EUGLOREH project




5.14 Dental and oral diseases

5.14.3 Data description and analysis

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5.14.3 Data description and analysis


Dental caries


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 denturesranging from 25% to 70% across the seven countries of the WHO International Collaborative II studiesexperience 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.


Periodontal diseases


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.


Dental erosion


Evidence has been collected that dental erosion, i.e. the loss of tooth enamel caused by acid attack, is currently increasing among young people. The prevalence measure in a random sample of 1379 12-year old children in Leicestershire and Rutland (United Kingdom) was about 60% (Dugmore and Rock, 2004a). In the same study the authors found significant positive associations of dental erosion with decay experience and drinking fruit juice and carbonated drinks (Dugmore and Rock, 2004b). Dental erosion showed a higher than average prevalence in ethnic minorities.


Economic impact


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 countriesclear 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.