Abstract.
When it comes to oral health, children and adults with special healthcare needs are reportedly an underserved segment of the population in most countries, with limited access to quality oral care and many unmet treatment needs. Healthcare systems are organized and financed in different ways in various countries, and efficiency in providing targeted prevention and oral care may vary a lot from one country to another. The paper explores and compares the ways oral care is taken care of in France, Italy, Turkey and Romania. Successful healthcare models of countries that efficiently meet the needs of their population with general pathologies need to be carefully analysed, adapted and implemented in countries where current management policies had proven to be less successful. This goal can be achieved with consistent comprehensive support from authorities and by raising awareness of both healthcare providers and general population.
Key words: Special healthcare needs, oral health, healthcare systems
Introduction
Decrease in infant mortality along with the increase in life expectancy have increased, over the past years, the number of people with special healthcare needs (SHCN) within the general population. In 2016 over 1 billion people with SHCN were reported representing a rough 15% of the world’s population. Their number is expected to increase through the aging of the population and the increasing incidence of these conditions. At European level, the number of people with SHCN is about 80 million people [1].
The term disability refers to a person’s impairment, activity limitations and participation restrictions, due to a certain health condition, that may negatively affect aspects of their interactions and quality of life [2]. Patients with SHCN are not only impaired by their health condition, but by attitudinal and environmental inequalities that restrict their participation in society in similar manner to general population. Therefore, the United Nations Convention on the Rights of Persons with Disabilities (CRPD), adopted in 2006, aimed to overcome these shortcomings by promoting integration in society of people with SHCN with respect for their inherent dignity, and by protecting and ensuring full, equal human rights and fundamental freedoms. This reflects the major shift in global understanding and responses towards disability [1]. The CRPD also reinforces the right of persons with disabilities to access high standard and affordable healthcare similar to general population, available without discrimination [3].
Patients with SHCN may associate a wide range of conditions that impair or limit their activities, some of which may be evolving later from the poor health and high health care needs that were unmet. In fact, most of the time, patients with SHCN require the help of a legally responsible person to perform daily activities, including medical interventions. Healthcare systems should adapt in order to meet this category of patients’ needs. According to WHO reports, all spectrum of health services, promotion, prevention and treatment, have unmet needs for patients with SHCN [1]. This may be a consequence of misconceptions regarding the need of patients with SHCN to have access to promotion and prevention of diseases, as well as screenings [4]. Additionally, SHCN people may experience limited access to health promotion due to their primary health condition, like for example patients with intellectual impairment or mental health problems [5].
Regarding dental care, it is still often that even simple treatments needs are not met for patients with SHCN [6]. These patients are much less often treated by dentists, due to the difficulties of cooperation in the doctor-patient relationship, resulting in increased carious experience complicated with pulp involvement and more edentulous patients as compared to clinically healthy individuals. Actually, patients with SHCN are more likely to seek dental services for emergency treatments, due to complications that may occur (e.g. pulpitis, apical periodontitis, abscesses, dental trauma) [7].
Oral and general health of patients with SHCN is dependent on health and educational systems of their respective countries. Under- and postgraduate dental education in the field of special care in the four countries involved in the Erasmus+ Project Oral Special Care Academic Resources (O.S.C.A.R.) – France, Italy, Romania, Turkey – were discussed in a previous paper [8]. Governments can promote access to affordable and high-quality health care services by understanding the barriers responsible for their situation: financial, human resources, administrative or infrastructure [9] and by adjusting health policies and legislation. The present research aims to investigate how oral care for children and people with SHCN is organized in the above mentioned four countries, to compare and find potential ways of reforming national health policies in order to improve oral health for this traditionally underserved category of population.
Material and methods
Data on provision of oral healthcare for children and people with SHCN in France, Italy, Romania and Turkey were sought in official reports. Details with regard to both organization and financing of these services in the respective health systems were compared.
Results
1. ROMANIA
The estimated population of Romania, in July 2021, was 19,127,774 inhabitants, out of which 861,016 were represented by special needs people. From those, 75,721 (8.79%) were under 18 years old, an increase of 25% compared to 10 years ago (60,269 – in 2011) [10]. In 2019, the number of active dentists providing oral care for the population was 17,003, from which 87.6% were in urban areas and 12.4% in rural ones. The reported number of inhabitants per dentist varies from one geographical region of the country to another, but the mean number of inhabitants per active dentist was 1142 [11].
