promouon relaLes Lo denLal carles prevenuon and conLrol of perlodon-
Lal dlseases. SLrong evldence exlsLs LhaL Loplcal uorldes (uorlde LooLhpasLe, uorlde varnlsh and uorlde
mouLh rlnses) can prevenL LooLh decay.
Cum dlseases can be prevenLed by good personal oral hyglene pracuces, lncludlng brushlng and cleanlng
beLween LeeLh, whlch are lmporLanL for Lhe conLrol of advanced perlodonLal condluons as shown by suc-
cessful programmes e.g. ln Sweden.
LlmlLed evldence exlsLs for Lhe eecuveness of screenlng for early deLecuon of oral cancer on a populauon
basls, buL assessmenL of Lhe oral so ussues should be a rouune parL of an oral examlnauon, especlally for
groups aL hlgher rlsk of oral cancer, such as smokers and heavy drlnkers.
Across Lhe Lu, a varleLy of successful communlLy-based publlc oral healLh programmes exlsL. 1hese focus
on Lhe dellvery of prevenLauve LreaLmenLs, lncreaslng awareness and enhanclng pauenL educauon Lo en-
courage healLhy rouunes and self-care. Powever, Lhere ls a conslsLenL lack of coordlnauon beLween publlc
auLhorlues ln ldenufylng and sharlng good pracuces. ln parucular, cosL-eecuveness sLudles of prevenLa-
uve lnluauves are lacklng.
Good pracnce: Denmark's preventanve ora| hea|th care mode|
ApproxlmaLely 40 years ago, uanlsh chlldren's oral healLh was among Lhe pooresL ln Lurope.
Powever, a LargeLed and proacuve approach Lo dellver prevenuve care wlLhln Lhe publlc oral
healLh care servlce has had slgnlcanL resulLs. 8eLween 1974 and 2000, Lhe average uMl1
scores ln 12-year-old uanlsh chlldren fell by 78 from 4.3 Lo 0.98. 8y 1997, more Lhan 99 of
uanlsh chlldren recelved oral healLh care every year.
All munlclpallues ln uenmark are obllged Lo esLabllsh local cllnlcal faclllues Lo provlde all chll-
dren and adolescenLs resldlng ln Lhe munlclpallLy wlLh free and comprehenslve oral healLh
care, lncludlng healLh educauon and prevenuon, from newborn Lo 18-year-old chlldren. Clln-
lcs are oen locaLed ln, or nearby prlmary schools.
A sophlsucaLed reglsLer of all chlldren resldlng ln Lhe munlclpallLy ls uullsed Lo monlLor aL-
Lendance Lo Lhe cllnlc. 1he lnlual vlslL Lo Lhe cllnlc ls organlsed by Lhe local oral healLh servlce.
A leuer ls posLed home Lo lnform parenLs LhaL Lhelr chlld ls now enuLled Lo free denLal care.
revenLauve eorLs are dlrecLed aL Lhe lndlvldual Lhrough Lallored advlce and guldance. Pow-
ever, slgnlcanL emphasls ls also placed upon relnforclng Lhese messages wlLhln oLher healLh,
soclal and educauon envlronmenLs Lhrough sLa ln day-care cenLres, Leachers, healLh vlslLors
and paedlaLrlclans (Assoclauon of ubllc PealLh uenusLs ln uenmark 1997).
11
Key points
- A tooqe of e[ecuve popolouoo-boseJ pteveotouve loluouves bove beeo lmplemeoteJ octoss o-
tope. 1bese locloJe wotet footlJouoo ptoqtommes (ltelooJ, lolooJ, 5etblo, 5polo, uk), footlJoteJ
solt ptoqtommes (5wltzetlooJ, 5lovoklo, ltooce, Cetmooy ooJ tbe czecb kepobllc) ooJ footlJoteJ
mllk ptoqtommes totqeuoq cbllJteo (8olqotlo, uk).
- Otol beoltb eJocouoo ptoqtommes JellveteJ lo o scbool sem oq bove JemoosttoteJ lmptovemeots
lo cbllJ Jeotol beoltb, especlolly wbeo JellveteJ olooqslJe oJJluoool bome soppott ooJ commoolty
lotetveouoos (ltooce, Cetmooy, ltelooJ ooJ uk).
- A totqeteJ ooJ ptoocuve opptoocb to Jellvet pteveouve cote wltblo tbe pobllc otol beoltb cote set-
vlce lo ueomotk bos boJ slqolfcoot tesolts. locol cllolcol foclllues ptovlJe cbllJteo ooJ oJolesceots
wltb ftee ooJ comptebeoslve otol beoltb cote, osloq o sopblsucoteJ teqlstet to mooltot oueoJooce.
- vlJeoce-boseJ toolklts fot tbe pteveouoo of otol Jlseose coo be JevelopeJ by Mlolsttles of neoltb
to ptovlJe Jeousts ooJ tbe pobllc wltb occesslble ooJ occotote lofotmouoo (uk).
- 5evetol cooottles (llolooJ, Cetmooy ooJ 5wltzetlooJ) ocuvely ptomote soqot-ftee ptoJocts
- kesttlcuoq motkeuoq, ooJ lmptovloq tbe lobellloq of cettolo fooJ ptoJocts, os pott of btooJet loluouves
to tockle tbe soclo-bebovlootol ooJ eovltoomeotol foctots of otol Jlseoses, bos sbowo some e[ect.
- Ao lotetoouoool exomple of qooJ ptocuce locloJes tbe oolloe coooJloo 8est ltocuces lottol wblcb
sbowcoses e[ecuve best ptocuces moJels, metboJs, ooJ teseotcb evlJeoce lo tbe felJs of com-
moolty boseJ beoltb ptomouoo ooJ Jlseose pteveouoo lotetveouoos.
Good pracnce: An ev|dence-based too|k|t for prevennon
ln Lhe uk, Lhe ueparLmenL of PealLh and Lhe 8rlush Assoclauon for Lhe SLudy of CommunlLy
uenusLry have [olnLly produced an evldence-based LoolklL for Lhe prevenuon of oral dlsease
by prlmary care denLal Leams uellverlng 8euer Cral PealLh: An evldence-based LoolklL for
prevenuon" (uP 2009). 1hls LoolklL provldes easy Lo use advlce on Lhe prevenuon of denLal
carles, perlodonLal dlseases and oral cancer. 1he Lhlrd revlsed edluon ls due Lo be released
shorLly, and Lhe Lool ls currenLly belng LranslaLed lnLo Spanlsh.
12
Conclusions and recommendations for European decision-makers
ln Lhe lasL 30 years, desplLe ma[or lmprovemenLs ln Lhe prevalence of denLal carles ln chlldren and young
adulLs who llve ln WesLern Lurope, lL ls evldenL LhaL oral dlseases, and oral healLh lnequallues, remaln a
slgnlcanL publlc healLh problem ln Lurope.
ln many Lu Member SLaLes, oral healLh care ls noL fully lnLegraLed lnLo nauonal or communlLy healLh pro-
grammes. 1here ls a clear lack of research ln oral healLh promouon, and very few hlgh quallLy ouLcome
measures exlsL for use ln Lhe evaluauon of oral healLh pollcy and envlronmenLal lnLervenuons. 1hls prob-
lem ls compounded by Lhe lack of rouunely avallable and comparable Lu oral healLh daLa.
1here are also challenges ln ldenufylng besL pracuce measures, and sharlng learnlng ouLcomes from oral
healLh promouon acuvlues. A more progresslve healLh promouon approach LhaL recognlses Lhe lmpor-
Lance of Lackllng Lhe underlylng soclal, pollucal and envlronmenLal deLermlnanLs of oral healLh ls requlred.
Powever, across Lurope, Lhere ls a lack of sulLably Lralned advlsors wlLh Lhe ablllLy Lo develop oral healLh
epldemlologlcal lnfrasLrucLures and asslsL ln oral healLh sLraLegy and pollcy developmenL.
1o address Lhe burden of dlsease, Lhe followlng acuons should be consldered by Luropean declslon-makers:
Maklng a commlLmenL Lo lmprovlng oral healLh as parL of Lu pollcles by 2020,
Addresslng lncreaslng oral healLh lnequallues,
Lncouraglng good pracuce sharlng,
lmprovlng Lhe daLa and knowledge base, brldglng Lhe research gap ln oral healLh promouon and devel-
oplng common meLhodologles ln daLa collecuon processes,
Supporung Lhe developmenL of Lhe denLal workforce ln Lurope.
13
key pollcy tecommeoJouoos
- kecoqolse tbe commoo tlsk foctots fot otol Jlseoses ooJ otbet cbtoolc Jlseoses, ooJ wotk towotJs
llokloq otol beoltb pollcles octoss otbet u pollcles.
- 8euet loteqtote otol beoltb loto televoot oouoool ooJ u beoltb ptoqtommes ooJ pollcles.
- uevelop o cobeteot otopeoo sttoteqy fot tbe ptomouoo of otol beoltb ooJ tbe pteveouoo of otol
Jlseoses.
- AJJtess tbe mojot otol beoltb cbolleoqes of cbllJteo ooJ oJolesceots, soclo ooJ ecooomlcolly Je-
ptlveJ qtoops, oo locteosloq elJetly popolouoo ooJ otbet voloetoble popolouoos lo otope.
- mploy oo opptoocb tbot focosses oo tbe wlJet pollucol, eovltoomeotol, soclol ooJ ecooomlc Jtlv-
ets tbot cteote otol beoltb loepoollues. A molu-sttoteqy opptoocb ls oeeJeJ tbot cooslJets fottbet
meosotes socb os leqlslouoo, fscol pollcy ooJ commoolty Jevelopmeot. 1bls toJlcol pollcy teotleo-
touoo ls ptloclpolly tbe temlt of oouoool pollcy mokets ooJ ptofessloool otqoolsouoos.
- uevelop soppotuve otol beoltb eovltoomeots lo locol semoqs socb os scbools, colleqes, bospltols,
wotkploces ooJ cote otqoolsouoos.
- ocootoqe ooJ ptomote pollcles to eosote occess to footlJe fot tbe wbole popolouoo.
- Cootootee ovolloblllty ooJ occess to blqb poollty ooJ o[otJoble otol beoltb cote, locloJloq ftee
boslc tteotmeot fot loJlvlJools ooJet 18 yeots of oqe
- osote occess to televoot ooJ evlJeoce boseJ otol beoltb lofotmouoo to eocootoqe poueot empow-
etmeot ooJ self-cote.
- Moxlmlse tbe poteouol of tbe Jeotol teom (Jeousts, byqleolsts, tbetoplsts, ootses, tecbolcloos, otol
beoltb ptomotets ooJ eJocotots) to eosote oo opptoptlote ose of sklll mlx lo ooJettokloq pteveoto-
uve lotetveouoos.
- uevelop tbe tole of otol beoltb ptofessloools lo qeoetlc beoltb ptomouoo to oJJtess tlsk foctots
socb os clqoteue smokloq, poot Jlet, blqb olcobol coosompuoo, ooJ seJeototy llfestyles.
- 5oppott tbe ttololoq ooJ eJocouoo of Jeousts to Jevelop tobost otol beoltb eplJemloloqlcol lofto-
sttoctotes ooJ osslst lo otol beoltb sttoteqy ooJ pollcy Jevelopmeot.
- Moke otol beoltb ooJ tbe pteveouoo of otol Jlseoses o ptlotlty ooJet tbe otopeoo beoltb ooJ te-
seotcb ptoqtommes to speclfcolly focos oo commoolty-boseJ teseotcb oo tbe soclol Jetetmlooots
of qeoetol ooJ otol beoltb, ooJ loepoollues lo beoltb.
- lmptove tbe collecuoo of vollJoteJ otol beoltb Joto, ollqo metboJoloqles betweeo u cooottles,
ooJ ftepoeotly collect telloble ooJ compotoble Joto. 1bls moy lovolve cteouoq ooJ fooocloq oto-
peoo loftosttoctotes socb os o Jotobose ot o teqlstty.
- ulssemloote oll mojot teseotcb ootcomes, best ptocuce meosotes ooJ leotoloq expetleoces lo otol
beoltb pollcy to eobooce ptoboblllty of bollJloq o systemouc boJy of evlJeoce.
14
Section 1: About oral health
Key points
- Otol beoltb ls oot solely coocetoeJ wltb teetb, bot olso wltb qoms ooJ tbe soppotuoq booe ooJ
sof ussoes of tbe mootb, tooqoe ooJ llps. 1be tbtee molo qtoops of otol Jlseoses ote Jeotol cotles
(tootb Jecoy), qom Jlseoses (koowo os petloJootol Jlseoses) ooJ otol coocet.
- Otol Jlseoses oot ooly lmpoct oo tbe loJlvlJool tbtooqb polo ooJ Jlscomfott, ooJ tbe btooJet lm-
poct oo tbelt qeoetol beoltb ooJ poollty of llfe, bot olso oo tbe wlJet commoolty, tbtooqb tbe beoltb
system ooJ ossocloteJ ecooomlc costs.
- Otol beoltb ls loteqtol to qeoetol beoltb. cbtoolc ooo-commoolcoble Jlseoses ooJ cooJluoos socb
os obeslty, beott Jlseose, sttoke, coocet, Jlobetes, ooJ otol Jlseoses oll sbote o set of commoo tlsk
foctots. AlooqslJe locteosloq loepoollues lo tbe ptevoleoce of tbese mojot Jlseoses of tbe 21st ceo-
toty, otol beoltb loepoollues olso coosutote o slqolfcoot pobllc beoltb ptoblem.
- Otol Jlseoses ote lotqely pteveotoble, ooJ sbote oeuoloqlcol foctots wltb otbet cooJluoos. 5ostolo-
oble lmptovemeots lo otol beoltb ooJ o teJocuoo lo loepoollues moy be ocbleveJ by coottollloq tbe
tlsk foctots fot otol Jlseoses.
- ueotol cotles ls o Jlseose of tbe botJ ussoes of tbe teetb cooseJ by tbe lotetocuoos ovet ume
betweeo mlctootqoolsms foooJ lo Jeotol plopoe ooJ Jletoty fetmeotoble cotbobyJtotes (ptlocl-
polly soqots, socb os soctose). ueotol Jecoy ls eoutely pteveotoble, bot ls ooe of tbe most commoo
cbtoolc Jlseoses. ueotol cotles expetleoce omooq 12 yeot olJ cbllJteo ls ossesseJ by tbe uecoyeJ,
Mlssloq ooJ lllleJ 1eetb (uMl1) loJex, wblcb meosotes tbe llfeume expetleoce of Jeotol cotles lo
petmooeot Jeouuoo.
- Com ot petloJootol Jlseoses ote cooseJ by lofommouoo of tbe qoms ooJ booe tbot soppott ooJ
oocbot teetb. wbeo sevete, tbe booy soppott fot teetb ls exteoslvely comptomlseJ coosloq otbet-
wlse beoltby teetb to be lost. llopoe Jeposlts oo tbe qom motqlos of teetb, ls tbe ptlmoty foctot
tbot cooses qom Jlseose. Otbet foctots tbot locteose soscepublllty locloJe oqe, tobocco, sttess,
qeoeuc JlsotJets ooJ locol foctots, socb os ctowJeJ teetb. lootly coottolleJ Jlobetes ls o well-
estobllsbeJ tlsk foctot fot Jeveloploq petloJootol bteokJowo ooJ lt ls olso tecoqolseJ tbot tbete ls
o blJltecuoool telouoosblp, wltb teceot teseotcb sbowloq bow cbtoolc petloJoouus bos oo oJvetse
e[ect oo tbe coottol of blooJ soqot, ooJ tbe loclJeoce of Jlobeuc compllcouoos.
- Otol coocets tefet to coocets of tbe llp, tooqoe, qom, mootb ooJ otqoos otoooJ tbe mootb ooJ
oeck. lmpottoot tlsk foctots ote oqe, qeoJet, soollqbt, tobocco, olcobol, poot Jlet, vltol lofecuoos,
ooJ pollouoo. A poteouol tole fot tbe bomoo poplllomo vltos lo otol coocet bos olso beeo Joco-
meoteJ.
- A tooqe of beoltb cooJluoos ote ossocloteJ wltb otol Jlseose. Com Jlseoses ote ossocloteJ wltb
tbeomotolJ ottbtlus, oJvetse pteqooocy ootcomes, ooJ cotoooty beott Jlseose, oltbooqb cooso-
uoo bos oot beeo ptoveo. loot otol beoltb ls olso ossocloteJ wltb ospltouoo poeomoolo ooJ lofec-
uve eoJocotJlus.
15
Cral healLh ls noL solely concerned wlLh LeeLh, buL also wlLh gums and Lhe supporung bone and so ussues
of Lhe mouLh, Longue and llps. 1he Lhree maln groups of oral dlseases are denLal carles (LooLh decay), gum
dlseases (known as perlodonLal dlseases) and oral cancer.
Cral healLh ls essenual Lo general healLh and quallLy of llfe. lL ls a sLaLe of belng free from mouLh and faclal
paln, oral and LhroaL cancer, oral lnfecuon and sores, perlodonLal (gum) dlseases, LooLh decay, LooLh loss,
and oLher dlseases and dlsorders LhaL llmlL an lndlvldual's capaclLy ln blung, chewlng, smlllng, speaklng,
and psychosoclal wellbelng." WPC 2012(a).
Cral dlseases noL only lmpacL on Lhe lndlvldual Lhrough paln and dlscomforL, and Lhe broader lmpacL on
Lhelr general healLh and quallLy of llfe, buL also on Lhe wlder communlLy, Lhrough Lhe healLh sysLem and
assoclaLed economlc cosLs. A sLudy underLaken ln Cermany has demonsLraLed how oral healLh relaLed
quallLy of llfe lmpacLs upon general healLh-relaLed quallLy of llfe, boLh physlcally and menLally (Zlmmer aL
al. 2010). 1hls shows how oral well-belng has an lmpacL on general well-belng. lor chlldren ln parucular,
poor oral healLh can have a deLrlmenLal eecL on Lhelr quallLy of llfe, performance aL school and success
ln laLer llfe (kwan eL al. 2003).
What are oral diseases?
