5.14.3 Data description and analysis
In a European perspective, the variability of the
extent of tooth decay observed in the 1970s has greatly declined. At least in
countries within the Union, tooth decay status greatly improved in the recent
past. An analysis of the literature on this subject states that: between 1970
and 2000 improvement among children rose from 50 to 80%. Similarly, most
cavities were treated. These are predominantly cases of quality dental care,
meaning more fillings and fewer extractions. An even more remarkable fact is
that the state of dental health among European populations, including adults,
appears to have been « internationalised». All countries within the Union are currently converging on a serious decay threshold at age 12, varying around 1-1.5
score of decay severity (DMFT). (Table 5.14.1). For instance, the actual level of dental caries in Portuguese children
seems to be relatively low and now similar to what has been observed recently
for countries with advanced public oral health care programmes for children.
For 12-year-olds the United Kingdom has reported the mean caries experience at
1.1 DMFT, France at 1.1, whilethe corresponding figure for Denmark is 1.0 DMF-T.
Table 5.14.1. Dental Health in 12
year-old children in selected EUGLOREH countries
Such a positive trend of lower dental caries experience in
children is shown also for certain Eastern European countries where school oral
health programmes were established and maintained until recently This is the
case for instance for Slovenia and Hungary. However, the general pattern is
that the prevalence rate of dental caries in children has remained high in most
of Central and Eastern Europe but, equally important, the decayed element of
the index is also high in children. This shows that significant proportions of
children are in need of dental care. In adults, the data underlined the global
amelioration of the oral health status in the last 20 years.
Despite the widespread decline in caries prevalence and
severity in permanent teeth in high-income countries over the past few decades,
disparities remain and many children and adults still develop caries. The rate
of progression of the disease slows down with increased age. The disease is
mainly found in specific teeth and tooth types in both primary and permanent
teeth. In some countries, the positive trend in caries decline could deter
action to further improve oral health or sustain achievements. It might also
lead to the belief that the caries problems no longer exists at least in
developed countries, resulting in precious resources currently available for
caries prevention being diverted to other areas. However, it must be stressed
that dental caries, as a disease, has not been not eradicated but only
controlled to a certain extent.
Despite the great achievements of oral health in European
countries in the last 20 yrs, an unsolved and ongoing problem still remains.
Minorities and deprived groups in many European countries have a high level of
untreated diseases. Oral health is characterized by social inequalities in the
face of disease and patient management. In France, 40% of 12-year olds have no
caries experience; most other children fall in the range of 1 to 4 DMFT teeth.
In contrast, 10.8% of all children have a dental caries experience greater than
4 teeth. In the trend observed in European countries with good demography, 30%
of the children have about 80% of decayed teeth, and 25% of the children have
about 65% of DMF teeth, 10% of the children have about 40% of DMF teeth.
Current researches indicate that children from low income households have
higher caries rates and more unmet dental treatment needs than their higher
income counterparts.
Despite the widespread decline in caries prevalence and
severity in permanent teeth in high-income countries over the past few decades,
disparities remain and adults still develop caries. Dental caries is increasing
in frequency among elderly people and elsewhere as more people are retaining
more teeth throughout their lifespan. Older adults might have similar or higher
levels of new caries formation than children. Studies show that nursing home
residents are more likely to have root caries than elderly people who live in
their own homes. Other population groups at high risk for dental caries include
people living in poverty; people with poor education or low socioeconomic
status; ethnic minority groups; individuals with developmental disabilities;
recent immigrants; elderly people who are frail; and people with several risky
lifestyle factors. Only adults aged 65-74 present significant differences for
what concerns the rate of tooth loss in Europe (Figure 5.14.1). Edentulous
prevalence differs significantly within European countries (12.8% in Italy, 16.3% in France, 58% in United Kingdom, 65.4% in Netherlands). These differences are related
to sanitary conditions and historical cultural customs, but should rapidly
disappear in the future.
Figure 5.14.1. Edentulous people aged
65 in selected EUGLOREH countries
The effect of dental caries on the overall quality of
health and wellbeing has not been studied well . This disease and its sequelae
can cause significant pain and are expensive to treat. The burden of dental
caries lasts a lifetime because once the tooth structure is destroyed it will
usually need restoration and additional maintenance throughout life. As
retention of teeth in populations in Europe increases, dental caries has become
a burden for ageing adults. In Canada, Locker reported that one third of adults
aged 50 or older reported problems with eating, communication, and social
interaction, while 18·7% worried a great deal about their oral health. Almost a
third were dissatisfied with some aspect of their oral health status. Adults in
France also reported high needs for dental care. Physical functioning
together with social functioning is one of the dimensions of oral health
related quality of life. Dissatisfaction with the ability to chew (subjective
measure) and difficulty to chew hard foods (objective measure) have been found
to be strongly related to socio-economic level, low income being a strong
predictor of dissatisfaction with oral functioning measure. Studies have also
shown that large proportions of adults wearing dentures – ranging from 25% to
70% across the seven countries of the WHO International Collaborative II
studies – experience difficulty in eating and speaking clearly because of their
denture. Difficulty in chewing can lead to nutritional problems and affect
general health; this is particularly true with the older population groups. It
can also profoundly affect one’s social life, make people avoid getting
together around meals, an important component of social behaviour in the ageing
population. Measures of oral pain and oral functional limitation were more
strongly predictive of oral disadvantage than disease and tissue damage
antecedents. Surveillance of oral disadvantage due to functional limitation has
implications regarding the use of oral disadvantage to assess the long-term
effectiveness of dental care.