In Romania, The National Health Insurance Trust (CNAS) is the main source of finance for the public healthcare system. By law, health insurance is mandatory for all citizens, with few exceptions (children, disabled people, and pregnant women). Unlike for general medicine, there are few dental procedures enlisted in the CNAS list. Dental treatment costs for children under the age of 18 are fully supported, as well as emergency endodontic treatment, periodontal management of abscesses, or consultations regarding oral and head and neck cancer [12]. There is however a very small percentage of dentists that collaborate with CNAS. The treatment costs are paid by clinical procedure. The costs per procedure are the same for disabled patients as they are for non-disabled. However, a limited number of dental procedures are covered by CNAS for each collaborating dentist, dependant on the allocated monthly amount of money which is fixed and cannot be supplemented [12, 13]. Dentists easily reach this limit by treating non-disabled patients and therefore there is no financial incentive for them to provide treatment to people with SHCN [12]. Considering also the lack of clinical experience in managing this category of patients and self-perceived inadequate level of knowledge [14], many Romanian dentists choose to refer SHCN patients rather than to take the challenge.
Furthermore, poor access to quality oral care for SHCN patients could be a consequence of low financial status of their families, as well as the decreasing percentage of dentists working in collaboration with CNAS. At present, almost 90% of dentists work in private dental clinics which seldom have collaboration with the CNAS [12].
In Romania there are currently no national programs for prevention of oral disease targeted on children/people with SHCN and local initiatives in this respect are scarce. University dental clinics and NGOs put a lot of effort in implementing small scale programs. Special Olympics-Special Smiles, addressing athletes with intellectual disabilities, is one example of such initiatives.
2. FRANCE
The estimated population of France (2020) was about 65,273,511 inhabitants, 20% of which (almost 15 mil.) were children and adolescents. Almost 12 million persons have a type of disability [15,16].
Regarding oral health care, in 2018 there were approximately 42,348 active dentists in France, of which about 5,000 in state clinics. The average number of dentists per 1000 inhabitants reported in 2018 was 0.65 [15].
Enrolment in France’s hybrid health insurance system is mandatory. The system covers most costs for hospital or physician care, as well as prescription drugs. Patients are responsible for co-payments if the physician’s charges exceed the covered fees. 95% of citizens have supplemental insurance to help with these out-of-pocket costs, as well as, for instance, dental care. Children aged 6 to 18 years get a free dental check-up every 3 years. Basic dental procedures (e.g. check-ups, restorations, extractions) are covered by the state, but more complex treatments (or cosmetic ones), which are are more expensive, need to be paid out of pocket or by private insurance [17, 18].
Patients with SHCN are treated by general practitioners in private or state clinics or offices, either under common dental office circumstances or under nitrous sedation or general anaesthesia (GA). Procedures can be complex and parents have to identify a general practitioner who is willing and capable to provide the treatment. The waiting list for the first dental visit can be long. If treatment plan fails, or if the child is uncooperative, the patient is referred to a dentist specialized in SHCN patients or to a University hospital [19].
Regarding the possibility of treatment for SHCN patients in university hospitals, 14 out of 16 hospitals perform dental treatments under GA for children (up to 6 children/week) with a waiting period between 3 to 9 months. In 6 hospitals, dental treatments are performed under sedation with Midazolam, and in all 16 university hospitals nitrous-oxide sedation is used on a daily basis in dental practice [16].
Sixty-seven public dental practices and 45 private dental offices have adequate settings for providing dental GA for children and adolescents with SHCN; however, they are unevenly distributed in the country and mostly treat children between 3 and 5 years of age [16].
In France, rare diseases have been regarded as one of the five priorities of the Public Health Law (as established in 2004 in the first National Plan for Rare Diseases), which proposed concrete measures and structures in order to organize provision of health care in this country. Referral Centres for rare diseases were created in order to obtain scientific and clinical excellence, and a network of specialized care was subsequently built around these centres in order to facilitate both patients’ access and formation of health care professionals interested in this particular field [20].
More recently, a second Plan for Rare Diseases has been established for the period 2011-2014. The National health policy helped develop a network of 134 Certified Referral Centers (Centre de Référence Maladies Rares – CRMR) each dedicated to the treatment of one or a group of related diseases. These CRMR are linked to a network of more than 500 Skilled Centers. Of the 134 CRMR in France, two are focused on diagnosing and treating oro-facial and dental malformations: Referral Centre for rare oral and dental diseases – Service d’Odontologie des Hôpitaux de Strasbourg (since 2006) and Reference centre for rare malformations of the face and oral cavity (Centre de référence des fentes et malformations faciales MAFACE) – Service de chirurgie maxillo-faciale et plastique, Hôpital Necker – Enfants Malades (since 2007) [20].
Within this context, France has also developed a dedicated network for rare oral and dental diseases – O-Rares. The O-Rares Network currently consists of a Coordinating Centre (Strasbourg – Civil Hospital), a Constituent Centre (Paris – Rothschild Hospital) and 16 Competence Centres spread throughout the territory: Angoulême, Besançon, Bordeaux, Dijon, Lyon, Marseille, Montpellier, Nancy, Nantes, Paris APHP Henri Mondor Créteil, Paris APHP Pitié Salpétrière, Reims, Rennes, Rouen, Toulouse, Tours). The purpose of this network is to provide patient care and follow-up as close as possible to their home [21].