Dental caries (tooth decay)
uenLal carles ls a dlsease of Lhe hard ussues of Lhe LeeLh caused by Lhe lnLeracuons over ume beLween
mlcroorganlsms found ln denLal plaque and dleLary fermenLable carbohydraLes (prlnclpally sugars, such as
sucrose). 1hls lnLeracuon produces organlc aclds whlch dlssolve LooLh subsLance. uenLal decay ls enurely
prevenLable, buL ls one of Lhe mosL common chronlc dlseases. rogresslve denLal carles may resulL ln cavl-
ues, paln, and loss of LeeLh, whlch may lmpalr some of Lhe mosL baslc funcuons of eaung, sleeplng, speak-
lng and belng producuve. lL can become a poLenual barrler Lo aualnlng healLh by lnLerferlng wlLh growLh
and welghL galn, especlally ln young chlldren (Shelham 2003, Shelham 2006).
uenLal carles experlence among 12 year old chlldren ls assessed by Lhe uecayed, Mlsslng and lllled 1eeLh
(uMl1) lndex, whlch measures Lhe llfeume experlence of denLal carles ln permanenL denuuon.
Gum (Periodontal) Diseases
Cum or perlodonLal dlseases are caused by lnammauon of Lhe gums and bone LhaL supporL and anchor
LeeLh. When severe, Lhe bony supporL for LeeLh ls exLenslvely compromlsed causlng oLherwlse healLhy
LeeLh Lo be losL. 1here are a number of gum (or perlodonLal) dlseases. Powever, Lhe dlsease wlLh Lhe mosL
publlc healLh lmpllcauons ls chronlc perlodonuus ln adulLs. Chronlc perlodonuus can cause bleedlng gums,
loss of bres and bone LhaL hold Lhe LeeLh ln place, recesslon of gums, perlodonLal abscesses, drllng of
LeeLh, LooLh moblllLy and ulumaLely LooLh loss. 1hese sympLoms can have a slgnlcanL lmpacL on Lhe lndl-
vldual ranglng from hallLosls (smelly breaLh) and dlscomforL, Lo changes ln appearance and loss of funcuon
(CorbeL 2007).
laque deposlLs on Lhe gum marglns of LeeLh are Lhe causal facLor. Powever, oLher facLors LhaL lncrease
suscepublllLy lnclude dlabeLes, smoklng, sLress, geneuc dlsorders and local facLors, such as crowded LeeLh
(CorbeL 2007). erlodonLal dlseases Lend Lo be more prevalenL ln men Lhan women (Shlau 2010).
16
Oral cancer
Cral cancers refer Lo cancers of Lhe llp, Longue, gum, mouLh and organs around Lhe mouLh and neck. 1he
mosL common slLes are Lhe llp and Longue. Causes are predomlnanLly llfesLyle-relaLed, lncludlng Lobacco,
areca nuL, alcohol, poor dleL, vlral lnfecuons and polluuon (!ohnson eL al. 2011). CLher lmporLanL rlsk fac-
Lors are age, gender and sunllghL, alLhough a role for candlda and Lhe human papllloma vlrus has also been
documenLed (Scully 2009). auenLs rarely seek help for oral cancer aL an early sLage of Lhe dlsease due Lo
lLs palnless naLure ln Lhe early sLages and consequenLly oral cancers are usually well advanced aL dlagnosls.
1he overall ve year survlval raLes for cancers of Lhe Longue, oral cavlLy and oropharynx are around 30-60
(8ogers eL al. 2009).
Risk factors for oral diseases
Cral dlseases are largely prevenLable, and share aeuologlcal facLors wlLh oLher condluons. Cral healLh ls
deLermlned by a number of facLors lncludlng dleL, oral hyglene, smoklng and alcohol use (Shelham and
Wau 2000, 8enzlan eL al. 2012) and Lherefore soclo-behavloural and envlronmenLal facLors play an lm-
porLanL role, as well as access Lo healLh servlces (eLerson eL al. 2003). SusLalnable lmprovemenLs ln oral
healLh and a reducuon ln lnequallues may be achleved by conLrolllng Lhe rlsk facLors for oral dlseases.
Lxposure Lo rlsk facLors ls deLermlned by lndlvldual blologlcal facLors and oral healLh-relaLed behavlours,
whlch ln Lurn ls governed by economlc, pollucal and envlronmenLal condluons whlch lnuences Lhe soclal
and communlLy conLexL (Wau and luller 2007).
CerLaln healLh damaglng llfesLyle behavlours can lncrease Lhe rlsk of oral dlsease. 1hese are llsLed and de-
tailed below in greater detail:
oor d|et and nutr|non
oor oral healLh ls assoclaLed wlLh a poor dleL (now[ack-8aymer and Shelham 2003, Sahyoun and krall
2003). 1he frequenL and hlgh consumpuon of sugars ls Lhe ma[or cause of LooLh decay (Moynlhan 2003),
and forms a common rlsk facLor for oLher healLh problems such as obeslLy (Pan eL al. 2010).
8ecenL sLudles of adolescenL healLh and well-belng have shown LhaL socloeconomlc lnequallues exlsL ln
adolescenL eaung hablLs, (8lchLer eL al. 2009, vereecken eL al. 2003), wlLh Lhose from a hlgher soclal class
oen reporung a more favourable dleL. lrulL consumpuon, for example, was seen Lo lncrease wlLh fam-
lly maLerlal wealLh and parenLal occupauonal sLaLus across Lurope, whereas so drlnk consumpuon was
lower among adolescenLs of hlgher parenLal occupauonal sLaLus ln many Luropean Member SLaLes (ver-
eecken eL al. 2003).
Assoclauons wlLh head and neck cancer have been ldenued for low lnLake of frulL and vegeLables (Chuang
eL al. 2012).
oor ora| hyg|ene
8egular brushlng of Lhe LeeLh and gums from an early age wlLh a uorlde LooLhpasLe wlll help prevenL
LooLh decay and also perlodonLal dlseases (Marlnho eL al. 2003, Wong eL al. 2011).
1obacco
Smoklng ls recognlsed as an lmporLanL rlsk facLor for perlodonLal dlseases (!ohnson and CuLhmlller 2000).
lL ls also one of Lhe maln rlsk facLors for oral cancer. Collecuvely, assoclauons wlLh lncreased raLes of head
and neck cancer have been ldenued for: long durauon of passlve smoklng, especlally for pharyngeal and
laryngeal cancers (Lee eL al. 2008), lncreased use of alcohol and Lobacco, especlally used LogeLher (Lubln
eL al. 2009, Pashlbe eL al. 2009, urdue eL al. 2009).
17
Smoklng comblned wlLh excesslve consumpuon of alcohol can lead Lo a 38 umes greaLer rlsk of develop-
lng oral cancer compared Lo absLalners (8loL 1988). 1obacco use ls also llnked Lo a range of oLher healLh
problems such as coronary hearL dlseases and lung cancer.
A|coho| consumpnon
1here ls a well-recognlsed relauonshlp beLween alcohol mlsuse and oral dlsease. 8esearch suggesLs LhaL
pauenLs suerlng from alcohol use dlsorders experlence poor oral healLh, lncludlng slgnlcanL levels of
denLal carles, glnglval lnammauon, so ussue abnormallues, LooLh eroslon and an lncreased rlsk of de-
veloplng perlodonLal dlseases (Arau[o 2004).
Lxcesslve alcohol consumpuon, parucularly splrlLs, ls a furLher rlsk facLor for oral cancer, especlally when
comblned wlLh smoklng and a poor dleL. lncreased consumpuon of alcohol has been lmpllcaLed ln Lhe
lncreaslng lncldence of Lhe dlsease ln Lhe uk (Plndle 2000) aL a ume when Lobacco use ls falllng (Cgden
2003). ln addluon, excesslve alcohol consumpuon ls consldered Lo be of parucular lmporLance ln Lhe de-
velopmenL of mallgnancy ln younger cohorLs (em and Scully 2003), glven Lhe volume of splrlLs consumed
ln blnge drlnklng.
Age
8eLalnlng LeeLh lnLo laLer llfe presenLs lncreased resLorauve problems, and ls assoclaLed wlLh lncreased
perlodonLal dlsease (Lrlcsson 2009, PolureLer 2010). ln addluon, complex medlcal condluons and reduced
manual dexLerlLy and moblllLy lmpacL on oral hyglene rouunes, and may resLrlcL access Lo approprlaLe
denLal provlslon.
Good oral health is an integral part of general health and well-being
Cral healLh ls lnLegral Lo general healLh and should noL be consldered ln lsolauon, as many of Lhe key fac-
Lors LhaL lead Lo poor oral healLh are rlsk facLors for oLher dlseases. Chronlc non-communlcable dlseases
and condluons such as obeslLy, hearL dlsease, sLroke, cancer, dlabeLes and oral dlseases all share a seL of
common rlsk facLors.
A range of general healLh condluons are assoclaLed wlLh oral dlsease. oorly conLrolled dlabeLes ls a well-
esLabllshed rlsk facLor for developlng perlodonLal breakdown. Cum dlseases are also assoclaLed wlLh rheu-
maLold arLhrlus, adverse pregnancy ouLcomes, and coronary hearL dlsease, alLhough causauon has noL
been proven. A poLenual role for Lhe human papllloma vlrus ln oral cancer has been documenLed. oor oral
healLh ls also assoclaLed wlLh asplrauon pneumonla and lnfecuve endocardlus. 1hese facLors are descrlbed
ln greaLer deLall below.
18
D|abetes
oorly conLrolled dlabeLes ls a well-recognlsed rlsk facLor for developlng perlodonLal dlseases (Sep-
pala 1993, apapanou 1996) wlLh evldence lndlcaung LhaL people wlLh boLh 1ype 1 and 1ype 2
dlabeLes experlence gum dlsease, and, lL ls of greaLer severlLy Lhan ln Lhe general populauon (llrlau
1997, Sandberg 2000).
lL ls also recognlsed LhaL Lhere ls a bldlrecuonal relauonshlp beLween dlabeLes and perlodonLal dls-
eases, wlLh recenL research showlng how chronlc perlodonuus has an adverse eecL on Lhe conLrol
of blood sugar and Lhe lncldence of dlabeLes compllcauons (Crossl 1998, SLewarL 2001, 1aylor 2001).
8ecenL evldence has suggesLed LhaL Lhere may be a small buL slgnlcanL lmprovemenL ln blood
sugar conLrol from Lreaung pre-exlsung gum dlsease ln people wlLh 1ype 2 dlabeLes melllLus (Slmp-
son 2010).
Adverse pregnancy outcomes
lL has been suggesLed LhaL gum dlsease ls assoclaLed wlLh adverse pregnancy ouLcomes (vergnes
and Slxou 2007, xlong eL al. 2006). 1here ls also some evldence Lo suggesL LhaL perlodonLal lnLerven-
uon may reduce adverse pregnancy ouLcomes (Scannapleco 2003).
Coronary heart d|sease
Cum dlsease ls assoclaLed wlLh coronary hearL dlsease (MaLhews 2008, Pumphrey eL al. 2008) al-
Lhough causauon has noL been proved. lurLhermore, gum dlsease and coronary hearL also share
slmllar rlsk facLors such as smoklng, dlabeLes melllLus, obeslLy and hyperLenslon (lrledewald 2009).
numan pap|||oma v|rus |nfecnon
Puman papllloma vlrus has a causal role ln several Lypes of cancer, and an assoclauon may exlsL wlLh
oral cancer (Syr[anen eL al. 2011).
1he relauonshlp beLween Pv lnfecuon and cancer ls well esLabllshed for cancer ln Lhe oropharynx,
buL lnconslsLenL for cancer ln Lhe oral cavlLy. 1he ma[or evldence, observed aL a populauon level ls
Lhe decreaslng Lrend for cancer ln Lhe oral cavlLy relaLed Lo alcohol and Lobacco consumpuon, and
Lhe lncreaslng Lrend for cancer ln Lhe oropharynx occurrlng ln some counLrles (Cllllson eL al. 2009,
Crullch eL al. 2010, Peck eL al. 2010, Chaudhary eL al. 2010).
1he eecuveness of Lhe Pv vacclne ln prevenung oropharyngeal cancers ls unknown (Cleveland eL
al. 2011).
Asp|ranon pneumon|a, |nfecnve endocard|ns and rheumato|d arthr|ns
oor oral healLh ls also assoclaLed asplrauon pneumonla and lnfecuve endocardlus (Loesche and
Lopaun 1998). Cum dlsease has been llnked Lo rheumaLold arLhrlus (Cruz 2009), alLhough causauon
has noL been proved.
19
Section 2: The prevalence of
oral diseases in EU Member States
Key points
ueotol cotles
- lo tbe lost J0 yeots, tbete bos beeo o mojot lmptovemeot lo tbe ptevoleoce of Jeotol cotles lo cbll-
Jteo ooJ yoooq oJolts wbo llve lo westeto otope, ooJ some lmptovemeot lo osteto otopeoo
Membet 5totes. lot exomple, tbe meoo oouoool uMl1 scote lo ueomotk fot 12 yeot olJs bos Je-
cteoseJ ftom 5 lo 1980, to 0.7 lo 2008, ooJ lo lltbooolo lt bos JecteoseJ ftom 4.5 lo 198J, to J.7 lo
2005.
- nowevet, popolouoo ovetoqes coo mosk otol beoltb loepoollues, ooJ lo splte of o Jeclloe lo cbllJ-
booJ cotles, loepoollues exlst betweeo soclol closses ooJ betweeo cettolo etbolc mlootlty qtoops.
ueotol cotles sull temolos o ptoblem fot mooy qtoops of people lo osteto otope, ooJ fot tbose
ftom soclo-ecooomlcolly JeptlveJ qtoops lo oll otopeoo uoloo (u) Membet 5totes.
letloJootol Jlseoses
- plJemloloqlc Joto oo petloJootol Jlseoses ote of vety poot poollty, ooJ ote obseot ftom sevetol
otopeoo Membet 5totes.
- lt bos beeo soqqesteJ tbot ovet 50X of tbe otopeoo popolouoo so[et ftom some fotm of petl-
oJoouus ooJ ovet 10X bove sevete Jlseose, wltb ptevoleoce locteosloq to 70-85X of tbe popolouoo
oqeJ 60-65 yeots of oqe. 1bete ls o petcepuoo tbot petloJootol beoltb moy be Jetetlotouoq wltblo
tbe popolouoo of tbe u. 1bls ls ptloclpolly Joe to o lotqet oombet of people tbot ote tetololoq
some of tbelt teetb loto olJ oqe, ooJ oo locteose lo tbe ptevoleoce of Jlobetes.
- 1bete ls o motkeJ soclol closs qtoJleot lo tbe Jlsttlbouoo of petloJootol Jlseoses, wltb stoJles sbow-
loq tbot petloJootol Jlseoses ote ossocloteJ wltb loJlvlJools locome ooJ soclo-ecooomlc stotos.
Otol coocet
- Otol coocet ls tbe elqbtb most commoo coocet wotlJwlJe. lo tbe u, llp ooJ otol covlty coocet ls
tbe 12tb most commoo coocet lo meo. lo 2008, tbete wete opptoxlmotely 1J2,000 coses of beoJ
ooJ oeck coocet octoss otope, tesoluoq lo 62,800 Jeotbs. 1be blqbest esumoteJ oqe-stooJotJlseJ
loclJeoce totes pet 100,000 of llp ooJ otol coocet (botb sexes ooJ oll oqes) ote foooJ lo 5polo (6.7)
ooJ nooqoty (9.4).
- 1be loclJeoce of otol coocet ls sttooqly teloteJ to soclol ooJ ecooomlc Jeptlvouoo. 1teoJs lo otol
coocet ote oow sbowloq o qeoJet ooJ oqe sblf. lo most otopeoo Membet 5totes, otol coocet lo-
clJeoce ls locteosloq lo womeo, petbops lotqely tefecuoq locteosloq totes of smokloq. lo potts of
otope, loclJeoce totes fot otol coocet sltes teloteJ to nlv lofecuoos ote locteosloq lo yoooq oJolts.
1bls moy be Joe to cbooqes lo otol sexool bebovloot.
- Mottollty totes bove coouooeJ to locteose lo sevetol osteto otopeoo Membet 5totes, locloJloq
nooqoty ooJ 5lovoklo, wblcb bove tbe blqbest mottollty totes. 5toJles bove sbowo bow tbe 5-yeot
telouve sotvlvol tote fot coocet lo tbe otol covlty ls lowet lo osteto otope (2JX), wbeo compoteJ
to Nottbeto otope (51X).
20
Prevalence and trends in dental caries
ln Lhe lasL 30 years, Lhere has been a ma[or lmprovemenL ln Lhe prevalence of denLal carles ln chlldren and
young adulLs who llve ln WesLern Lurope, and a decllne ln Lhe percenLage of people wlLh no naLural LeeLh.
1hls ls presumed Lo be malnly due Lo lmproved llvlng condluons, Lhe wldespread use of uorldes, espe-
clally uorlde LooLhpasLe, changed dleLary pauerns and Lo some exLenL lmproved oral hyglene pracuces.
Powever, populauon averages can mask oral healLh lnequallues, and ln splLe of a decllne ln chlldhood
carles, lnequallues exlsL beLween soclal classes and beLween cerLaln eLhnlc mlnorlLy groups (Wau and
Shelham 1999, Locker 2000, Sabbah eL al. 2007). uenLal carles sull remalns a problem for many groups of
people ln LasLern Lurope, and for Lhose from soclo-economlcally deprlved groups ln all Lu Member SLaLes
(llgure 1 and 1able 1). As an example, ln LlLhuanla, Lhe mean nauonal uMl1 score ln 12 year olds ls hlgh
aL 3.7 (WPC 2012b). ln addluon, ln Spaln, young adulLs from lower soclo-economlc groups have Lwlce as
much unLreaLed LooLh decay when compared Lo Lhose from hlgher soclo-economlc groups (Conse[o uen-
usLas Crganlzacln Coleglal de uenusLas de Lspana 2010).
ln chlldren from low soclo-economlc sLaLus backgrounds, Lhe prevalence of carles ls hlgher Lhan ln oLher
chlldren, and Lhere ls more unLreaLed dlsease (uroz eL al. 2006). ln uenmark, a sLudy has demonsLraLed
how, ln all age groups, ma[or lnequallues ln denLal healLh were found when famllles wlLh uanlsh and non-
uanlsh backgrounds were compared (ChrlsLensen eL al. 2010). 1hese ndlngs parallel resulLs from slmllar
sLudles ln oLher Scandlnavlan Member SLaLes (WendL eL al. 1999, Skele 2003). Powever, Lhese concluslons
are worrylng glven LhaL desplLe ln many of Lhese Member SLaLes, chlldren and adolescenLs auend a free
publlc denLal servlce based on prevenuve denusLry, a soclal gradlenL sull exlsLs for denLal healLh.
