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Debate: Poor teeth are a serious matter

Health and oral and dental disease are of crucial importance for the rest of the body. There is increasing international focus on this. But in Denmark, dental diseases remain underprioritised in the healthcare sector.

By Allan Flyvbjerg, Dean of the Faculty of Health, Aarhus University

In the old days, if your teeth hurt you visited the blacksmith. He grabbed his tongs, got hold of the tooth with them and then pulled. And that was that! A poor set of teeth and the loss of teeth are not viewed as an illness, but more a natural decline in line with greying hair and wrinkles. This is presumably the reason why dental services have been sidelined in the development of the health insurance societies that began more than a century ago and right up until the current Danish public healthcare system with free access to healthcare services.

A holed set of teeth and poorly looked after teeth do not only have cosmetic and social importance. People suffering from chronic inflammation of the mouth, for instance, also have an associated risk of serious diseases such as cancer, heart disease and diabetes. Bacteria from inflammation of the teeth can be carried by the blood to the heart, where they can cause inflammation of the heart valves. For diabetics, suffering from paradontosis can be life-threatening, not forgetting that they also have a much higher risk of this than healthy people.

Around the world, oral and dental diseases are considered just as serious and challenging for the population’s state of health and a country’s health economics as diabetes, cardiovascular disease, musculoskeletal disorders and chronic obstructive pulmonary disease.

A world conference was held in 2015 in Japan on the topic of oral and dental disease. The World Health Organisation WHO subsequently presented a range of clear recommendations for how national health authorities could increase focus on the importance of preventing and treating oral and dental disease and ways of doing this. These recommendations are stated in the ‘Tokyo declaration on dental care and oral health for healthy longevity’.

In Denmark we usually take pride in maintaining an international level in terms of disease prevention and treatment. But when it comes to the dental area we are seriously lagging behind.

We do not have the same focus on the health-related, demographic and social consequences of oral and dental disease. In addition, we have a self-payment system that functions inappropriately when seen in light of the model for the Danish health service in general, and which wholly unreasonably increases the risk of social inequality in the healthcare sector.

For elderly people with their own teeth, of which there is an increasing number, maintaining healthy teeth is a particular problem. Clean and well-maintained teeth help to prevent infectious diseases such as pneumonia, which often has a hard impact on the weakest elderly citizens.

A study by the public dental hygiene programme in the City of Copenhagen a few years ago showed that poor dental hygiene among the elderly costs society DKK 20-25 million alone in hospital admissions, and that between one and two-hundred elderly people die every year as a result of pneumonia incurred due to poorly brushed teeth.

In addition, tooth ache and problems chewing will also affect the quality of life of many elderly people far more than other disorders where treatment is freely available in the Danish healthcare service.

Once a citizen leaves the child and adolescent dental care programme at the age of eighteen, all dentist appointments are generally speaking at your own expense. Since the 1980s, the proportion of the dentist's bill that a person must pay himself or herself for general adult dental care has increased from 55 per cent to 82 per cent. In 2013 the government at the time removed first DKK 180 million kroner and subsequently DKK 120 million in subsidies to dental scaling and check-ups respectively. The money saved was to be used for special subsidies for the dental health of vulnerable groups. That this did not take place as intended is another – quite serious – problem.

Contrary to the principles of the Danish healthcare sector in general, there is actually a high degree of self-payment for having a preventive check-up or actual treatment of oral and dental diseases. 

Even though all logic indicates that the treatment of oral and dental diseases ought to be free of charge, there is a discussion about whether an element of smaller self-payment for preventative initiatives could be reasonable.

The Danish Dental Association believes that co-financing of dental treatment gives the patient a share in the responsibility for dental health – they literally learn the cost of having their teeth. This is one of the areas where there is unlikely to be any evidence-based knowledge. On the other hand, what is certain is that there is a social imbalance in the Danish system. Self-payment – whatever the level – leads to social inequality in the area of dental care and treatment. There are large groups in society who are unable to maintain their teeth or undertake treatments that mean they can keep their own teeth for the rest of their lives due to economic reasons. This is not only true of the most marginalised groups such as the homeless and those receiving social security. The cost of dental services can be so extensive that paying them is unrealistic for groups such as students, low-paid workers, single-parents and people on transfer income.

A particularly vulnerable group are people suffering from congenital tooth diseases that require many expensive treatments throughout life.

It is correct that a decision has been taken to provide public funding for the treatment of a number of rare diseases, which occur in fewer than 1 out of 10,000 citizens. But there are also congenital tooth diseases that have not managed to make it through the eye of the needle and onto the exclusive list of subsidies.

This is e.g. the case for the eight per cent of the population who are born with missing teeth or aplasia, as it is called, where people are born without facilities for permanent teeth. In other words, no new tooth appears when the milk tooth falls out. The disease most often results in a lack of one tooth or a few teeth, but in rare cases almost all teeth are missing. The disorder is initially treated in the child and adolescent dental care system, where orthodontics is free of charge and where patients can receive dental implants if they are missing many teeth.

But when the adult patient finally loses the milk teeth that they have attempted to retain, or when the implants need to be replaced, then it is a case of self-payment. Adult patients with congenital aplasia can therefore expect huge dental expenses for implants, unless they choose (or are forced) to wonder around with gaping holes among their teeth.

Internationally recognised

The situation becomes even more ridiculous when we see that research into oral and dental diseases has long been part of the health sciences – and that we in Denmark can demonstrate a high international level in the area. The two Danish departments of dentistry at Aarhus University and the University of Copenhagen respectively are recognised worldwide for their research contributions within a wide range of oral diseases and enjoy many cooperation agreements around the world.

The professional dental practitioners are also constantly becoming more and more skilled – while hard up citizens with poor teeth are excluded and forced to watch developments from the sidelines. That is unless they have already been admitted for treatment of serious diseases that could have been avoided if they had received preventive dental treatment.

Viewing oral and dental disease as being less serious than all other types of physical disease is an illogical, unfair and almost harmful prioritisation.

Kronikken er bragt i Morgenavisen Jyllands-Posten den 26. marts 2016.

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