Therefore, the « traditional» preventive methods
emphasized in most cases limitations among population groups with a high risk
of tooth decay. These populations at high risk for tooth decay -perhaps not
their only risk factor - remain on dental health charts recorded in the years
1965, the same populations for whom treatment is apparently difficult to come
by. The failure of prevention is also the failure of the dental health care
system. It is therefore necessary to identify alternative approaches if we wish
to make progress. Getting rid of inequalities for minorities and deprived
people should be the primary purpose of the health system, whence the
suggestion of innovative, integrated approaches.
Gingival bleeding is highly prevalent among adult
populations in all regions of Europe; advanced disease with deep periodontal
pockets (6 mm or more) affects 10% to 15% of adults (Figure 5.14.2). According
to the results of recent epidemiologic surveys in industrialized countries,
gingivitis affects most adolescents and 40 to 50% of adults. Surveys also show
that early-onset periodontitis are rare. Moderate periodontitis affects the
majority of the adult population but the severe generalized form of
periodontitis is clustered in only 5% to 10% of any population.
The majority of the young adult population adults in
Western countries have few periodontal problems. In older adults moderate
periodontitis affects a large proportion but the extent of the disease is very
limited. Severe periodontal destruction is clustered in only 5% to 10% of the
adult population. In the 35 to 44 years old group, the prevalence of deep
pockets is lower in populations of OECD countries with 2% to 28% when compared
to the Eastern European countries where 2% to 40% of the population is
affected. Prevalence of deep pockets (> 5 mm) is low (10.21%); this underlines that periodontal pockets, is an uncommon condition in France (2003). Most localized forms were slight (96%), well ahead of the moderate (3%),
cases. Severe forms were marginal in this regard (1%). The distribution of
generalized forms was even more: 78% slight, 18% moderate and 4% severe.
Figure 5.14.2. Adults aged 35-44 with
Severe Periodontal Health Assessment (Pocket >6mm) in selected EUGLOREH
countries
Untreated, severe periodontal disease is a potential risk
for general health and well-being, and has been implicated as a co-factor in
the progression of diabetes, some cardiovascular diseases and the risk of
premature birth. Periodontal health disparities are associated with the burden
of these diseases and disorders, falling disproportionately upon adults from
particular underrepresented minorities, and lower socioeconomic classes. It is
therefore essential to detect from the point of view of oral health planning,
the percentage of these people in the population as a whole. Proper diagnosis and
risk assessment are prerequisites for prevention. Knowledge of periodontal
health assessment is an essential element for decision-making and would reduce
the cost of care for periodontal disease and shift more professional time and
health care funds to patients who need more intensive and frequent professional
management due to severe periodontal destruction. In its severe form,
periodontal disease could affect 10% of all European adults in a few places.
Because of the economic and political changes in Eastern Europe, oral health systems are now in transition. Prior to 1989, oral health care
for children was provided by public health services and most countries of the region
had established school dental services. Since 1989, privatization and
decentralization of oral health services has been taking place and most public
health programmes have been brought to a halt. This change in the systems has
had a negative impact on utilization of oral health services. Figure 5.14.3
illustrates the difference in dental visit frequency of children across Europe. In Portugal, toothbrushing twice a day was reported for 31% of 6-year-olds and
55.6% of 12-year-olds; 17.8% of children aged 6 had seen a dentist during the
past year and this was found to be 58.3% at the age of12.
Figure 5.14.3. Children aged 12 with a
dental contact within the previous twelve months
In Eastern Europe, many children attend the dentist with
dental emergencies (pain/problems) rather than for preventive reasons. Recent
surveys carried out in Eastern Europe revealed that the dental self-care
capacity of schoolchildren needs to be improved. For example, studies in Poland showed that only 64% of schoolchildren brushed their teeth at least twice a day.
Serious
disparities exist in the access to oral health care across Europe, especially
for low income populations. Poor children are more than twice as likely as
their peers to have dental decay and their disease is more likely to go
untreated. Low-income people often have difficulty in finding a dental provider
who will treat them, even if they have insurance coverage or qualify for the
oral health insurance program. Residents of institutions face several barriers
for obtaining needed dental services.
Several national
surveys show that the proportion of the population that annually makes at least
one dental visit and the average number of visits made that vary significantly
depending on age, race, dental status, level of education and family income.
The oral health
care system in Europe, which represents 4-8% of the total health expenses, has
an economic significance, thus the industrialized countries’ clear policy,
despite the disparities observed in health care expenses. 245 169 dentists, 13
295 dental hygienists work in 1998 the European Union and EEA. The dental
profession has an impact on employment in advanced health care. Dental
expenditures represent 3.8 to 8% of all health care expenditures. For the eight
OCDE countries used in this example, average expenditures for dental care per
individual increased by 1.5 between 1990 and 2000, with variable differences
according to the country (Widström
and Eaton, 2004).
In 2000,
expenditures for dental care represented an average of 0.5% of the GDP, or
approximately 1/17th of overall health care expenditures. Germany spent proportionally the most for its oral health: 0.8% of the GDP. France falls in the middle with 9.3% of the GDP devoted to health care and 0.5% reserved
for dental care. Finland (0.4%) and the Netherlands (0.3%) have the smallest
expenditures.