1able 1 and llgure 1 show how Lhere has been a slgnlcanL reducuon ln Lhe prevalence of denLal carles ln 12
year-olds ln all WesLern Luropean counLrles, and some lmprovemenL ln LasLern Luropean Member SLaLes, ln
Lhe lasL LhlrLy years. Powever, lL ls noL perunenL Lo make a dlrecL comparlson of Lhe uMl1 scores beLween
lndlvldual Member SLaLes (LaLon eL al. 2003) as dlerenL meLhodologles are oen used Lo collecL Lhese daLa,
some of Lhe surveys concerned are noL nauonal, and Lhey are frequenLly collecLed ln dlerenL years.
1ab|e 1: Changes |n mean Decayed M|ss|ng I|||ed 1eeth (DMI1) scores for 12 year o|ds from proh|ed Member States between
the 1980s and hrst decade of 2000 (WnC 2012b)
Country DMI1 score |n the 1980s DMI1 score |n the 2000s
Austria 3.8 (1984) 1.04 (2002)
Cyprus 2.2 (1990) 0.63 (2003-2004)
uenmark 3 (1980) 0.7 (2008)
France 4.2 (1987) 1.23 (2006)
Cermany 3.8 (1989) 0.7 (2003)
lreland 2.6 (1984) 1.4 (2001-2001)
lLaly 4.9 (1986) 1.1 (2004-2003)
LlLhuanla 4.3 (1983) 3.7 (2003)
oland 4.4 (1983) 3.2 (2003)
8omanla 3.1 (1986) 2.8 (2000)
Spaln 4.2 (1984) 1.3 (2003)
uk* 3.1 (1983) 0.7 (2008-2009)
noLe: 1able 1 presenLs WPC daLa. More up-Lo-daLe daLa may be avallable on Lhe CLCuC daLabase or from Lhe Chlef uenLal Cf-
cers of Lhe respecuve counLrles. *Lngland only

21
I|gure 1: Changes |n mean nanona| Decayed M|ss|ng I|||ed 1eeth (DMI1) scores for
12 year o|ds from proh|ed Member States between the 1980s and hrst decade of 2000 (WnC 2012b)
Notes:
lreland: uMl1 score for chlldren recelvlng uorldaLed waLer aL home slnce blrLh
uMl1 score for oland ln 2003 was ascerLalned from examlnauon of 180 chlldren ln Cdansk reglon
uMl1 score ln uk ln 2008-2009 ls for Lngland only
WhllsL Lhe overall Lrend appears posluve, lL conceals gross lnequallues. lor example, oland has experl-
enced a slower raLe of lmprovemenL LhaL ls Lyplcal of LhaL seen ln many oLher LasLern Luropean Member
SLaLes (llgure 1 and 1able 1). 1hls may reecL Lhe facL LhaL slnce 1989 Lhe provlslon of free oral healLh care
for chlldren from publlc healLh servlces has greaLly dlmlnlshed (eLersen 2008) and LhaL many people are
unable or unwllllng Lo pay prlvaLe fees for Lhelr oral healLh care.
The state of periodontal health in Europe
A recenL revlew of Lhe llLeraLure on perlodonLal healLh ln Lurope concluded: Actool eplJemloloqlc Joto oo
petloJootol Jlseoses ote ooo-bomoqeooos ooJ obseot ftom sevetol otopeoo cooottles (knlg eL al. 2010).
AnoLher recenL revlew (Leroy eL al. 2010) hlghllghLed Lhe problems wlLh regard Lo Lhe collecuon of rellable
daLa on perlodonLal healLh and suggesLed how Lhey could be lmproved.
SLudles reporL how severe perlodonuus aecLs 3-20 of mosL adulL populauons worldwlde, and lL ls a
ma[or cause of LooLh loss ln boLh developed and developlng counLrles (eLersen eL al. 2003, lhlsLrm eL
al. 2003, !ln eL al. 2011). lL has been suggesLed LhaL over 30 of Lhe Luropean populauon suer from some
form of perlodonuus and over 10 have severe dlsease (knlg eL al. 2011), wlLh prevalence lncreaslng Lo
70-83 of Lhe populauon aged 60-63 years of age. 1here ls also a percepuon LhaL perlodonLal healLh may
be deLerloraung wlLhln Lhe populauon of Lhe Lu. 1hls ls prlnclpally due Lo a larger number of people LhaL
are reLalnlng some of Lhelr LeeLh lnLo old age, and an lncrease ln Lhe prevalence of dlabeLes.
0
1
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DMFT Score in 2000 - 2009
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1he nauonal daLa for perlodonLal healLh ln Lu Member SLaLes LhaL are avallable, have been collecLed from
relauvely small samples and show very wlde varlauons, whlch lL seems llkely are due Lo lnconslsLencles ln
meLhodology as much as Lo acLual dlsease levels. lor example, beLween 1998 and 2001, surveys ln uen-
mark, Cermany and Lhe uk reporLed advanced perlodonLal breakdown (CommunlLy erlodonLal lndex = 4)
ln 14 of uanes, 76 of Cermans and 31 of 8rlush aged 63- 74 years (1able 3. (knlg eL al. 2010). ln splLe
of Lhese problems ln daLa collecuon, Lhere ls a percepuon LhaL perlodonLal healLh may be deLerloraung
among Lhe populauon of Lhe Lu, and lndeed Lhe world.
1he World PealLh Crganlsauon (WPC) conslders LhaL because far more people are reLalnlng some of Lhelr
LeeLh lnLo old age, and Lhere are more dlabeucs, who are aL rlsk of perlodonLal dlseases, far more empha-
sls should be placed on Lhe prevenuon of perlodonLal breakdown. As wlLh denLal carles, Lhere are marked
lnequallues ln Lhe dlsLrlbuuon of perlodonLal dlseases, wlLh sLudles showlng LhaL perlodonLal dlseases are
assoclaLed wlLh lndlvlduals' lncome and soclo-economlc sLaLus (Shelham and nlcolau 2003, Sabbah eL al.
2010).
WPC plans Lo launch a revlsed meLhodology for perlodonLal epldemlology and Lo hold a global conference
Lo hlghllghL Lhe need for lmprovemenL, ln Lurope and around Lhe world.
Oral cancer in Europe
Cral cancer ls Lhe elghLh mosL common cancer worldwlde (!ohnson eL al. 2011), however, Lhe lncldence
of head and neck cancer varles wldely across Lhe world. 8eglons wlLh a hlgh lncldence of head and neck
cancer lnclude much of SouLhern Asla and parLs of CenLral and SouLhern Lurope (8oyle and Levln 2008). ln
Lhe Lu, llp and oral cavlLy cancer ls Lhe 12Lh mosL common cancer ln men (lA8C 2012a: CLC8CCAn 2008).
Across Lurope, Lhere were approxlmaLely 132,000 cases of head and neck cancer ln 2008 (91,900 cases of
cancer of Lhe oral cavlLy and pharynx and 40,400 cases of cancer of Lhe larynx), resulung ln 62,800 deaLhs
(lerlay eL al. 2010).
1he lncldence of oral cancer ls sLrongly relaLed Lo soclal and economlc deprlvauon, wlLh Lhe hlghesL raLes
occurrlng ln Lhe mosL dlsadvanLaged secuons of Lhe populauon (Menvlelle 2003, Conway 2007, Conway
2008, Warnakulasurlya 2009).
Pead and neck cancer ls more Lhan Lwlce as common ln men, Lhan ln women (lerlay eL al. 2008). Powever,
Lrends are now showlng a gender and age shl. 1he lncldence of head and neck cancer ls lncreaslng ln
women, and decreaslng ln men (Curado and Pashlbe 2009). 1hls lncrease ln head and neck cancer ln fe-
males ln mosL Luropean Member SLaLes may reecL Lhe lncreaslng raLes of smoklng (Caravello eL al. 2010).
lurLhermore, ln young adulLs ln Lhe unlLed SLaLes, and ln some Member SLaLes ln Lurope, lncldence raLes
for oral cancer slLes relaLed Lo Pv lnfecuons, such as Lhe oropharynx, Lonsll, and base of Lhe Longue, are
lncreaslng (8oblnson and Macfarlane 2003, Shlboskl eL al. 2003, Conway eL al. 2006, PammarsLedL eL al.
2006, ChaLurvedl eL al. 2008, !emal eL al. 2011) whlch lL ls proposed may parLly be due Lo changes ln oral
sexual behavlour (Marur eL al. 2010).
lncldence of oral cancer varles across Lu Member SLaLes, and Lhe pauern apparenLly relaLes Lo reglonal
dlerences ln rlsk facLor exposure. 1he hlghesL esumaLed age-sLandardlsed lncldence raLes per 100,000 of
llp and oral cancer (boLh sexes and all ages) are found ln Spaln (6.7) and Pungary (9.4) (llgure 2). 1he hls-
Lorlcally hlgh raLes ln norLh-WesLern lrance are now sLablllslng, and Lhe sull-growlng raLes ln cenLral and
LasLern Lurope (lerlay eL al. 2010) are assoclaLed wlLh heavy Lobacco and alcohol use - Lhe lauer lnvolvlng
aceLaldehyde-conLalnlng frulL dlsullaLes.
23
I|gure 2: Lsnmated age-standard|sed |nc|dence rate (Ik) per 100,000 of cancer |n the
||p, ora| cav|ty, both sexes and a|| ages across Lurope (IAkC 2012b: GLC8CCAN 2008)
Cf equal concern Lo Lhe lncreaslng lncldence ln oral cancer, ls Lhe pauern of age sLandardlsed morLallLy
raLes, whlch varles across Lurope (llgure 3). Slovakla and Pungary have Lhe hlghesL morLallLy raLes and
Cyprus and lceland have Lhe lowesL (lA8C 2012c). Cral cavlLy cancer morLallLy raLes among males have
decreased slgnlcanLly ln mosL counLrles, lncludlng Lhose of Lurope and Asla, over Lhe pasL decades (Ca-
ravello eL al. 2010, Mayne eL al. 2006). 8uL raLes have conunued Lo lncrease ln several LasLern Luropean
Member SLaLes, lncludlng Pungary and Slovakla (Caravello eL al. 2010).
I|gure 3: Lsnmated age standard|sed morta||ty rate per 100,000 of cancer of the
||p, ora| cav|ty, both sexes and a|| ages across Lurope (IAkC 2012c: GLC8CCAN 2008)
Survlval raLes of cancer of Lhe oral cavlLy and oropharynx show dlsuncL geographlcal varlauons across Lurope.
1here are also marked dlerences beLween soclo-economlc groups. As wlLh mosL cancers, survlval ls beuer
for aMuenL groups (Ldwards and !ones 1999). SLudles have shown how Lhe ve-year relauve survlval raLe for
cancer ln Lhe oral cavlLy was 23 ln LasLern Lurope versus 31 ln norLhern Lurope (Zlgon eL al. 2011).
< 3.6 < 4.1 < 4.7 < 3.3 < 9.4
< 0.9 < 1.3 < 1.7 < 2.3 < 4.7
24
Section 3: Economic impact
of oral diseases in Europe

Key points
- Otol Jlseoses temolo o mojot pobllc beoltb lssoe fot blqb-locome cooottles, wbete expeoJltote oo
tteotmeot ofeo exceeJs tbot fot otbet Jlseoses, locloJloq coocet, beott Jlseose, sttoke, ooJ Jemeo-
uo. 1bls ls Jlstotbloq, qlveo tbot mocb of tbe otol Jlseose botJeo lo blqb-locome cooottles ls Joe
to Jeotol cotles ooJ lts compllcouoos, ooJ tbls ls pteveotoble tbtooqb tbe ose of footlJe ooJ otbet
cost-e[ecuve meosotes.
- ueotol tteotmeot ls costly, ovetoqloq 5X of totol beoltb expeoJltote ooJ 16X of ptlvote beoltb ex-
peoJltote octoss Ocu cooottles lo 2009. uoto ftom Aosttollo sbow bow otol cooJluoos wete tbe
secooJ-most expeoslve Jlseose qtoop to tteot, jost below cotJlovoscolot Jlseose. ueotol cooJluoos
wete foooJ to be mote expeoslve to tteot tboo oll coocets combloeJ. 5toJles bove olso sbowo bow
lo some loJosttlollseJ cooottles tbe mootb ls tbe most expeoslve pott of tbe boJy to tteot. lo 2000,
lt wos esumoteJ tbot tbe totol speoJ oo oll ospects of cote ooJ tteotmeot ptovlJeJ by Jeousts lo
tbe olJ u (15 Membet 5totes) wos ovet t54 blllloo pet yeot. 1be fqote fot tbe cotteot u (27
Membet 5totes) ls oow mote llkely to be closet to t79 blllloo. lf cotteot tteoJs coouooe, tbls fqote
coolJ be os blqb os t9J blllloo lo 2020.
- uoto soqqests tbot oot-of-pocket Jeotol expeoJltote ls llkely to voty occotJloq to tbe sttoctote of
tbe otol beoltb cote system. lo Membet 5totes socb os 5polo, otol beoltb setvlces ote mololy pto-
vlJeJ by ptlvote ptocuuooets, ooJ tbos poueots osoolly poy tbe totol cost. 1bls moy cteote occess
ptoblems fot low-locome qtoops. lo ueomotk, otol beoltb cote ls ftee of cbotqe fot oll cbllJteo
ooJet tbe oqe of elqbteeo, ooJ oJolts poy fot tteotmeot ftom ptlvote Jeotol ptocuuooets tbtooqb
o system of qovetomeot sobslJles. lo Membet 5totes socb os ltooce ooJ Cetmooy, pteveouoo ooJ
tteotmeot ote coveteJ wltblo tbe boslc pockoqe of pobllc beoltb losotooce, bot o sbote of tbe cost
ls botoe by poueots.
- loJltect costs otlse ftom tbe soclol botJeos of poot otol beoltb ooJ lts lotetocuoo wltb systemlc
Jlseoses ooJ cooJluoos locloJloq Jlobetes, beott ooJ cltcolototy Jlseoses, ooJ tbe e[ects of poly-
pbotmocy oo otol beoltb ooJ vlce-vetso
- 1bete ls sttooq evlJeoce tbot tbe beoefts of pteveouoq tootb Jecoy exceeJ tbe costs of tteotmeot.
lot exomple, sovloqs lo Jeotol expeoJltote bove beeo JemoosttoteJ lo Membet 5totes socb os
ueomotk ooJ 5weJeo, wblcb bove lovesteJ lo tbe ptovlsloo of pteveotouve otol beoltb setvlces, ooJ
wbete posluve tteoJs bove beeo ooteJ lo tetms of teJocuoo lo tbe ptevoleoce of otol Jlseose.
25
Spending on health and oral health
ln Lhe Lu, Lhe overall spendlng by Member SLaLes on all forms of general healLhcare (lncludlng denusLry)
appears Lo vary slgnlcanLly, generally buL noL wholly ln llne wlLh a counLry's wealLh as measured by Cnl
per caplLa, (llgure 4 and llgure 3).
I|gure 4: GNI per cap|ta, |n 2010 [current |nternanona| 5] (Wor|d 8ank 2012)
I|gure S: nea|th expend|ture per cap|ta |n 2010 [current US5] (Wor|d 8ank 2012)
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Cral dlseases remaln a slgnlcanL publlc healLh lssue for many hlgh-lncome counLrles, where expendlLure
on LreaLmenL oen exceeds LhaL for oLher dlseases, lncludlng cancer, hearL dlsease, sLroke, and demenua.
1hls ls a cause for concern, glven LhaL much of Lhe oral dlsease burden ln hlgh-lncome counLrles ls due
Lo denLal carles and lLs compllcauons, and Lhls ls prevenLable Lhrough Lhe use of uorlde and oLher cosL-
eecuve measures (lus eL al. 2011). uaLa from AusLralla shows how oral condluons are Lhe second-mosL
expenslve dlsease group Lo LreaL, [usL below cardlovascular dlsease. uenLal condluons were found Lo be
more expenslve Lo LreaL Lhan all cancers comblned (AusLrallan lnsuLuLe of PealLh and Welfare 2010). ln
addluon, sLudles have shown how ln some lndusLrlallsed counLrles Lhe mouLh ls Lhe mosL expenslve parL
of Lhe body Lo LreaL (Schnelder eL al. 1998, 8auer eL al. 2009).
lL appears LhaL expendlLure on oral healLh care ls slgnlcanL, averaglng 3 of LoLal healLh expendlLure,
and 16 of prlvaLe healLh expendlLure across Crganlsauon for Lconomlc Co-operauon and uevelopmenL
(CLCu) counLrles ln 2009 (CLCu 2011).
1he esumaLed percenLage of Cross nauonal roducL (Cn) spenL on Lhe provlslon of oral healLh care varles
slgnlcanLly across Lurope (llgure 6).
I|gure 6: Lsnmated percentage of GN spent on ora| hea|th |n 2010 (unpub||shed data from CLCDC 2012)*
*no daLa avallable for Spaln
ln 2000, lL was esumaLed LhaL Lhe LoLal spend on all aspecLs of care and LreaLmenL provlded by denusLs ln
Lhe old" Lu (13 Member SLaLes) was over t34 bllllon per year (WldsLrm and LaLon 2004). 1he gure for
Lhe currenL Lu (27 Member SLaLes) ls now more llkely Lo be closer Lo t79 bllllon. lf currenL Lrends conunue,
Lhls gure could be closer Lo t93 bllllon across Lhe Lu ln 2020 (1able 2).