Despite these measures, a deficient of dental assistance for patients with SHCN remains. This deficit is responsible for: (1) increases in failures of treatments done under nitrous-oxide sedation indicated due to lack of access to dental procedures under GA; (2) the increase of dental emergencies; (3) extractions which are not performed in accordance with the guidelines’ recommendations; (4) dissatisfaction of parents; (5) decrease in quality of life of the dental team [19]. Given the above, SHCN patients gained priority when it comes to dental treatments under GA, in detriment of healthy patients.
3. ITALY
The estimated number of residents of Italy was 60,656,000 on January 1st 2016, the fourth largest population in the European Union (EU). The number of active dentists in December 2014 was 59,324, with a ratio of one dentist for every 1025 inhabitants [22].
The Italian public healthcare system – Servizio Sanitario Nazionale (SSN) – is provided by public, private and private-public entities and is financed by general taxation. SSN provides universal coverage largely free of charge especially for children, vulnerable people and individuals who need emergency oral care. For other patients, dental treatments are not generally covered by SSN, and in many areas only emergency dental treatment is provided within the SSN [22].
The National LEA (Levels of Essential Assistance) establish a minimum level of oral care offered within the SSN, but regions have exclusive authority in planning and delivery of healthcare and determine the entity and type of public dental services supplied in accordance with the LEA [23]. LEA include patients with health conditions which make oral care necessary or even essential. This ‘sanitary vulnerable’ category of population includes: 1) patients with diseases or systemic treatments that aggravate oro-dental diseases and/or that make oral treatment hazardous or who require a particularly complex dental treatment; 2) patients with rare diseases, if oral problems are related to the primary disease; 3) patients who suffer from diseases and/or conditions where health could worsen or be compromised by concurrent oral pathologies; 4) patients born with severe physical, sensory and psychiatric conditions. Considering the extent and the gravity of pathologies, patients within the mentioned population groups may be entitled to guaranted treatment except for aesthetic interventions [22].
The public oral healthcare system provides only 5 to 8 % of all the services in approximately 370 dental clinics and the percentage varies from one region to another. Out of the 59,324 dentists, about 3400 work in public practices or hospitals providing oral healthcare to both inpatients and outpatients. Access to specialized oral healthcare services within the SSN can be directly obtained without a general practitioner’s referral [22].
The Ministry of Health provides evidence-based national guidelines and recommendations for daily work of all oral health professionals and promotes preventive dentistry programs. There are nine issued national guidelines on oral health and oral disease prevention, some of them including clinical management of dental trauma, clinical prevention (prenatal, childhood and adulthood) or the prevention and treatment of the sleep-apnoea syndrome, but none for SHCN people [22].
In order to improve availability of dental services and to ensure better access to dental care, an agreement was made between the Ministry of Health and private dentists for some services to be applied to socioeconomically vulnerable categories (e.g. pregnant women) at lower fees than usually [22].
S.I.O.H. (Società Italiana di Odontostomatologia per l’Handicap/ Italian Society of Odontostomatology for Handicap) is an interdisciplinary scientific society established in 1985, focusing on the study of oral-dental-maxillary diseases of psycho-physical, neurological and severe sensory disabilities. Its Code of Ethics aims at improving the quality of life and integration of the person with disabilities, safeguarding their cognitive, emotional, cultural, character and personal autonomy development, taking care of their relational integration, promoting the value of the Human Person and educational development through the Care Relationship. S.I.O.H. promotes training of dentists dedicated to the so-called “Special Dentistry”, standing for Dentistry for patients with Special Needs. The cultural updating is carried out under all aspects, from approach strategies to those of prevention and treatment, and members of the S.I.O.H. carry out continuous training, awareness and dissemination of the peculiar aspects of special dentistry within the dental world. The aim of this approach is to ensure that the SHCN patient will to be treated in accordance with his/her clinical picture and degree of collaboration, in a manner comparable in effectiveness and quality to that provided for rest of the population.
In this respect, Bambino Gesù Hospital in Rome not only provides special oral care to young children and children with various pathologies under sedation or GA, but also implemented the “Bedside Dentistry” concept, enabling children with serious general conditions to get quality professional oral in their own hospital bed.