0,0
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1ab|e 2: Lsnmated pred|cted LU (27) spend on the prov|s|on of ora| hea|th care serv|ces
CounLry Cnl 2010 ($)* Cnl (t)**
of Cn
spenL on CP
ln 2010***
Spend on oral healLh care servlces (t)
2010 2012 2013 2020
Austria 377 308 0.32 1.60 1.67 1.77 1.93
8elglum 478 390 0.3 1.93 2.03 2.13 2.38
8ulgarla 46 38 0.18 0.07 0.07 0.07 0.08
Cyprus 23 19 0.3 0.06 0.06 0.06 0.07
C. 8epub 179 146 0.3 0.44 0.46 0.48 0.33
uenmark 319 260 0.33 0.86 0.89 0.93 1.03
Estonia 18 13 0.39 0.06 0.06 0.06 0.07
Finland 242 198 0.4 0.79 0.82 0.87 0.96
France 2607 2128 0.43 9.38 9.96 10.37 11.67
Cermany 3341 2728 0.8 21.82 22.70 24.09 26.60
Greece 293 239 1.1 2.63 2.74 2.91 3.21
Pungary 122 100 0.16 0.16 0.17 0.18 0.19
lreland 171 140 0.6 0.84 0.87 0.92 1.02
lLaly 2031 1674 0.82 13.73 14.28 13.16 16.74
LaLvla 24 20 0.24 0.03 0.03 0.03 0.06
LlLhuanla 36 29 0.19 0.06 0.06 0.06 0.07
Luxembourg 38 31 0.29 0.09 0.09 0.10 0.11
MalLa 8 7 0.4 0.03 0.03 0.03 0.03
neLherlands 773 631 0.3 3.16 3.28 3.48 3.83
oland 432 369 0.2 0.74 0.77 0.81 0.90
orLugal 221 180 0.4 0.72 0.73 0.80 0.88
8omanla 139 130 0.18 0.23 0.24 0.26 0.28
Slovak 8ep. 86 70 0.13 0.11 0.11 0.12 0.13
Slovenla 46 38 0.36 0.14 0.14 0.13 0.16
Spaln 1389 1134 0.4 4.34 4.72 3.01 3.33
Sweden 467 381 0.68 2.39 2.70 2.86 3.16
uk 2272 1833 0.3 9.27 9.63 10.24 11.31
1C1AL (bllllon) t 76 t 79 t 84 t 93
Notes and exp|ananon
* Cnl (Cross nauonal lncome ln currenL uSu) ln 8llllons 2010 (World 8ank 2012)
** Cnl 2010 converLed Lo Luro aL a raLe of 1 uSu = 0.816310 on 08/07/2012
*** Cn spenL on Lhe provlslon of oral healLh care servlces ln 2010 (unpubllshed CLCuC daLa 2012). 1he Cn esumaLes for
several former LasLern 8loc Member SLaLes may noL lnclude prlvaLe expendlLure
uaLa for Spaln, Lhe Czech 8epubllc and 8ulgarla are esumaLes.
A predlcLed annual 2 lncrease ln expendlLure on oral healLh was uullsed Lo calculaLe predlcLed expendlLures up Lo 2020.
lL ls lmporLanL Lo noLe LhaL Lhese gures are esumaLes, as lL ls exLremely dlmculL Lo collecL daLa for Member SLaLes ln whlch Lhere
ls very llule publlc or lnsurance fundlng of oral healLh.
AlLhough Lhese daLa may well be lnaccuraLe for some Member SLaLes, Lhey do glve an overall plcLure of Lhe level of Lhe cosL of oral
healLh across Lhe Lu.
28
ln almosL every Member SLaLe, Lhe overall levels of expendlLure and Lhe amounL of care provlded by pracu-
uoners ls dlrecLly lnuenced by Lhe regulauons whlch govern pauenLs' fees and prlvaLe denusLs' remunera-
uon. 8ecause of Lhe domlnance of prlvaLe pracuuoners" ln oral healLh care provlslon, regulauons abouL
pauenL paymenLs, xed remunerauon fees, and subsldy sysLems can all aecL Lhe denusL's lncenuve Lo
LreaL, and Lhe pauenL's lncenuve Lo seek LreaLmenL.
ln addluon, CLCu daLa suggesLs LhaL ouL-of-pockeL denLal expendlLure ls llkely Lo vary accordlng Lo Lhe
sLrucLure of Lhe oral healLh care sysLem (llgure 7). ln Member SLaLes such as Spaln, oral healLh servlces
are malnly provlded by prlvaLe pracuuoners, and pauenLs usually pay Lhe LoLal cosL. 1hls may creaLe access
problems for low-lncome groups. ln uenmark, oral healLh care ls free of charge for all chlldren under Lhe
age of elghLeen, and adulLs pay for LreaLmenL from prlvaLe denLal pracuuoners Lhrough a sysLem of gov-
ernmenL subsldles. ln Member SLaLes such as lrance and Cermany, prevenuon and LreaLmenL are covered
wlLhln Lhe baslc package of publlc healLh lnsurance, buL a share of Lhe cosL ls borne by pauenLs.
I|gure 7: Cut-of-pocket denta| expend|ture, 2009 or nearest year (CLCD 2011)
Lsumaung expendlLure on oral healLh servlces can be exLremely challenglng due Lo Lhe dlmculues ln as-
sesslng ouL-of-pockeL or prlvaLe expendlLure". ln many Member SLaLes, for example Creece and lLaly, Lhe
assessmenL of prlvaLe spendlng ls made Lhrough self-reporung ln household surveys, whlch may lnLroduce
lnaccuracles.
uenLal dlsease and lLs sequalae can lmpose a slgnlcanL nanclal burden Lo an lndlvldual and socleLy. lor
example, ln Lhe uk, Lhe cosLs of malnLalnlng LeeLh, especlally for adulLs ln Lhe second half of Lhelr llves,
who frequenLly have heavlly resLored LeeLh, appears Lo be rlslng (SLeele 8eporL 2009). 1here are also lndl-
recL cosLs Lo conslder, arlslng from Lhe soclal burdens of poor oral healLh and ume o work. 1hls burden ls
lncreaslng as more and more people reLaln Lhelr LeeLh laLer and laLer lnLo llfe.
1he common rlsk facLors for chronlc dlseases, lncludlng chronlc oral dlseases, have been recognlsed for
some years (Shelham and Wau, 2000). uslng dlabeLes as an example, ln Lhe lasL few years evldence has
been publlshed suggesung how gum dlseases have an adverse eecL on Lhe conLrol of blood sugar levels
and Lhe lncldence of dlabeLes compllcauons (Crossl 1998, SLewarL 2001, 1aylor 2001). 1he cosL Lo Lhe
healLh budgeL of managlng people wlLh dlabeLes ls subsLanual. ln Lhe uk, esumaLes suggesL 3 of LoLal
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nauonal PealLh Servlce (nPS) resources and up Lo 10 of hosplLal ln-pauenL resources are used for Lhe
care of people wlLh dlabeLes (uP 2001).
1he challenges of assesslng Lhe healLh-economlc eecLs of carles prevenuon meLhods are well accepLed ln
Lhe llLeraLure. Powever, sLudles have hlghllghLed how Lhe beneLs of prevenung LooLh decay exceed Lhe
cosLs of LreaLmenL (Cscarson 2007, 8urL 1998), as well as Lhe cosL-eecuveness of uslng uorlde LooLh-
pasLe Lo prevenL denLal carles (uavles 2003, ?ee 2004).
lurLhermore, savlngs ln denLal expendlLure have been demonsLraLed ln Member SLaLes such as uenmark
and Sweden, whlch have lnvesLed ln Lhe provlslon of prevenLauve oral healLh servlces, and where posluve
Lrends have been noLed ln Lerms of reducuon ln Lhe prevalence of oral dlsease (Wang eL al. 1998).
llnally, a sLudy analyslng Lhe uSA oral healLh sysLem descrlbes Lhe global slLuauon: A sysLem focused
prlmarlly on LreaLmenL of dlsease ln lndlvlduals ls noL economlcally susLalnable, soclally deslrable, or eLhl-
cally responslble. 1he undersLandlng exlsLs Lo prevenL a very large proporuon of oral dlseases (Cooch eL
al. 2009 1ruman eL al. 2002), and communlLy-based prevenuon generally ls cosL-savlng compared wlLh a
LreaLmenL-focused approach, parucularly for communlues and lndlvlduals aL hlgh rlsk for dlsease" (1omar
and Cohen 2010).
30
Section 4: Inequalities relating to the
treatment of oral diseases in Europe

Key points
- 1be otopeoo lotllomeot kesolouoo oo keJocloq neoltb loepoollues lo tbe u (2011) ockoowl-
eJqeJ tbot tbe u foces o cbolleoqe otlsloq ftom tbe wlJe Jlspotlues lo pbyslcol ooJ meotol beoltb
wblcb exlst, ooJ ote qtowloq botb betweeo ooJ wltblo u Membet 5totes. loepoollues lo beoltb
betweeo people lo blqbet ooJ lowet eJocouoool, occopouoool ooJ locome qtoops bove beeo foooJ
lo oll Membet 5totes. 1bete ote ptofoooJ otol beoltb Jlspotlues octoss u cooottles, teloteJ to
soclo-ecooomlc stotos, oqe, qeoJet, ot qeoetol beoltb stotos. poltoble occess to Jeotol setvlces ls
oo lmpottoot foctot lo teJocloq otol beoltb loepoollues.
- uesplte lmptovemeots, ptoblems lo occess petslst, most commooly omooq voloetoble ooJ low lo-
come qtoops. 1bese loJlvlJools ofeo expetleoce Jl[colues lo occessloq Jeotol cote, qeoetolly ot-
teoJloq setvlces less ftepoeotly tboo tbe qeoetol popolouoo, fot ptlmoty cote ot emetqeocy tteot-
meot wbeo lo polo, totbet tboo fot pteveouve loJlcouoos. lo ltooce, lt bos beeo tepotteJ tbot
J0-40X of people llvloq lo teslJeouol bomes oeeJ testotouve Jeotol tteotmeot. lt bos olso beeo
blqbllqbteJ tbot ooe oot of evety tbtee loJlvlJools wltb pbyslcol ot leotoloq Jlsoblllues bove ot leost
ooe ootteoteJ covlty.
- A foctot wblcb lmpocts opoo Jeotol oueoJooce ls tbe sttoctote fot tbe Jellvety of otol beoltb cote
setvlces, wblcb votles slqolfcootly betweeo loJlvlJool membet stotes. A fot lowet petceotoqe of
tbe popolouoo oppeot to oueoJ tbe Jeoust lo soclolly ooJ ecooomlcolly less well JevelopeJ u
Membet 5totes, wbete tbete ls llule ot oo pobllcolly fooJeJ Jeoustty, tboo lo tbose wblcb ptovlJe
pobllcolly sobslJlseJ otol beoltb cote. lo some Membet 5totes, low-locome qtoops oppeot to be
JlsoJvootoqeJ by otol beoltb losotooce ptoqtommes. cooomlc ooJ pollucol cbooqes lo osteto
otope bove leJ to tbe Jeceottollsouoo of otol beoltb setvlces, wltb less empbosls ploceJ oo tbe
ptovlsloo of pobllc beoltb ptoqtommes. 1bls bos boJ o oeqouve lmpoct oo tbe oullsouoo of otol
beoltb setvlces.
- otobotometet sotvey Joto soqqest tbot of tbose wbo tespooJeJ to tbe sotvey, tbe tespooJeots
most llkely to bove vlslteJ o Jeoust lo tbe lost twelve mootbs teoJ to be lobobltoots of oottbeto
u Membet 5totes. tbe NetbetlooJs (8JX), ueomotk (78X), Cetmooy ooJ loxembootq (77X), fol-
loweJ by 5lovoklo (7JX) ooJ 5weJeo (71X). lobobltoots of sevetol cooottles lo u Membet 5totes
lo osteto otope oppeot to be tbe leost llkely to bove vlslteJ o Jeoust Jotloq tbe post yeot. lltbo-
oolo (46X), lolooJ (44X) ooJ komoolo (J4X). 1bls ls olso tbe cose fot teslJeots lo botb 5polo (4JX)
ooJ lottoqol (46X). 1be petceotoqe of tbe popolouoo wbo clolm to bove vlslteJ o Jeoust lo tbe lost
twelve mootbs lo Aosttlo (56X), ltelooJ (54X), cyptos (54X), ltoly (52X) ooJ ltooce (52X) ote oll
below tbe u (27) ovetoqe petceotoqe of 57X.
- leople wltb blqb locomes oppeot to be mote llkely to bove vlslteJ o Jeoust wltblo tbe lost 12
mootbs. 1be ossoclouoo betweeo eJocouoo ooJ oueoJooce ot tbe Jeoust votles slqolfcootly be-
tweeo Membet 5totes. otopeoos wbo ote lo foll ume eJocouoo tbe looqest, oppeot to be mote
llkely to vlslt o Jeoust fot o cbeck-op. wbete Jeotol oueoJooce ls qeoetolly poot fot tbe eoute popo-
louoo, tbls Jl[eteoce ls eveo mote ptoooooceJ. lot exomple lo 2004, ooly 27X ooJ JJX of tbe most
eJocoteJ meo ooJ womeo lo komoolo wete tepotteJ os occessloq Jeotol setvlces lo tbe ptevloos
12 mootbs. lot tbose wbo boJ ooly tbe most boslc level of eJocouoo tbls petceotoqe JtoppeJ to 4X
of meo ooJ 5X of womeo.
31
1he WPC Clobal Commlsslon on Soclal ueLermlnanLs of PealLh (CSuP) sLaLed LhaL: [PealLh lnequallues are]
caused by Lhe unequal dlsLrlbuuon of power, lncome, goods and servlces, globally and nauonally, Lhe conse-
quenL unfalrness.ln access Lo healLh care, schools, educauon, condluons of work and lelsure, homes, com-
munlues,. and chances of leadlng a ourlshlng llfe.. oor and unequal llvlng condluons are Lhe consequence
of poor soclal pollcles and programmes, unfalr soclal arrangemenLs and bad pollucs" (CSuP 2008).
1he Luropean arllamenL 8esoluuon on 8educlng PealLh lnequallues ln Lhe Lu (2011) acknowledged LhaL
Lhe Lu faces a challenge arlslng from Lhe wlde dlsparlues ln physlcal and menLal healLh whlch exlsL, and
are growlng beLween, and wlLhln, Lu Member SLaLes. lnequallues ln healLh beLween people ln hlgher and
lower educauonal, occupauonal and lncome groups have been found ln all Member SLaLes.
ln addluon Lo economlc, soclal and envlronmenLal facLors, healLh ls also lnuenced by people's llfesLyles
and access Lo healLhcare servlces, lncludlng healLh lnformauon, educauon, dlsease prevenuon and denl-
uve LreaLmenL. Lower socloeconomlc groups are more suscepuble Lo poor nuLrluon, Lobacco and alcohol
dependency, all of whlch are ma[or conLrlbuLory facLors ln many dlseases and condluons.
1here are profound oral healLh dlsparlues across Lu counLrles, relaLed Lo soclo-economlc sLaLus, age, gen-
der, or general healLh sLaLus. Marked lnequallues remaln wlLhln soclo-economlcally deprlved and/or vul-
nerable groups ln socleLy:
eople llvlng ln areas of maLerlal and soclal deprlvauon (MarmoL and 8ell 2011)
8esldenLs of psychlaLrlc hosplLals (vlglld eL al. 1993)
1he frall and vulnerable elderly populauon (Crlmn eL al. 2012)
rlsoners (!ones eL al. 2003, Walsh eL al. 2008)
Pomeless (uealma eL al. 2003)
8efugees (Angellllo eL al. 1996)
lmmlgranLs (Peldmann and ChrlsLensen 1983)
1ravelllng populauons (Ldwards and Wau 1997)
LLhnlc groups suerlng from soclal dlsadvanLages (verrlps eL al. 1992, WendL eL al. 1999, Sundby and
eLersen 2003, ChrlsLensen eL al. 2010)
AdulLs wlLh learnlng dlsablllues (1lller eL al. 2001, Classman eL al. 2003)
1hroughouL Lhe Lu, lL ls acknowledged LhaL Lhese groups have a poor level of oral healLh, and oen expe-
rlence dlmculues ln accesslng denLal care. 1hey generally auend servlces for prlmary care or emergency
LreaLmenL when ln paln, raLher Lhan seek prevenuon. lor example, ln lrance, lL has been reporLed LhaL 30-
40 of people llvlng ln resldenual homes need resLorauve denLal LreaLmenL. lL has also been hlghllghLed
LhaL one ouL of every Lhree lndlvlduals wlLh physlcal or learnlng dlsablllues have aL leasL one unLreaLed
cavlLy (PauLe AuLorlLe de SanLe 2010).
Toothbrushing habits in Europe
1hose who brush Lhelr LeeLh more Lhan once a day by 12 years of age are more llkely Lo conunue Lo do so
LhroughouL Lhelr Leenage years and lnLo adulLhood (kolvusllLa eL al. 2003).
A survey lnvesugaung Lhe LooLhbrushlng hablLs ln 11 year olds across Lurope revealed how brushlng more
regularly ls assoclaLed wlLh hlgher famlly lncome (PS8C 2010).
32
1hese ndlngs mlrror Lhe resulLs from prevlous research demonsLraung how carles experlence ls hlghesL
among chlldren of low-lncome famllles (Maes eL al. 2006) and Lhose llvlng ln low-SLS areas (Levln eL al. 2009).
A sLudy from ScoLland has lllusLraLed how home rouunes and good parenL-chlld communlcauon are as-
soclaLed wlLh more regular LooLh brushlng among adolescenLs, suggesung LhaL famlllal facLors may have a
proLecuve eecL on oral healLh behavlours (Levln and Currle 2010).
Access to dental services
LqulLable access Lo denLal servlces ls an lmporLanL facLor ln reduclng oral healLh lnequallues. lL ls wldely
recognlsed LhaL Lhere are ma[or dlsparlues ln general and oral healLh across Lhe Lu, and wlLhln Member
SLaLes, whlch are relaLed Lo soclo-economlc sLaLus, age and gender, and LhaL Lhey have noL been adequaLe-
ly addressed.
A facLor whlch lmpacLs upon denLal auendance ls Lhe sLrucLure for Lhe dellvery of oral healLh care servlces,
whlch varles slgnlcanLly beLween lndlvldual Member SLaLes (1able 3). ln Lerms of oral healLh lnequall-
ues, Lhe provlslon of oral healLh care servlces for chlldren, and vulnerable populauon groups ls especlally
lmporLanL Lo conslder.
1ab|e 3: Mode|s of hea|thcare prov|s|on and the prov|s|on of denta| serv|ces for ch||dren and vu|nerab|e
popu|anon groups (based on a tab|e from 1he LU Manua| of Denta| racnce, CLD 2009, w|th updates)
Model of
healthcare provision
ubllc denLal servlces for chlldren and vulnerable populauon groups
SLaLe funded
CaLegorlcal:
Mojotlty of fooJloq ls ftom oouoool ot locol toxouoo, bot setvlce ls llmlteJ to cettolo qtoops
Cyprus 80 per cenL of Lhe populauon, lncludlng all prlmary school chlldren, lndlvlduals
on a low lncome, governmenL employees, members of Lhe nauonal Cuard and
pollce omcers are enuLled Lo free denLal LreaLmenL wlLhln Lhe publlc secLor.
Powever, Lhe vasL ma[orlLy of Lhe populauon uullse Lhe prlvaLe secLor where
Lhey pay a fee per lLem of servlce. uomlclllary care ls avallable.
lreland ubllc denLal servlce for chlldren up Lo Lhe age of 16 years, and oLhers who
cannoL aord prlvaLe care, have resLrlcLed access Lo denLal servlces and have
speclal needs.
Spaln AlmosL all oral healLh care ln Spaln ls provlded by prlvaLe pracuuoners and adulL
pauenLs usually pay Lhe full cosL. ln mosL auLonomous reglons, Lhere ls a small
publlcly funded caplLauon sysLem for chlldren aged beLween 7 and 14 years.
unlversal:
1bls setvlce ls ovolloble to oll cluzeos lo tbeoty, bot tteotmeot opuoos ooJ ovolloblllty moy be llmlteJ lo teollty.
uenmark Cral healLh care ls free for chlldren up Lo Lhe age of 18 years, and ls usually pro-
vlded aL school. vulnerable populauon groups, lncludlng Lhe elderly, and Lhose
of low soclo-economlc sLaLus also recelve free denLal care.
lLaly ln Lheory, chlldren up Lo Lhe age of 14 years, and vulnerable populauon groups
recelve free denLal LreaLmenL. Powever, ln pracuce, ln many areas only emer-
gency denLal LreaLmenL ls provlded by Lhe nPS.
uk Croups recelvlng free nPS denLal care lnclude: chlldren under 18 years, preg-
nanL or nurslng moLhers, lndlvlduals on cerLaln welfare beneLs, and Lhose un-
der 19 years old who are ln full ume educauon. uomlclllary care ls avallable.
33
Soclal lnsurance Lype
lncome celllng*:
locome-boseJ ctltetlo testtlct occess to otol beoltb cote setvlces
Cermany 1he vasL ma[orlLy of Lhe populauon are members of noL-for-proL 'slck funds'
whlch glves Lhe member enuLlemenL Lo a package of free baslc denLal care,
wlLh advanced LreaLmenL opuons such as crowns and brldges and orLhodonucs
someumes requlrlng slgnlcanL pauenL co-paymenLs. A publlc denLal servlce
exlsLs buL ls resLrlcLed Lo examlnauon, dlagnosls and prevenuon.
no lncome celllng**:
Otbet ctltetlo exlst wblcb Jetetmloe occess to sobslJlseJ cote
Austria 1he cosL of baslc resLorauve and prevenLauve denLal LreaLmenLs are gener-
ally covered by compulsory healLh lnsurance schemes, alLhough beneLs vary
across schemes. Chlldren are covered by Lhe same scheme as Lhelr parenLs.
ln every counLy (8undesland"), prevenLauve (solely educauonal) denLal pro-
grammes are dellvered ln schools, and ln Lhe ma[orlLy of counues chlldren's
LeeLh are examlned regularly. uomlclllary care ls avallable.
France Chlldren and Leenagers aged 6,9,12, and beLween 13 and 18 years are enuLled
Lo a free check up. Any subsequenL LreaLmenL requlred ls also free (8ochereau
and Azogul 2007). revenLauve lnLervenuons are provlded up Lo Lhe age of 12
years aL school. uomlclllary care ls avallable.
LlLhuanla lree publlc oral healLh care ls provlded free of charge Lo chlldren and Leenagers
up Lo Lhe age of 18 years. rosLhodonuc care (denLures and crown/brldgework)
for pensloners and Lhe dlsabled ls relmbursed wlLh a xed sum of money. lor
adulLs beLween Lhe ages of 18 and 63 years, denLal care ln Lhe publlc denLal ser-
vlce ls parLly nanced by Lhe fund and parually by co-paymenLs from pauenLs.
oland rovlslon of oral healLh care funded by common healLh lnsurance ls llmlLed.
As a mlnlmum, Lhls lncludes an annual check-up, buL chlldren under Lhe age
of 18 and pregnanL women are able Lo obLaln a wlder range of servlces more
frequenLly.
8omanla Cral healLh care LreaLmenL ls funded by Lhe publlc healLh lnsurance sysLem. An-
nual check-ups and free LreaLmenL ls avallable Lo chlldren under Lhe age of 18
years. 1hose people who are unemployed, pregnanL and nurslng moLhers, mlll-
Lary personnel, war veLerans, or ln prlson are exempL from paylng conLrlbuuons
Lo Lhe lnsurance sysLem buL are sull covered by lL (Amarlel and LaLon 2009).
noLe: * lncome celllng: 1here are lncome crlLerla for excludlng some adulLs from access Lo all or mosL of care wlLhln schemes. So
Lhere ls malnly prlvaLe provlslon and nance, wlLh a governmenL organlsed resldual healLh servlce for speclc prlorlLy" groups
** no lncome celllng: 1here may be oLher crlLerla for access, buL Lhere ls usually full access for Lhe elderly, chlldren, medlcally
compromlsed groups, and low lncome adulL groups.
34
AnoLher facLor whlch lmpacLs upon denLal auendance ls Lhe provlslon of publlcally subslded oral healLh
care. A far lower percenLage of Lhe populauon appear Lo go Lo Lhe denusL ln soclally and economlcally
less well developed Member SLaLes, where Lhere ls llule or no publlcally funded denusLry, Lhan ln Lhose
whlch provlde publlcally subsldlsed oral healLh care. An example ls Lhe dlerence beLween CaLalunla (Lhe
wealLhlesL parL of Spaln) where Lhere ls vlrLually no publlc fundlng for oral healLh care, and 8elarus, where
Lhere ls sull slgnlcanL publlc fundlng for oral healLh care. ln CaLalunla ln 2006, lL was reporLed LhaL only
32 of men and 38 of women had vlslLed a denusL (Casals eL al. 2007). Whereas ln 8elarus ln 2007 Lhe
reporLed gure for a vlslL Lo denusL was 60 (1serakheva eL al. 2011).
ln Lu Member SLaLes ln LasLern Lurope, prlor Lo 1989, oral healLh care for chlldren was provlded by publlc
healLh servlces and mosL Member SLaLes had denLal servlces wlLhln schools. Powever, Lhe recenL prlvau-
sauon and decenLrallsauon of oral healLh servlces have meanL LhaL mosL publlc healLh programmes have
ceased operauon (Amarlel and LaLon 2009, Peldl wlkl 2012).
ln all Lu Member SLaLes, Lhere ls a Lheoreucal enuLlemenL for each lndlvldual Lo recelve elLher sLaLe or
soclal lnsurance funded healLh care as a consuLuuonal rlghL, or as a sLaLed prlnclple (CLu 2009). Powever,
Lhls ls rarely guaranLeed and ln some Member SLaLes, low-lncome groups appear Lo be dlsadvanLaged by
oral healLh lnsurance programmes.
Inequalities in attendance
ln general, lL appears LhaL Lhe recommended frequency of auendance aL Lhe denusL varles across Lu Mem-
ber SLaLes (1able 4).
1ab|e S: kecommended frequency of auendance at the dennst
(based on a tab|e from 1he LU Manua| of Denta| racnce, CLD 2009, w|th updates)
kecommended frequency LU Member State
ApproxlmaLely every 6
monLhs
oland
Lvery 9 Lo 12 monLhs uenmark
Annually AusLrla, Cyprus, lrance, Cermany,
lreland, lLaly, LlLhuanla*, and 8omanla
According to need uk (nlCL 2004)
unclear Spaln
noLe * lor chlldren under Lhe age of elghLeen years
LurobaromeLer survey daLa suggesL LhaL of Lhose who responded Lo Lhe survey, Lhe respondenLs mosL
llkely Lo have vlslLed a denusL ln Lhe lasL Lwelve monLhs Lend Lo be lnhablLanLs of norLhern Lu Member
SLaLes: Lhe neLherlands (83), uenmark (78), Cermany and Luxembourg (77), followed by Slovakla
(73) and Sweden (71). lL ls lnLeresung Lo noLe LhaL for some of Lhese Member SLaLes lL ls compulsory
for lnhablLanLs Lo auend Lhelr denusL annually, or even every slx monLhs, as parL of Lhelr sLaLuLory medl-
cal lnsurance requlremenLs (LurobaromeLer 2010). Powever, lL ls worLh noung LhaL even ln Lhese Member
SLaLes, problems can exlsL wlLhln parucular age groups. lor lnsLance, one of Cermany's largesL sLaLuLory
healLh lnsurance companles hlghllghLed ln a recenL annual reporL LhaL Lwo ouL of Lhree chlldren (aged be-
Lween 2 and a half Lo 6 years of age) are noL auendlng annual oral healLh examlnauons (8armer CLk 2012).
35
lnhablLanLs of several counLrles ln Lu Member SLaLes ln LasLern Lurope appear Lo be Lhe leasL llkely Lo have
vlslLed a denusL durlng Lhe pasL year. 1hese Member SLaLes lnclude LlLhuanla (46), oland (44) and 8oma-
nla (34). 1hls ls also Lhe case for resldenLs ln boLh Spaln (43) and orLugal (46) (LurobaromeLer 2010).
1he percenLage of Lhe populauon who clalm Lo have vlslLed a denusL ln Lhe lasL Lwelve monLhs ln AusLrla
(36), lreland (34), Cyprus (34), lLaly (32) and lrance (32) are all below Lhe Lu (27) average percenL-
age of 37 (LurobaromeLer 2010).
Inequalities in types of dental treatment
lnequallues ln Lypes of denLal LreaLmenL, wheLher curauve or prevenuve, are also apparenL across Lurope.
A recenL sLudy among Luropeans aged 30 years and over, demonsLraLed how ln comparlson wlLh oLher
Luropean reglons, Lhere was a Lendency Loward more frequenL and prevenuve denLal LreaLmenLs belng
underLaken ln Lhe elderly populauons resldlng ln Scandlnavla and WesLern Lurope. 1he auLhors reporLed a
hlgh lncldence of operauve LreaLmenL ln Member SLaLes such as AusLrla, lLaly, and lrance, whereas ln Lhe
neLherlands, Sweden, uenmark, SwlLzerland, and lreland, Lhe lncldence of operauve LreaLmenL was low ln
comparlson (LlsLl, 2011).
Powever, ln cerLaln Member SLaLes, a hlgher lncldence of solely cllnlcal LreaLmenL may be observed. Ac-
cordlng Lo Lhe LurobaromeLer survey (2010), Lhe lnLervlewees whose lasL vlslL Lo a denusL was for rouune
LreaLmenL, were lnhablLanLs of AusLrla, Cermany, LlLhuanla and oland. A hlgher percenLage of Lhe popula-
uon ln Cyprus and 8omanla auend Lhe denusL, buL solely for emergency LreaLmenL.
Inequalities in income status and dental attendance
8ecenL ndlngs suggesL LhaL people wlLh a hlgh lncome were more llkely Lo have vlslLed a denusL ln Lhe lasL
12 monLhs (CLCu 2011). 1hls ls desplLe dlerences ln publlc or prlvaLe oral healLh coverage, and Lhe exLenL
of relmbursemenL. lnequallues appeared Lo be larger ln Member SLaLes wlLh a lower llkellhood of a denLal
vlslL such as oland and Spaln. lor example, ln Spaln, young adulLs from lower soclo-economlc groups have
Lwlce as much unLreaLed decay when compared Lo Lhose ln wealLhler soclo-economlc groups (Conse[o
uenusLas Crganlzacln Coleglal de uenusLas de Lspana 2010).
Inequalities in education levels and dental attendance
1he assoclauon beLween educauon and auendance aL Lhe denusL varles slgnlcanLly beLween Member
SLaLes. Luropeans who remaln ln full ume educauon Lhe longesL appear Lo be more llkely Lo vlslL a denusL
for a check-up. Accordlng Lo Lhe LurobaromeLer survey daLa (2010), senlor execuuves, sLudenLs, employ-
ees and self-employed people are more llkely Lo vlslL a denusL for a check-up, Lhan unemployed people,
pensloners and manual workers. ln Member SLaLes where denLal auendance ls generally poor for Lhe en-
ure populauon, Lhls dlerence ls even more pronounced. lor example ln 2004, only 27 and 33 of Lhe
mosL educaLed men and women ln 8omanla were reporLed as resorung Lo denLal servlces ln Lhe prevlous
12 monLhs. lor Lhose who had only Lhe mosL baslc level of educauon Lhls percenLage dropped Lo 4 of
men and 3 of women (LurosLaL 2004).
36
Reasons impacting upon dental attendance
lndlvlduals can be relucLanL Lo go for rouune check-ups and denLal care for a varleLy of reasons lncludlng
denLal anxleLy, fear of cosL, lnconvenlence and percelved dlmculLy ln ndlng a LrusLed denusL.
ln a 2010 survey, Lhe maln reason glven by respondenLs for noL havlng consulLed a denusL ln Lhe lasL Lwo
years was LhaL Lhelr denLal problem was noL consldered Lo be serlous enough (LurobaromeLer 2010). Pav-
lng no LeeLh, or Lhe facL LhaL Lhe respondenL had false LeeLh, and Lhe cosL of denLal consulLauon and LreaL-
menL were also frequenLly menuoned reasons.
ln Member SLaLes such as 8omanla, Lhe cosL of seeklng denLal LreaLmenL can be a very slgnlcanL barrler Lo
LreaLmenL. Powever, Lhls ls less of an lssue ln llnland, Slovenla and Lhe uk (LurosLaL 2010).
When Lhe daLa are analysed by age, ln Lhe older populauons, Lhe cosL of denLal LreaLmenL appears Lo be
a fundamenLal facLor upon denLal auendance (LurosLaL 2010 and LurobaromeLer 2010). 1he leasL advan-
Laged caLegorles e.g. unemployed people, manual workers, and pensloners, and Lhose who remalned ln
full ume educauon for Lhe shorLesL ume may be more llkely Lo menuon cosL as Lhelr reason for noL consulL-
lng a denusL (LurobaromeLer 2010).
37
Section 5: Oral health policies, the promotion of
oral health and the prevention of oral diseases in
Europe
Key points
- ltepoeot exposote to footlJe, teqolot btosbloq, o beoltby Jlet ooJ toouoe otol cote oll coottlbote
to lmptoveJ otol beoltb ootcomes ooJ o teJocuoo lo otol beoltb loepoollues.
- Most of tbe evlJeoce lo otol beoltb ptomouoo telotes to Jeotol cotles pteveouoo ooJ coottol of
petloJootol Jlseoses. 5ttooq evlJeoce exlsts tbot toplcol footlJes (footlJe tootbposte, footlJe vot-
olsb ooJ footlJe mootb tloses) coo pteveot tootb Jecoy.
- Cloqlvlus coo be pteveoteJ by qooJ petsoool otol byqleoe ptocuces, locloJloq btosbloq ooJ cleoo-
loq betweeo teetb ooJ wbete tbe tootb ooJ qoms meet, wblcb ote lmpottoot fot tbe coottol of
oJvooceJ petloJootol cooJluoos.
- llmlteJ evlJeoce exlsts fot tbe e[ecuveoess of scteeoloq fot eotly Jetecuoo of otol coocet oo o
popolouoo bosls, bot ossessmeot of tbe otol sof ussoes sboolJ be o toouoe pott of oo otol exoml-
oouoo, especlolly fot qtoops ot blqbet tlsk of otol coocet, socb os smokets ooJ beovy Jtlokets.
- Actoss tbe u, o votlety of soccessfol commoolty-boseJ pobllc otol beoltb ptoqtommes exlst.
- Ao lotetoouoool exomple of qooJ ptocuce locloJes tbe oolloe coooJloo 8est ltocuces lottol wblcb
sbowcoses e[ecuve best ptocuces moJels, metboJs, ooJ teseotcb evlJeoce lo tbe felJs of com-
moolty boseJ beoltb ptomouoo ooJ Jlseose pteveouoo lotetveouoos.
Preventing oral diseases
Cral dlsease such as denLal carles, perlodonLal dlseases, and oropharyngeal cancers are ma[or publlc
healLh problems. 8esearch has shown LhaL lndlvldual, professlonal and communlLy prevenuve measures
can be eecuve ln prevenung denLal carles. Across Lhe Lu, a varleLy of communlLy-based publlc healLh
programmes and lnluauves exlsL.
lrequenL exposure Lo uorlde, regular brushlng, a healLhy dleL and rouune oral care all conLrlbuLe Lo lm-
proved oral healLh ouLcomes and a reducuon ln oral healLh lnequallues. MosL of Lhe evldence ln oral
healLh promouon relaLes Lo denLal carles prevenuon and conLrol of perlodonLal dlseases. 8rushlng Lwlce
per day wlLh a uorlde LooLhpasLe ls eecuve aL prevenung denLal carles, and can also prevenL glnglvlus
and perlodonLal breakdown (Marlnho eL al. 2003).
SLudles lnvesugaung Lhe evldence for screenlng for oral cancer concluded LhaL llmlLed evldence exlsLs
on Lhe eecuveness of screenlng Lhe enure populauon (ku[an eL al. 2006, uowner eL al. 2006). Powever,
general agreemenL exlsLs LhaL assessmenL of Lhe oral so ussues should be a rouune parL of an oral examl-
nauon, especlally for groups LhaL have hlgher rlsks of developlng oral cancer such as smokers and heavy
drlnkers. 1he World PealLh Crganlsauon recommends LhaL prevenuon of oral cancer be an lnLegral parL of
nauonal cancer conLrol programs and LhaL oral healLh professlonals or prlmary healLh personnel should be
lnvolved ln deLecuon, early dlagnosls and LreaLmenL (eLersen 2009). Soclal markeung uullslng mass medla
has been used successfully Lo ralse awareness abouL oral cancer and Lo encourage people Lo have a mouLh
examlnauon (Sankaranarayanan eL al. 2003).
38
Fluorides and oral health
1he use of uorldes ls recognlsed as an lmporLanL measure ln carles prevenuon (WPC 2007). Lxposure Lo
uorldes can be achleved ln many forms and varlous modes of uorlde use have evolved, each wlLh lLs own
recommended concenLrauon, frequency of use, and dosage schedule. lluorlde can be lngesLed as a parL
of dleL ln waLer, salL, LableLs or mllk, or applled Loplcally from LooLhpasLes, mouLhrlnses, varnlshes, or gels.