4. TURKEY
According to the data provided by the “Address Based Population Registration System”, the total population of Turkey was, by 31st of December 2019, 83,154,997 people. In order to meet the need for data regarding population with disabilities, a “National Disabled Data System” has been established within the Ministry of Family, Labour and Social Security based on the Disability Health Board Reports in public institutions and organizations. According to Ministry of Family, Labour and Social Security statistical bulletin published in March 2020, the number of persons with disabilities registered and alive in the National Disability System was 2.533.209, with 1,423,334 (56%) males and 1,109,875 (44%) females [24]. The number of persons with disabilities under 18 years of age was 139,178. This report does not include persons who had not applied to authorized hospitals for a Disability Health Board Report and had not applied for government services.
Healthcare in Turkey consists of a mix of public and private health services. Turkey introduced universal healthcare, known as Universal Health Insurance – Genel Sağlık Sigortası -, which is government funded by taxes. Universal Health Insurance – Genel Sağlık Sigortası provides health care services free of charge for children under 18 years old and persons with disabilities who got a Disability Health Board Report; people with this report have priority in health care services.
Oral health care, like all other health services, is mainly provided by the Ministry of Health, university clinics and private practitioners. According to the data of the Turkish dental association for 2020 [25], 17,178 dentists serve in governmental services, including in hospitals affiliated to the Ministry of Health, university hospitals and other public institutions. In addition, 22,260 dentists work in private clinics and institutions. While Universal Health Insurance-contracted governmental services offer dental care, in most cases, patients must rely on private dental services and are responsible for covering the costs themselves. Therefore, except for children under 18 years of age and people with a degree of disability of 40% or more (as specified in the Disability Health Board Report), oral treatments performed in private clinics and in dental units of governmental health service providers that do not have a contract with the Universal Health Insurance are not paid by this insurance.
In Turkey Specific training in “Special Care Dentistry” care is available (e.g. in Marmara University of Istanbul), but restricted to foreign postgraduate Master students [8]. Turkish dentists are not accepted in these programs, therefore dental care for patients with disabilities is mostly provided by paediatric dentists [26].
Discussion
Healthcare systems are organized in very different manners in the four countries of the OSCAR project that were evaluated. Specific conditions for provision of oral care for children and people with SHCN vary widely, in terms of funding, availability of dedicated premises, professional qualification of oral health providers and existing targeted prevention programs.
The diversity of manners in which various healthcare systems handle patients with SHCN encourages comparisons between countries and evaluation of their efficiency in providing quality oral care for this category of patients. Successful organisation models could and should be adapted in countries where national healthcare systems do not seem to cope with the actual needs of this underprivileged category of population. The French O-Rares Network is a very eloquent example in this respect, as is as the organization of Special Care Dentistry within Bambino Gesù Hospital in Rome. With effort from dental professionals, endorsed by organisations of patients with various pathologies and with a lot of comprehensive support from local authorities, such models can be adapted and replicated in countries where the situation is less privileged.
The key point towards achieving a better oral health for people with SHCN is education, addressing parents, families, children, healthcare professionals and society itself, by raising population’s awareness on all levels. Primary prevention is more efficient when informed parents act as the first and main oral care providers for their children and professional dental care providers are part of an integrative team, monitoring their evolution. Authorities’ and governments’ contribution is essential in terms of modifying healthcare policies in accordance to actual findings and reported needs.
Within this context, our current Erasmus+ Oral Special Care Academic Resources (O.S.C.A.R) started in 2019, aiming to help dental practitioners interested in providing treatment to SHCN patients. The O.S.C.A.R. team developed a digital platform (https://oscarpd.eu/) where dental practitioners can easily access practical information on how to evaluate and manage patients with special oral and health care needs. The platform also contains a section dedicated to parents, families and caretakers of children with SHCN, comprising written information on oral health care and video support for home oral hygiene, as well as tutorials on how to use tele-dentistry as a handy tool for efficient communication between family and the dental team (ERASMUS+ Project 2019-1-RO01-KA202-063820).
The platform also introduces special oral care concepts that have proven their effectiveness and utility. For example, the Dental Home concept, adapted by the American Association of Paediatric Dentistry (2004) from previously described Medical Home concept by the American Academy of Paediatrics (1992), can easily be adopted and implemented with good results. As a matter of fact, the Dental Home model is already implemented in some European countries, although not necessarily under the same generic name. For example, in Sweden, National medical guidelines recommend, for children with Down syndrome, an established contact with dental health care, including oral hygiene follow-ups if necessary, from around one year of age [27].
Conclusions
Successful healthcare models of countries that efficiently meet the needs of their population with general pathologies need to be carefully analysed, adapted and implemented in countries where current management policies have been proven less successful.
This goal can be achieved with consistent comprehensive support from authorities and by raising awareness of both healthcare providers and general population.
This research is part of ERASMUS+ Project 2019-1-RO01-KA202-063820 Oral Special Care Academic Resources (O.S.C.A.R)
The authors have no conflict of interests to declare.
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