1ooLhpasLe ls Lhe mosL wldespread vehlcle of uorlde, and Lhe decllne ln carles experlence ln chlldren ln
WesLern Lurope over Lhe pasL 30 years has been aurlbuLed Lo lLs regular use. 1he eecuveness of uorlde
LooLhpasLe ln reduclng carles ln chlldren ls well esLabllshed (Marlnho eL al. 2003).
Good practice from across Europe
Cood practice: Water fluoridation
WaLer uorldauon ls Lhe conLrolled ad[usLmenL of Lhe underlylng uorlde concenLrauon ln
drlnklng waLer Lo a level LhaL prevenLs denLal decay. 1he opumal concenLrauon ln Lemper-
aLe cllmaLes ls 1 parL per mllllon (ppm). lL ls safe, cosL-eecuve and has a demonsLrable
long Lerm beneL Lo populauon denLal healLh. noLwlLhsLandlng reporLs from anu-uorlda-
uonlsL groups, over Lhe lasL 30 years, Lhe uorldauon of waLer has been a slgnlcanL meLhod Lo help ln Lhe
prevenuon of LooLh decay, especlally ln Lhe unlLed SLaLes of Amerlca, where waLer uorldauon has been
ldenued by Lhe CenLers for ulsease ConLrol ln Lhe uS as one of Lhe Len greaL publlc healLh achlevemenLs"
ln Lhe LwenueLh cenLury (CenLers for ulsease ConLrol 1999).
1he besL avallable evldence suggesLs LhaL Lhe uorldauon of drlnklng waLer reduces Lhe prevalence of car-
les, boLh ln Lerms of Lhe proporuon of chlldren who are carles free and by Lhe mean change ln uMl1. 1here
ls also evldence Lo suggesL LhaL waLer uorldauon reduces Lhe severlLy of carles (as measured by uMl1)
across soclal groups and beLween geographlcal locauons (Mc uonagh eL al. 2000). WaLer uorldauon ls
consequenLly one of Lhe few publlc healLh lnLervenuons LhaL dlrecLly reduces dlsparlues ln denLal decay
beLween hlgh and low socloeconomlc sLaLus groups (8urL 2002, neldell eL al. 2010).
ln Lhe Lu, uorldauon schemes operaLe ln Lhe uk, Lhe lrlsh 8epubllc, Spaln, and oland (1able 3).
1ab|e 6: I|uor|danon schemes across Lurope (8r|nsh I|uor|danon Soc|ety 2004)
Country Number of peop|e
supp||ed w|th arn-
hc|a||y uor|dated
water
Number of peop|e
supp||ed w|th
natura||y uor|-
dated water
1ota| (arnhc|a|
and natura|)
ercentage of popu-
|anon w|th opnma|-
|y uor|dated water
lrlsh 8epubllc 3230 000 200 000 3430 000 73
oland 80 000 300 000 380 000 1
Spaln 4230 000 200 000 4430 000 11
unlLed klngdom 3797 000 330 000 6127 000 10
A hlgher percenLage of Lhe populauon of Lhe lrlsh 8epubllc (73) ls supplled wlLh opumally uorldaLed
waLer Lhan ln any oLher Luropean counLry. Powever, boLh Lhe uk and Spaln have hlgher overall numbers
of people drlnklng uorldaLed waLer.
39
Good practice: Fluoridated salt programmes
lluorldaLed salL ls wldely used ln parLs of Lurope, for example SwlLzer-
land, Slovakla, lrance, Cermany, and Lhe Czech 8epubllc (1he 8orrow
loundauon 2012, CLu 2009), and ls consldered Lo be beneclal Lo chll-
dren, especlally for Lhelr permanenL denuuon (?eung eL al. 2011).
ln Cermany, a uorldaLed salL programme was lnLroduced ln 1991. 1hls was
a carefully managed process whlch lnvolved esLabllshlng a sclenuc board and uullslng a publlc relauons
agency Lo ensure LhaL Lhe lssue of uorldaLed salL malnLalned a meanlngful and permanenL presence ln
publlc medla. Slnce lLs lnLroducuon, Lhe markeL share of uorldaLed salL conunued Lo lncrease unul 2007,
where lL reached a maxlmum of 70 and lL has remalned aL Lhls level slnce. ln comparlson, uorldaLed salL
achleved a 60 markeL share ln lrance ln 1993 shorLly aer lLs lnLroducuon. Powever, wlLhouL Lhe supporL
of a sclenuc board and promouonal campalgns, Lhe markeL share dropped Lo 8 ln 2010. ln oLher Luropean
counLrles, Lhe markeL share of uorldaLed salL ls comparauvely lower: 3 ln Slovakla, and 33 ln Lhe Czech
8epubllc (MarLhaler eL al. 2011).
Good practice: Fluoridated milk programmes
Mllk uorldauon programmes LargeLed aL chlldren are currenLly ln operauon ln
8ulgarla and Lhe uk (1he 8orrow loundauon 2012, CLu 2009). A sysLemauc re-
vlew Lo deLermlne Lhe eecuveness of uorldaLed mllk for prevenung carles on
a communlLy basls found lnsum clenL sLudles of good quallLy Lo make a denluve
concluslon, buL sLaLed uorldaLed mllk may be beneclal ln Lhe permanenL den-
uuon (?eung eL al. 2003). Mllk ls oen avallable Lo chlldren Lhrough school and
nuLrluonal programmes and can be LargeLed aL Lhe communlues ln greaLesL need
of lnLervenuon. lL ls parucularly approprlaLe ln Lhose communlues where Lhe uo-
rldauon of nelLher waLer nor salL ls posslble.
Good practice: Childsmile Program, Scotland
1he Chlldsmlle rogram (Chlldsmlle 2012) operaung ln predomlnanLly non-uorldaLed ScoLland lncorporaLes:
Cral healLh educauon and free dally supervlsed LooLhbrushlng ln all nurserles and prlorlLy schools
lree denLal packs wlLh LooLhbrush and LooLhpasLe, Lo supporL LooLhbrushlng aL home
Advlce and lnformauon for parenLs and carers Lo help Lhem care for Lhelr chlld's LeeLh
8lannual uorlde varnlsh appllcauons Lo hlgh rlsk young chlldren's LeeLh ln prlorlLy nurserles and
schools by Lralned denLal nurses
Addluonal home supporL and communlLy lnLervenuons dellvered by a range of parLners
An enhanced programme of care wlLhln rlmary Care uenLal Servlces
Slnce Lhe lmplemenLauon of Lhe programme, chlldren's denLal healLh ln Lhls age-cohorL across ScoLland has
shown a dlsuncL lmprovemenL. llgures released ln 2010 showed Lhe hlghesL ever percenLage of chlldren wlLh
no decay. ln addluon, Lhe mean uMl1 score decreased from 1.86 ln 2008, Lo 1.32 ln 2010 (nul 2010).
40
Good practice: Denmarks preventative oral health care model
ApproxlmaLely 40 years ago, uanlsh chlldren's oral healLh was among Lhe pooresL ln Lurope. Powever, a
LargeLed and proacuve approach Lo dellver prevenuve care wlLhln Lhe publlc oral healLh care servlce has had
slgnlcanL resulLs. 8eLween 1974 and 2000, Lhe average uMl1 scores ln 12-year-old uanlsh chlldren fell by
78 from 4.3 Lo 0.98. 8y 1997, more Lhan 99 of uanlsh chlldren recelved oral healLh care every year.
All munlclpallues ln uenmark are obllged Lo esLabllsh local cllnlcal faclllues Lo provlde all chlldren and
adolescenLs resldlng ln Lhe munlclpallLy wlLh free and comprehenslve oral healLh care, lncludlng healLh
educauon and prevenuon, from newborn Lo 18-year-old chlldren. Cllnlcs are oen locaLed ln, or nearby
prlmary schools.
A sophlsucaLed reglsLer of all chlldren resldlng ln Lhe munlclpallLy ls uullsed Lo monlLor auendance Lo Lhe
cllnlc. 1he lnlual vlslL Lo Lhe cllnlc ls organlsed by Lhe local oral healLh servlce. A leuer ls posLed home Lo
lnform parenLs LhaL Lhelr chlld ls now enuLled Lo free denLal care.
revenLauve eorLs are dlrecLed aL Lhe lndlvldual Lhrough Lallored advlce and guldance. Powever, slgnl-
canL emphasls ls also placed upon relnforclng Lhese messages wlLhln oLher healLh, soclal and educauon
envlronmenLs Lhrough sLa ln day-care cenLres, Leachers, healLh vlslLors and paedlaLrlclans (Assoclauon of
ubllc PealLh uenusLs ln uenmark 1997).
Good practice: An evidence-based toolkit for prevention
ln Lhe uk, Lhe ueparLmenL of PealLh and Lhe 8rlush Assoclauon for Lhe SLudy
of CommunlLy uenusLry have [olnLly produced an evldence-based LoolklL for
Lhe prevenuon of oral dlsease by prlmary care denLal Leams uellverlng 8eL-
Ler Cral PealLh: An evldence-based LoolklL for prevenuon" (uP 2009). 1hls
LoolklL provldes easy Lo use advlce on Lhe prevenuon of denLal carles, perl-
odonLal dlseases and oral cancer. 1he Lhlrd revlsed edluon ls due Lo be re-
leased shorLly, and Lhe Lool ls currenLly belng LranslaLed lnLo Spanlsh.
Good practice: Community centre based programmes
Cral healLh promouon LargeLed aL lmmlgranL famllles wlLh pre-schoolers, dellvered vla an accesslble com-
munlLy cenLre has shown some success ln prevenung LooLh decay ln Sweden. 1he programme lnvolved Lhe
dellvery of parenL educauon, LooLhbrushlng lnsLrucuon, dleL advlce, and Lhe prescrlpuon of a free dally
0.23mg LableL of uorlde Lo chlldren from ln a low soclo-economlc area ln Malm (Wennhall eL al. 2008,
Wennhall eL al. 2003).
Good practice: Use of peer leaders in school-based oral health promotion
rogrammes lnvolvlng prlmary school-aged chlldren ln dlsadvanLaged areas of Cermany and lreland have
shown Lhe beneLs of uslng peers Lo Leach younger chlldren abouL oral healLh. Crade 4 sLudenLs devlsed a
LooLhbrushlng lnsLrucuon program for Crade 1 chlldren ln Cologne, Cermany, and ln Lhe process lncreased
Lhelr own oral hyglene skllls (8elnhardL eL al. 2009). ln a slmllar programme, eleven year old chlldren ln
a dlsadvanLaged area of 8elfasL, norLhern lreland were Lralned as 'LooLh Leachers' Lo Leach ve year olds
abouL dleL and snacklng. A decrease ln sugary snacklng occurred, as well as an lncrease ln knowledge
among Lhe LooLh Leachers compared Lo chlldren auendlng Lhe conLrol schools (lreeman and 8unung 2003).
41
Good practice: Integrating oral health checks within general
health assessments for elderly people living in the community
A sLudy lnvolvlng Lhree general medlcal pracuces ln rural Lngland found LhaL oerlng a denLal examlna-
uon Lo elderly pauenLs as parL of Lhelr general prevenuve healLh check led Lo a slgnlcanL lncrease ln Lhelr
subsequenL denLal auendance, when compared Lo Lhe conLrol group LhaL was noL oered a cllnlcal examl-
nauon (Lowe eL al. 2007). 1he oer of an oral healLh assessmenL was Laken up mosL readlly by Lhose wlLh
currenL oral problems, and Lhose wlLh no regular denusL. 1he auLhors reporLed how boLh Lhe lncluslon of
a denLal checkllsL wlLhln Lhe prevenuve healLh check, alongslde supporL ln arranglng a denLal appolnLmenL
showed poLenual as a way of ensurlng Lhe denLal needs of Lhls vulnerable populauon group are meL.
Good practice: raising patient awareness in oral hygiene
measures to encourage self-care and limit periodontal breakdown
A sLudy underLaken ln Sweden over a 30 year perlod demonsLraLes Lhe lm-
porLance of ralslng pauenL awareness ln oral hyglene measures Lo encour-
age self-care and llmlL perlodonLal breakdown (Axelsson eL al. 2004). As parL
of Lhe programme, each (adulL) pauenL was educaLed on an lndlvldual basls
ln self-dlagnosls and self-care focuslng on plaque conLrol measures, lncludlng
Lhe use of LooLhbrushes and lnLerdenLal cleanlng devlces (brush, denLal Lape,
LooLhplcks). 1hls occurred aL Lhe beglnnlng of Lhe programme and Lhen once
every 2 monLhs ln Lhe rsL 2 years, and Lhen once every 3-12 monLhs dur-
lng years 3-30. 1hese sesslons were dellvered by a denLal hyglenlsL, and also
lncluded a plaque-dlscloslng exerclse, and professlonal mechanlcal LooLh cleanlng, lncludlng Lhe use of a
uorlde-conLalnlng pasLe. WhllsL Lhe auLhors acknowledge Lhe llmlLauons of Lhe daLa (le pauenLs were
noL randomly selecLed), Lhe resulLs lllusLraLed how Lhe sLudy group experlenced a very low lncldence of
perlodonLal dlseases.
Good practice: Oral cancer screening of high risk groups
A plloL programme underLaken ln Pungary demonsLraLed how Lhe use of mass medla served Lo ralse
awareness of oral cancer, and encourage auendance for a denLal examlnauon (Cyenes eL al. 2006). CerLaln
aL-rlsk groups lncludlng adulLs who smoked and were heavy drlnkers were lnvlLed Lo auend for a free oral
healLh examlnauon. lnformauon abouL Lhe programme was dlssemlnaLed vla local and nauonal Lelevlslon,
radlo, newspapers and posLers, as well as a dedlcaLed webslLe. 1he exerclse served Lo ldenufy a slgnlcanL
number of lndlvlduals wlLh premallgnanL leslons, as well as dlagnoslng cases of early oral cancer.
Good practice: A national preventative programme to increase
the frequency that teenagers attend the dentist for check-ups
ln 1997, ma[or lrench healLh lnsurance funds lnLroduced a nauonal oral
screenlng and prevenuon programme (8llan 8ucco-uenLalre) for lmprovlng
access Lo denLal care for Leenagers. 1he maln ob[ecuve was Lo lncrease Lhe
frequency LhaL Leenagers auend Lhe denusL for check-ups, and also Lo ralse
awareness of Lhls prevenLauve approach Lo denLal care. 1hls was Lhe rsL oral
prevenuon programme Lo be lnLroduced on a nauonal scale, comprlslng of
a free annual check-up wlLh 100 relmbursemenL for any subsequenL LreaL-
menL Lo Lhose aged beLween 13 and 18 years. ln lrance, prevenLauve lnLer-
42
venuons underLaken ln a school envlronmenL are only provlded up Lo Lhe age of 12. lollowlng Lhls, gener-
ally only 33 of 13-18 year-olds vlslL a denusL annually.
AdolescenLs are lnvlLed Lo Lake parL ln Lhe scheme vla a leuer, senL every year Lo Lhelr home by Lhe healLh
lnsurance body, from Lhelr 13Lh Lo Lhelr 18Lh blrLhday. Adveruslng campalgns run concurrenLly Lo promoLe
Lhe scheme Lhrough 1v, radlo commerclals, and wrluen communlcauons ln denLal surgerles, [unlor and
hlgh schools, eLc.
More Lhan half of Lhe Leenagers who Look parL ln Lhe program requlred LreaLmenL. Powever, whlle Lhe
scheme provlded a good opporLunlLy for Leenagers from modesL-lncome households Lo auend for a check-
up, overall, Lhe paruclpauon raLe was qulLe low, especlally amongsL Lhe mosL deprlved groups (8ochereau
and Azogul 2007).
Good practice: Promotion of sugar-free products
Sugar-free producLs (such as chewlng gum and confecuonery) have sweeLenlng agenLs oLher Lhan Lhe sug-
ars whlch cause denLal decay. 1he mosL commonly used sugar subsuLuLes are Lhe polyols such as xyllLol,
sorblLol and manlLol. When sugars are replaced wlLh non-decay causlng sugar subsuLuLes, Lhe rlsk of LooLh
decay ls reduced. Many sLudles have reporLed Lhe lmpacL of chewlng sugar-free gum ln prevenung decay
(ueshpande eL al. 2008, Ly eL al. 2008).
1he Luropean lood SafeLy AuLhorlLy (LlSA 2010) have also concluded LhaL a cause and eecL relauonshlp
exlsLs beLween Lhe consumpuon of sugar-free chewlng gum and plaque acld neuLrallsauon, leadlng Lo a
subsequenL reducuon ln Lhe lncldence of carles. ln order Lo obLaln Lhe clalmed eecL, 2-3 g of sugar-free
chewlng gum should be chewed for 20 mlnuLes aL leasL Lhree umes per day aer meals. 1hese healLh
clalms have been lncluded ln Lu Commlsslon 8egulauons 432/2012 of 16/03/2012 and Commlsslon 8egu-
lauon 633/2011 of 11/07/2011.
Sales of sugar-free confecuonery are relauvely hlgh ln some Member SLaLes e.g. Cermany and SwlLzerland,
where Lhey are acuvely promoLed. AlmosL one-quarLer of confecuonery sold ln SwlLzerland ls LooLhfrlend-
ly, sold under Lhe logo Zahnfreundllch (LooLhfrlendly). 1he reglsLered Lrademark wordlng and logo, LooLh-
frlendly" ln comblnauon wlLh a dlagram of a smlllng LooLh under an umbrella, can be used worldwlde and
are already commonly used ln SwlLzerland, Cermany, 1urkey, korea, !apan, Chlna and oLher counLrles. 1o
quallfy for Lhe 1ooLhfrlendly" clalm, foods musL noL lower Lhe pP of Lhe denLal plaque below 3.7 durlng
consumpuon, and for up Lo 30 mlnuLes aer consumpuon. Moreover, foods conLalnlng aclds musL noL
expose Lhe LeeLh Lo excesslve amounLs of acld (noL more Lhan 40 mol P+ x mln) durlng consumpuon. 1he
LesLs can only be accompllshed ln cerued labs uslng Lhe lnLraoral plaque-pP-LelemeLry. CurrenLly, Lhree
unlverslLy lnsuLuLes ln SwlLzerland, Chlna and Cermany are cerued Lo perform such LesLs. 1he LooLh-
frlendly arucle 13.1 clalm was posluvely evaluaLed by Lhe LlSA ln lLs 3Lh baLch of Sclenuc Cplnlons on
healLh clalms ln 2011 (LlSA 2011a, LlSA 2011b). LlSA's sclenuc backlng sLrengLhens Lhe argumenL for Lhe
conunued use of Lhe 1ooLhfrlendly" quallLy seal, a reglsLered Lrademark slnce 1982. LlSA also makes ref-
erence Lo Lhe uS luA whlch accepLed Lhe 1ooLhfrlendly" healLh clalm ln 1997. 1he 1ooLhfrlendly" quallLy
seal ls llcensed Lo food manufacLurers for use ln labelllng, and ln Lhe promouon of Lhelr quallfylng foods by
1ooLhfrlendly lnLernauonal, an lnLernauonally acung non-proL organlsauon locaLed ln 8asle/SwlLzerland.
ln llnland, 'LooLhfrlendly' sweeLs have also been used exLenslvely and are consldered Lo have conLrlbuLed
Lo approxlmaLely 10 of Lhe reducuon ln chlldren's LooLh decay slnce Lhe 1960s (MarLhaler 1990).
43
Good practice: Restricting marketing and
improving the labelling of certain food products
Wau and Shelham (2012) have recenLly suggesLed how Lhe oral healLh Leam should Lackle Lhe upsLream
causes" of oral healLh lnequallues. 1hese lnclude lobbylng acuons dlrecLed aL Lhe acuvlues of Lhe manufac-
Lurers and dlsLrlbuLors of processed sugar producLs.
lL ls worLh noung, however, how ln recenL years, Lhe food lndusLry has made slgnlcanL changes Lo Lhe
fronL-of-pack labelllng Lo help consumers Lo undersLand nuLrluon labelllng. 1he lmplemenLauon of Lhe
Lu food lnformauon regulauon (Lu 8egulauon no 1169/2011) and Lhe nuLrluon and healLh clalms regula-
uon (8egulauon (LC) no 1924/2006) have boLh supporLed Lhese developmenLs Lhrough speclfylng requlre-
menLs regardlng CuA (guldellne dally amounLs), and nuLrlenL prollng ln denlng Lhe crlLerla LhaL foods
musL meeL ln order Lo bear nuLrluon and/or healLh clalms.
1he uk ueparLmenL of PealLh ls currenLly underLaklng a consulLauon on fronL of pack nuLrluon labelllng.
1he uk PealLh MlnlsLry wanLs Lo see all food manufacLurers and reLallers uslng Lhe same nuLrluon label-
llng sysLem Lo show, on Lhe fronL of packs, how much faL, salL and sugar and how many calorles ls ln Lhelr
producLs. 1hls would make lL easler for consumers Lo compare Lhe nuLrluonal lnformauon provlded on Lhe
food Lhey buy. rovldlng nuLrluon lnformauon conslsLenLly, on Lhe fronL of food packs, ls key Lo consumer
awareness, and uslng Lhls lnformauon Lo make healLhler cholces and lmprove Lhelr dleLs (uP 2012).
Also ln Lhe uk, Lhe lood SLandards Agency (lSA 2010) made recommendauons Lo food manufacLurers on
reduclng saLuraLed faL and added sugar ln key sweeL foods. 1hls lncluded:
8educlng saLuraLed faL ln blsculLs, cakes, buns and chocolaLe confecuonery
8educlng added sugar ln so drlnks
roduclng smaller slngle-poruon slzes more easlly avallable for chocolaLe confecuonery and so drlnks
A recenL developmenL ln Lhe Lu has been a change Lo Lhe regulauons on Lhe auLhorlsed lngredlenLs LhaL
can be added Lo frulL [ulce. 1he addluon of sugar Lo sweeLen frulL [ulce ls no longer permlued (Luropean
ubllc PealLh Alllance 2012). CurrenLly, many companles selllng frulL [ulce uullse LexL ln Lhe labelllng such
as 'no added sugar'. uurlng Lhls Lransluon phase, before 'no added sugar' ls phased ouL, manufacLurers wlll
need Lo lnform consumers LhaL 'from 2013 no frulL [ulces conLaln added sugars'. 1he new rules wlll apply
Lo any frulL [ulce belng markeLed ln Lhe Lu.
ln conslderlng adveruslng, Lusug eL al. (2012) argue LhaL governmenL lmposed regulauons on Lhe markeL-
lng of alcohol Lo young people have been qulLe eecuve, and suggesL LhaL slmllar measures may be help-
ful ln Lhe markeung of sugar-conLalnlng foodsLus. ln a recenL developmenL under Lhe framework of Lhe
Lu lauorm for Acuon on uleL, hyslcal AcuvlLy and PealLh, leadlng food and beverage companles have
pledged: no adveruslng of producLs Lo chlldren under 12 years, excepL for producLs whlch full speclc
nuLrluon crlLerla based on accepLed sclenuc evldence and/or appllcable nauonal and lnLernauonal dl-
eLary guldellnes. lor Lhe purpose of Lhls lnluauve, adveruslng Lo chlldren under 12 years" means adverus-
lng Lo medla audlences wlLh a mlnlmum of 33 of chlldren under 12 years." 1hls rule has been appllcable
slnce Lhe 1
st
of !anuary 2012, LhroughouL Lhe Lu (Lu ledge 2012).
44
International examples of good practice: An online forum to share best practices
1he Cral PealLh Secuon of Lhe Canadlan 8esL racuces orLal (ubllc PealLh Agency of Canada 2012a) ls
comprlsed of communlLy based healLh promouon and dlsease prevenuon lnLervenuons LhaL lmprove ac-
cess Lo care and oral healLh ouLcomes of Lhe populauon. Cral healLh besL pracuce approaches are consld-
ered ln Lerms of: access Lo care, susLalnablllLy, cosL-eecuveness and em clency, communlLy lnvolvemenL.
lL has been deslgned Lo provlde publlc healLh program declslon makers wlLh beuer access Lo lnformauon
abouL eecuve besL" pracuces models, meLhods, and research evldence ln chronlc dlsease prevenuon
and healLh promouon lnLervenuons (ubllc PealLh Agency of Canada 2012b).
45
Section 6: Conclusions:
Understanding the problems
key lolots
1be ptoblems.
cotteot tteoJs lo petloJootol beoltb ooJ otol coocet
- lt bos beeo soqqesteJ tbot ovet 50X of tbe otopeoo popolouoo so[et ftom some fotm of petl-
oJoouus ooJ ovet 10X bove sevete Jlseose, wltb ptevoleoce locteosloq to 70-85X of tbe popolouoo
oqeJ 60-65 yeots of oqe. 1bete ls o petcepuoo tbot petloJootol beoltb moy be Jetetlotouoq wltblo
tbe popolouoo of tbe u.
- Clobolly, teqloos wltb o blqb loclJeoce of beoJ ooJ oeck coocet locloJe mocb of 5ootbeto Aslo ooJ potts
of ceottol ooJ 5ootbeto otope. 1be blqbest loclJeoce totes lo otope ote foooJ lo 5polo ooJ nooqoty.
- 1teoJs lo otol coocet ote oow sbowloq o qeoJet ooJ oqe sblf. lo most otopeoo Membet 5totes,
otol coocet loclJeoce ls locteosloq lo womeo, petbops lotqely tefecuoq locteosloq totes of smokloq.
lo potts of otope, tbe loclJeoce of otol coocet ot sltes teloteJ to nlv lofecuoos ote locteosloq lo
yoooq oJolts.
- Mottollty ooJ sotvlvol totes fot otol coocet voty octoss otope.
locteosloq otol beoltb loepoollues
- Otol beoltb loepoollues coo be obsetveJ lo oqe, qeoJet, soclo-ecooomlc ooJ eJocouoo level, wltblo
ooJ betweeo u Membet 5totes. cotles sull temolos o mojot beoltb ptoblem fot mooy qtoops of
people lo osteto otope, ooJ lo oll otopeoo Membet 5totes, fot tbose ftom soclo-ecooomlcolly
JeptlveJ ot voloetoble qtoops. 1be loclJeoce of otol coocet ooJ petloJootol Jlseoses ls olso sttooqly
teloteJ to soclol ooJ ecooomlc Jeptlvouoo.
- uesplte lmptovemeots, ptoblems lo occess to otol beoltb cote setvlces petslst, most commooly
omooq voloetoble ooJ low locome qtoops.
- Ovet bolf of tbe u Membet 5totes Jo oot ploce pollcy empbosls oo teJocloq beoltb loepoollues.
A lock of cobeteot ooJ cootJlooteJ otol beoltb ptomouoo ooJ Jlseose pteveouoo pollcy
- lo mooy u Membet 5totes otol beoltb cote ls oot folly loteqtoteJ loto oouoool ot commoolty
beoltb ptoqtommes.
- 1bete ls o cleot lock of teseotcb lo otol beoltb ptomouoo. vety few blqb poollty ootcome meosotes
exlst fot ose lo tbe evoloouoo of otol beoltb pollcy ooJ eovltoomeotol lotetveouoos. 1bete ote
cbolleoqes lo lJeoufyloq best ptocuce meosotes, ooJ sbotloq leotoloq ootcomes ftom otol beoltb
ptomouoo ocuvlues.
- 1bete ls o oeeJ to Jefoe best ptocuce ptloclpols lo pteveouoo ooJ otol beoltb ptomouoo. A mote
ptoqtesslve beoltb ptomouoo opptoocb tbot tecoqolses tbe lmpottooce of tocklloq tbe ooJetlyloq
soclol, pollucol ooJ eovltoomeotol Jetetmlooots of otol beoltb ls tepolteJ.
46
key lolots
1be ptoblems.
lmptovloq tbe Joto ooJ koowleJqe bose
- lock of toouoely ovolloble ooJ compotoble u otol beoltb Joto (ooJ pobllc beoltb Joto), ooJ te-
seotcb koowleJqe poses oo obstocle to ossessloq tbe cotteot sltoouoo, lJeoufyloq best-ptocuces,
ooJ ollocouoq tesootces wbete tbey ote most oeeJeJ.
- plJemloloqlcol Joto telouoq to tootb Jecoy ooJ petloJootol Jlseoses ote potucolotly ootelloble.
1be Joto ote ftepoeotly eltbet esumotes ot collecteJ osloq Jl[eteot metboJoloqles. 1be otol beoltb
oeeJs of tbe most JlsoJvootoqeJ qtoops, socb os loJlvlJools wltb speclol oeeJs, losutouooollseJ
petsoos ooJ tbe bomeless, ote oot cleotly lJeoufeJ.
ueotol wotkfotce llmltouoos
- Actoss otope, tbete ls o lock of soltobly ttoloeJ oJvlsots wltb tbe oblllty to Jevelop otol beoltb
eplJemloloqlcol stoJles ooJ oeeJs ossessmeots ooJ osslst lo otol beoltb sttoteqy ooJ pollcy Jevel-
opmeot.
Current trends in periodontal health and oral
cancer and increasing oral health inequalities
ln Lhe lasL 30 years, Lhere has been a ma[or lmprovemenL ln Lhe prevalence of denLal carles ln chlldren and
young adulLs who llve ln WesLern Lurope. Powever, carles sull remalns a ma[or healLh problem for many
groups of people ln LasLern Lurope, and for Lhose from soclo-economlcally deprlved groups boLh across
Lhe Lu, and wlLhln all Lu Member SLaLes (eLersen eL al. 2003). uue Lo Lhe lnadequacles of perlodonLal
epldemlology (Leroy eL al. 2010), lL ls unclear wheLher Lhe perlodonLal healLh of Lhe Luropean populauon
ls lmprovlng or deLerloraung. Powever, lL ls evldenL LhaL Lhe number of dlabeucs ls rlslng and, LhaL more
people are reLalnlng Lhelr LeeLh lnLo Lhelr old age. 1hese groups are aL greaLer rlsk of perlodonLal break-
down. 1here appears Lo have been no lmprovemenL ln Lhe prevalence of oral cancer (SLewarL and klelhuls,
2003) or, ln some LasLern Luropean Member SLaLes, ln lLs early deLecuon. 1hese dlseases exacL a heavy
burden on lndlvldual quallLy of llfe, and cosLs Lo healLh care sysLems. 1he burden of oral dlsease, and lLs
lmpacL on Lhe quallLy of llfe ls parucularly hlgh among older people.
Whlle Lhere ls general agreemenL on Lhe prlnclple of reduclng healLh lnequallues, Lhe level of awareness
and Lhe exLenL Lo whlch acuon ls belng Laken varles subsLanually. Cver half of Lhe Lu Member SLaLes do noL
place pollcy emphasls on reduclng healLh lnequallues and Lhere ls a lack of comprehenslve lnLer-secLoral
sLraLegles (Commlsslon of Lhe Luropean Communlues 2009).
1hus, alongslde Lhe lnequallues ln Lhe prevalence of Lhe ma[or dlseases of Lhe 21sL cenLury (cancer, hearL
dlsease, sLroke, dlabeLes, and demenua), oral healLh lnequallues consuLuLe a slgnlcanL publlc healLh
problem, as a consequence of Lhese deLermlnanLs (Shelham eL al. 2011), and a fallure Lo adopL populauon-
based healLh promouon uslng a common rlsk facLor approach.
47
Improving the data and knowledge base, and mechanisms
for measuring, monitoring, evaluating and reporting
ln Lurope, Lhere are dlsuncL challenges ln esumaung Lhe burden of oral dlsease. 1hls ls prlnclpally due Lo
Lhe dlmculues ln lnLegraung oral healLh daLa lnLo nauonal and Luropean healLh lnformauon sysLems. 1he
followlng llmlLauons are observed:
roblems are assoclaLed wlLh Lhe uMl1 lndlcaLor, lncludlng lLs lack of reacuvlLy and lnsensluvlues Lo
healLh lnequallues (Ma[or and Chronlc ulseases 8eporL 2007).
varlauon ln meLhodology and frequency of epldemlologlcal sLudles llmlLs comparlsons beLween Lu
Member SLaLes and reglons
Plgh numbers of lndlcaLors can overwhelm epldemlologlsLs, llmlung Lhe evaluauon of programmes
and generaung cosLly and unnecessary monlLorlng eorLs. 620 lndlcaLors were ldenued ln 2004
(8ourgeols and Llodra, 2004)
ln general, llmlLed geographlc coverage - daLa oen are only avallable for selecLed clues or reglons.
1here ls a scarclLy of daLa from nauonal sLudles whlch are based on a represenLauve sample of Lhe
populauon of Lhe counLry. Cnly Lhe uk has secular epldemlologlcal daLa on Lhe prevalence of carles ln
young adulLs. Cermany has represenLauve epldemlologlcal daLa on a nauonal scale. Sweden and oLher
nordlc counLrles uullse counLry councll reporLs Lo Lhe nauonal 8oard of PealLh and Welfare Lhrough
Lhe publlc denLal servlce (Ma[or and Chronlc ulseases 8eporL 2007).
LlmlLed coverage of populauons - collecuon of admlnlsLrauve daLa someumes llnked Lo lndlvldual
characLerlsucs, such as lnsurance sLaLus.
1he oral healLh needs of cerLaln dlsadvanLaged groups, such lndlvlduals wlLh speclal needs, lnsuLuuon-
allsed persons and Lhe homeless, are noL clearly ldenued.
uaLa access llmlLauons - daLa collecLed by lnsuLuuons oLher Lhan nauonal governmenL or nauonal ln-
suLuLes may someumes noL be readlly accesslble due Lo condenuallLy lssues or lnLellecLual properLy
rlghLs lssues prevenung release.
1he cosL of oral dlseases ln many Lu Member SLaLes, lncludlng avoldable cosLs Lhrough prevenuon,
oral healLh promouon and publlc healLh pollcles, ls noL evaluaLed.
1he percenLage of Cn spenL on oral care can be esumaLed ln some Lu Member SLaLes. Powever,
esumaung expendlLure ls exLremely challenglng due Lo Lhe dlmculues ln quanufylng ouL-of-pockeL or
prlvaLe expendlLure".
A seL of 40 key lndlcaLors have been agreed beLween publlc auLhorlues durlng Lhe Lu-funded LCCPlu
pro[ecL buL Lhese are noL supporLed by conslsLenL, comparable and updaLed daLa.
A lack of research in oral health promotion
Cral healLh lnequallues wlll only be reduced Lhrough Lhe lmplemenLauon of eecuve and approprlaLe oral
healLh promouon pollcy. 1reaLmenL servlces wlll never successfully Lackle Lhe underlylng cause of oral dls-
eases (Wau and Shelham 1999). 8obusL and reecuve daLa ls of supreme lmporLance ln Lhe plannlng, lmple-
menLauon and evaluauon of communlLy prevenuve acuvlues and oral healLh promouon. Powever, very few
hlgh quallLy ouLcome measures exlsL for use ln Lhe evaluauon of oral healLh pollcy and envlronmenLal lnLer-
venuons. 1he lack of approprlaLe and hlgh quallLy ouLcome measures ls hamperlng Lhe developmenL of oral
healLh promouon (Wau eL al. 2006). As a resulL, Lhere are few daLa Lo demonsLraLe Lhe lmpacL and poLenual
of prevenLauve measures. lnsumclenL emphasls ls oen placed on Lhe prlmary prevenuon of oral dlseases.
48
Defining best practice principals in prevention and oral bealtb pro-
motion: Developing an oral health promotion model to address the
wider determinants of health
ln many Lu Member SLaLes oral healLh care ls noL fully lnLegraLed lnLo nauonal or communlLy healLh pro-
grammes. 1o daLe, Lhe common rlsk facLor approach (C8lA) has been hlghly lnuenual ln lnLegraung oral
healLh lnLo general healLh promouon, and chronlc dlsease prevenuon (Wllllams 2011). Powever, lL ls ln-
creaslngly acknowledged LhaL applylng Lhe C8lA Loo speclcally, and solely focusslng on changlng oral
healLh behavlours may be an lneecuve sLraLegy for Lackllng lnequallues (Wau and Shelham 2012). A more
progresslve healLh promouon approach LhaL recognlses Lhe lmporLance of Lackllng Lhe underlylng soclal,
pollucal and envlronmenLal deLermlnanLs of oral healLh ls needed.
Building capacity and capability in planning, delivering and assess-
ing oral health promotion and preventative activities: Dental work-
force limitations
uenLal publlc healLh (uP) ls Lhe branch of denusLry LhaL ls prlmarlly concerned wlLh Lhe prevenuon of oral
dlsease and promoung oral healLh, Lhus lmprovlng Lhe quallLy of llfe for populauons (uP 2010).
SpeclallsLs ln uP are Lralned Lo undersLand Lhe epldemlologlcal, demographlc, cllnlcal, soclal, pollucal and
nanclal aspecLs of Lhe provlslon of healLh and oral healLh care, and Lo glve advlce and leadershlp ln Lhe
Lhese areas.
Powever, Lhe speclallsm of denLal publlc healLh ls omclally recognlsed by only a few Member SLaLes: 8ul-
garla, llnland and Lhe uk (CLu 2009). ln 8ulgarla Lhere ls a speclalLy called Soclal Medlclne and uenLal
PealLh Crganlsauon (LaLon eL al. 2009). ln Lhe uk, where Lhe speclalLy ls relauvely well-esLabllshed, Lhe
ueparLmenL of PealLh has sLaLed LhaL Lhe currenL capaclLy of Lhe denLal publlc healLh workforce does noL
reecL Lhe subsLanually lncreased responslblllues of Lhe local healLh servlce for denusLry (uP 2010).
1hls lack of denLal publlc healLh capaclLy and capablllLy wlll llmlL Lhe ablllLy of lndlvldual Member SLaLes
Lo consLrucL and uullse oral healLh epldemlologlcal lnfrasLrucLures Lo develop robusL oral healLh sLraLegy
and pollcy.
49
Section 7: Recommendations
for European decision-makers
Key points
Acuoos sboolJ setve to.
Moke o commltmeot to lmptovloq otol beoltb os pott of u pollcles by 2020
- kecoqolse tbe commoo tlsk foctots fot otol Jlseoses ooJ otbet cbtoolc Jlseoses, ooJ wotk towotJs
llokloq otol beoltb pollcles octoss otbet u pollcles.
- 8euet loteqtote otol beoltb loto televoot oouoool ooJ u beoltb ptoqtommes ooJ pollcles.
- uevelop o cobeteot otopeoo sttoteqy fot tbe ptomouoo of otol beoltb ooJ tbe pteveouoo of otol
Jlseoses.
AJJtess locteosloq otol beoltb loepoollues
- AJJtess tbe mojot otol beoltb cbolleoqes of cbllJteo ooJ oJolesceots, soclo ooJ ecooomlcolly Je-
ptlveJ qtoops, oo locteosloq elJetly popolouoo ooJ voloetoble popolouoos lo otope.
- mploy oo opptoocb tbot focosses oo tbe wlJet pollucol, eovltoomeotol, soclol ooJ ecooomlc Jtlv-
ets tbot cteote otol beoltb loepoollues. A molu-sttoteqy opptoocb ls oeeJeJ tbot cooslJets fottbet
meosotes socb os leqlslouoo, fscol pollcy ooJ commoolty Jevelopmeot. 1bls toJlcol pollcy teotleo-
touoo ls ptloclpolly tbe temlt of oouoool pollcy mokets ooJ ptofessloool otqoolsouoos.
- ocootoqe o ctoss-sectotol opptoocb wblcb locotpototes beoltb ooJ soclol cote to oJJtess tbe so-
clol Jetetmlooots of otol beoltb. uevelop soppotuve otol beoltb eovltoomeots lo locol semoqs socb
os scbools, colleqes, bospltols, wotkploces ooJ cote otqoolsouoos.
- uevelop tbe toles of beoltb ooJ soclol cote ptofessloools, socb os qeoetol meJlcol ptocuuooets,
pbotmoclsts, cbllJ beoltb ootses, qeoetol ootses, mlJwlves, soclol wotkets ooJ oqeJ cote wotkets,
os otol beoltb ptomotets, os pott of tbelt btooJet beoltb ooJ wellbeloq ptomouoo tespooslblllues.
- ocootoqe ooJ ptomote pollcles to eosote occess to footlJe fot tbe wbole popolouoo.
- Cootootee ovolloblllty ooJ occess to blqb poollty ooJ o[otJoble otol beoltb cote, locloJloq ftee
boslc tteotmeot fot loJlvlJools ooJet 18 yeots of oqe.
- osote occess to televoot ooJ evlJeoce boseJ otol beoltb lofotmouoo to eocootoqe poueot empow-
etmeot ooJ self-cote.
50
Key points
Acuoos sboolJ setve to.
uevelop tbe Jeotol wotkfotce
- Moxlmlse tbe poteouol of tbe Jeotol teom (Jeousts, byqleolsts, tbetoplsts, ootses, tecbolcloos, otol
beoltb ptomotets ooJ eJocotots) to eosote oo opptoptlote ose of sklll mlx lo ooJettokloq pteveoto-
uve lotetveouoos.
- uevelop tbe tole of otol beoltb ptofessloools lo qeoetlc beoltb ptomouoo to oJJtess tlsk foctots
socb os clqoteue smokloq, poot Jlet, blqb olcobol coosompuoo, ooJ seJeototy llfestyles. 5mokloq
cessouoo lotetveouoos JellveteJ by otol beoltb ptofessloools bove beeo sbowo to be e[ecuve.
- 5oppott tbe ttololoq ooJ eJocouoo of Jeousts to Jevelop tobost otol beoltb eplJemloloqlcol lofto-
sttoctotes ooJ osslst lo otol beoltb sttoteqy ooJ pollcy Jevelopmeot.
AJJtess tbe lock of teseotcb lo otol beoltb ptomouoo
- Moke otol beoltb ooJ tbe pteveouoo of otol Jlseoses o ptlotlty ooJet otopeoo beoltb ooJ teseotcb
ptoqtommes.
- ltovlJe fooJloq fot teseotcb ooJet tbe keseotcb ltomewotk ltoqtomme speclfcolly totqeteJ ot.
1. commoolty-boseJ teseotcb oo tbe soclol Jetetmlooots of qeoetol ooJ otol beoltb, ooJ loepooll-
ues lo beoltb.
2. ltomouoq e[ecuve woys to loteqtote otol beoltb loto qeoetol beoltb ptomouoo.
J. lmptovloq tbe otol beoltb of blqb-tlsk qtoops, JeptlveJ commoolues ot loJlvlJools.
4. lmptovloq tbe cost e[ecuveoess of otol beoltb ptomouoo.
- locotpotote teseotcb oo otol beoltb os opptoptlote loto pollcles fot tbe loteqtoteJ pteveouoo ooJ
tteotmeot of cbtoolc ooo-commoolcoble ooJ commoolcoble Jlseoses, ooJ loto motetool ooJ cbllJ
beoltb pollcles.
- 5et op sostolooble otopeoo loftosttoctotes to ooJettoke collobotouve ctoss coootty teseotcb oo
otol beoltb ptomouoo ooJ pteveotouve sttoteqles.
lmptove tbe Joto ooJ koowleJqe bose
- uevelop pollcy objecuves to ollqo ooJ lmptove tbe collecuoo of beoltb Joto, locloJloq otol beoltb
Joto, octoss u Membet 5totes. 1bls moy lovolve cteouoq ooJ fooocloq otopeoo loftosttoctotes.
1. A teqlstty to lJeoufy oll cllolcol ttlols ooJ otbet types of commoolty-boseJ ttlols to osslst lo com-
potet seotcbes.
2. A Jotobose wblcb loteqtotes esseouol otol beoltb loJlcotots loto oouoool beoltb sotvelllooce,
coptotloq tobost, compotoble Joto ot o oouoool ooJ otopeoo level, ooJ olso ollowloq coouoool
ossessmeot of vollJlty.
- ulssemloote oll mojot teseotcb ootcomes, best ptocuce meosotes ooJ leotoloq expetleoces lo otol
beoltb pollcy to eobooce ptoboblllty of bollJloq o systemouc boJy of evlJeoce.
51
1hese recommendauons are lnLended Lo serve as a foundauon for Lhe pollcy debaLe, by complemenung
exlsung Luropean and nauonal pollcy lnluauves on oral healLh promouon and prevenLauve lnluauves.
1he lauorm ls commlued Lo supporung Lhe lmplemenLauon of Lhese recommendauons, and Lo Lhls end
wlll lnvlLe lnLeresLed sLakeholders Lo [oln speclc Lask forces. 1hese Lask forces wlll be asked Lo develop
speclc acuon plans wlLh concreLe goals and umellnes. 1he lauorm wlll monlLor Lhe progress achleved on
an on-golng basls.
Make a commitment to improving oral health and
preventing oral diseases across Europe and within individual
Member States by 2020
Acnons:
8ecognlse Lhe common rlsk facLors for oral dlseases and oLher chronlc dlseases, and work Lowards llnk-
lng oral healLh pollcles across oLher Lu pollcles and expand Lhe scope of oral healLh pollcy Lo relaLed
lssues.
uevelop more promlnenL oral healLh lnluauves and pollcles aL a nauonal and Luropean level.
lnLegraLe oral healLh lnLo nauonal or communlLy healLh programmes far more Lhan aL presenL.
uevelop a coherenL Luropean sLraLegy for Lhe promouon of oral healLh and Lhe prevenuon of oral
dlseases.
romoLe a comprehenslve approach Lo fosLerlng good healLh and Lackllng ma[or chronlc dlseases
Lhrough (CLu 2011):
1. lmprovlng lnformauon on rlsk facLors
2. laclllLaung cooperauon beLween sLakeholders and beLween Member SLaLes
3. Supporung general and oral healLh promouon and prevenuon campalgns aL Lu level
52
Address increasing oral health inequalities
Acnons:
Address exlsung oral healLh lnequallues as parL of Lhe lmplemenLauon of Lhe SLraLegy for 8educlng
PealLh lnequallues ln Lurope.
lnclude healLh lnequallues as one of Lhe prlorlLy areas wlLhln Lhe ongolng cooperauon arrangemenLs
on healLh beLween Lhe Luropean reglons and Lhe Commlsslon (Commlsslon of Lhe Luropean Commu-
nlues 2009).
rovlde furLher supporL Lo exlsung mechanlsms for pollcy coordlnauon and exchange of good pracuce
on healLh lnequallues beLween Member SLaLes such as Lhe Lu experL group on Soclal ueLermlnanLs
of PealLh and PealLh lnequallues, llnklng boLh Lo Lhe Soclal roLecuon Commluee and Lhe Councll
Worklng arLy on ubllc PealLh and Lhe Soclal roLecuon Commluee (Commlsslon of Lhe Luropean
Communlues 2009).
8evlew Lhe posslblllues Lo asslsL Member SLaLes Lo make beuer use of Lu Coheslon pollcy and sLruc-
Lural funds Lo supporL acuvlues Lo address facLors conLrlbuung Lo healLh lnequallues (Commlsslon of
Lhe Luropean Communlues 2009).
Address Lhe ma[or oral healLh challenges of chlldren and adolescenLs, of an lncreaslng elderly popula-
uon and of vulnerable populauon groups ln Lurope. PealLh promouon and dlsease prevenuon acuvl-
ues musL be Lallored Lo dlerenL populauon groups accordlng Lo Lhelr dlerlng llfesLyles, llfe sLages and
llfe condluons (CLu 2011).
Lmploy a more polluclsed approach Lo Lackle Lhe causes of oral healLh lnequallues, ln acuvely promoL-
lng a healLhy dleL and regulaung Lhe markeung and labelllng of food producLs. Lncourage and promoLe
pollcles Lo ensure access Lo uorlde for Lhe whole populauon (CLu 2011).
CuaranLee avallablllLy and access Lo hlgh quallLy and aordable oral healLh care, lncludlng free baslc
LreaLmenL for lndlvlduals under 18 years of age. Speclc acuons lnclude enhanclng access Lo, and up-
Lake of, oral healLh servlces for vulnerable and underserved populauons lncludlng chlldren and adulLs
from low lncome households, people wlLhouL healLh lnsurance and Lhe elderly.
locus local acuons on Lhe formulauon of oral healLh pollcy dlrecLed aL developlng supporuve oral
healLh envlronmenLs ln a varleLy of local semngs such as schools, colleges, hosplLals, workplaces and
care organlsauons.
uevelop Lhe roles of a range of healLh and soclal care professlonals, such as general medlcal pracuuo-
ners, pharmaclsLs, chlld healLh nurses, general nurses, mldwlves, soclal workers and aged care work-
ers, as oral healLh promoLers, as parL of Lhelr broader healLh and wellbelng promouon responslblllues.
lmplemenL oral healLh promouon programmes ln preschool semngs Lo ensure LhaL a supporuve early
llfe envlronmenL ls creaLed, may be parucularly lmporLanL (WPC 2008).
53
Define best practice principals in
prevention and oral health promotion
lncreaslng emphasls ls now belng placed on Lackllng Lhe shared sLrucLural, soclal and envlronmenLal de-
LermlnanLs of chronlc dlseases (kwan and eLersen 2010, WPC 2008). luLure oral healLh pollcy Lhus needs
Lo focus upon Lhe wlder pollucal, envlronmenLal, soclal and economlc drlvers LhaL creaLe oral healLh ln-
equallues ln socleLy. A mulu-sLraLegy approach ls needed LhaL conslders furLher measures such as leglsla-
uon, scal pollcy and communlLy developmenL. 1hls radlcal pollcy reorlenLauon ls prlnclpally Lhe remlL of
nauonal pollcy makers and professlonal organlsauons, and for Lhls approach Lo be successful ln achlevlng
susLalnable changes ln oral healLh, mulu-secLor work ls essenual.
Acnons
Lnhance Lhe exchange of lnformauon, knowledge, and besL pracuce alongslde lmprovlng Lhe coordlna-
uon of pollcles beLween dlerenL levels of governmenL and across a number of secLors (healLh care,
employmenL, soclal proLecuon, envlronmenL, educauon, youLh and reglonal
developmenL). 1hls can help Lo focus acuons on varlous soclal deLermlnanLs Lo conslsLenLly lmprove
healLh ouLcomes (Commlsslon of Lhe Luropean Communlues 2009).
Lnsure good access Lo relevanL and evldence based oral healLh lnformauon Lo encourage pauenL em-
powermenL and self-care.
Develop the dental workforce
Acnons
Maxlmlse Lhe poLenual of Lhe denLal Leam (denusLs, hyglenlsLs, LheraplsLs, nurses, Lechnlclans, oral
healLh promoLers and educaLors) Lo ensure an approprlaLe use of sklll mlx ln underLaklng prevenuve
lnLervenuons.
uevelop Lhe role of oral healLh professlonals ln generlc healLh promouon Lo address rlsk facLors such
as clgareue smoklng, poor dleL, hlgh alcohol consumpuon, and sedenLary llfesLyles. Smoklng cessa-
uon lnLervenuons dellvered by oral healLh professlonals have been shown Lo be eecuve (Carr and
LbberL 2007).
SupporL Lhe Lralnlng and educauon of denusLs Lo develop robusL oral healLh epldemlologlcal lnfra-
sLrucLures and asslsL ln oral healLh sLraLegy and pollcy developmenL.
54
Bridge the research gap in oral health promotion
Acnons
rovlde fundlng under Lhe 8esearch lramework rogrammes Lo focus on:
1. CommunlLy-based research on Lhe soclal deLermlnanLs of general and oral healLh, and lnequallues
ln healLh (Wllllams 2011).
2. Lecuve ways Lo lnLegraLe oral healLh lnLo general healLh promouon
3. lmprovlng Lhe oral healLh of hlgh-rlsk groups, deprlved communlues or lndlvlduals
4. CosL eecuveness of oral healLh promouon Lo ralse awareness of Lhe slze of oral healLh care cosLs
lncorporaLe research on oral healLh as approprlaLe lnLo pollcles for Lhe lnLegraLed prevenuon and
LreaLmenL of chronlc non-communlcable and communlcable dlseases, and lnLo maLernal and chlld
healLh pollcles (Shelham eL al. 2011).
SeL up susLalnable Luropean lnfrasLrucLures Lo underLake collaborauve cross counLry research on oral
healLh promouon and prevenLauve sLraLegles.
LsLabllsh and nance longer-Lerm publlcly funded research programmes.
Lmphaslse dlssemlnauon of good pracuces relevanL Lo addresslng healLh lnequallues by Lu Agencles,
lncludlng: Lhe Luropean loundauon for Lhe lmprovemenL of Llvlng and Worklng Condluons, Lhe Lurope-
an CenLre for ulsease revenuon and ConLrol and Lhe Luropean Agency for PealLh and SafeLy aL Work.
Improve the data and knowledge base, and mechanisms
for measuring, monitoring evaluation and reporting
1he burden of oral dlsease and needs of populauons are conunually changlng, and oral healLh sysLems and scl-
enuc knowledge are evolvlng rapldly. 1o address Lhese challenges eecuvely, publlc healLh admlnlsLraLors and
declslon-makers need Lhe Lools, lnformauon and a forum Lo access, lnLerpreL, and monlLor healLh needs, choose
relevanL lnLervenuon sLraLegles, and deslgn reecuve pollcy opuons Lo lmprove Lhe performance of Lhe oral healLh
sysLem. ollcy ob[ecuves are Lhus requlred Lo lmprove oral healLh lnformauon and daLa collecuon across Lurope.
Acnons:
ConsLrucuon of a daLabase whlch capLures quallLy assured daLa aL a nauonal and Luropean level, and
also allows Lhe conunual assessmenL of valldlLy.
lnLegrauon of essenual oral healLh lndlcaLors lnLo healLh survelllance and knowledge sysLems aL a na-
uonal and Luropean level. Cral healLh lndlcaLors need Lo be uullsed as markers of healLh lnequallues.
8esearch ls needed lnLo Lhe problem of lack of an evldence base for varlous communlLy-based oral healLh
lnLervenuons Lo reduce lnequallues ln oral healLh. A reglsLry Lo ldenufy all cllnlcal Lrlals and oLher Lypes of
communlLy-based Lrlals Lo asslsL ln compuLer searches could be beneclal (Shelham eL al. 2011).
Creauon and susLalnable nanclng of Luropean lnfrasLrucLures ls requlred Lo revlew and dlssemlnaLe
all ma[or research ouLcomes, besL pracuce measures and learnlng experlences ln oral healLh pollcy
Lhrough, for example, reglsLrles and daLabases. 1he evldence base should be LranslaLed lnLo easlly
undersLood pollcles and pracuces Lhrough pracucal LoolklLs and guldellnes.
55
56
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