Completed vignettes were received from 11 countries, including Bulgaria, Estonia, France, Germany, Ireland, Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden between October and December 2020. If answers were unclear, country experts were contacted to provide clarifications. Answers varied in granularity of provided information; occasionally the answers indicated that the differentiation between columns in the vignette template was unclear or interpreted differently than originally intended.
Some responses showed the complexity of the coverage system for dental care, indicating need for further explanation before being tailored in the vignettes, in particular on Ireland and Sweden. Dental services in Ireland are delivered through three publicly funded schemes: (i) the Public Dental Service (PDS) provides emergency and some routine oral healthcare for children under the age of 16 and certain vulnerable groups, (ii) the Dental Treatment Services Scheme (DTSS) entitles certain adults to some dental services free of charge, and (iii) under the Dental Treatment Benefit Scheme (DTBS) discounted dental treatment is provided to those who have paid three years of social insurance contributions [33–35]. In addition, private dental care is available that patients must pay fully out-of-pocket and claim back fees through tax relief up to a maximum of 20% of the treatment cost for certain non-routine procedures [36].
In Sweden dental care is free up to the age of 23, all others receive a general dental care allowance of EUR 30 to EUR 60 year to encourage dental check-ups and preventive care. People with certain illness or conditions (e.g. difficult-to-treat diabetes) receive a special dental care subsidy of EUR 60 every six months. In addition, most dental care in Sweden is subject to a high-cost protection scheme which aims to protect patients from very high dental care costs. Treatment costs above certain thresholds during a twelve-month period are covered at 50% (for costs between EUR 295 and 1 470) or 85% (costs above EUR 1 470) of the reference prices. The Netherlands stands out in regard to coverage of dental care by complementary voluntary health insurance (VHI). Most dental care services are not publicly covered but reimbursed fully or in part by voluntary health insurances which are taken up by 84% of the population. In France, private insurance also plays an important role in the reimbursement of non-routine dental care services not publicly covered.
The following sections summarize results on coverage per vignette, followed by results on service access across vignettes.
1. Coverage
Vignette 1: Urgent care with root canal and prosthodontic treatment
The first vignette explores treatment for acute pain due to caries. Related dental care services are in general covered in most responding countries, except for the Netherlands and Portugal (Table 2). Emergency services and radiography are covered in most countries, often with standard cost-sharing such as in France and Sweden (sometimes covered by complementary VHI) or with restrictions in regard to the number of emergency visits and radiographs covered, such as in Ireland, where patients are eligible for one emergency consultation per year only. In Bulgaria, Ireland and Slovakia emergency consultations are covered only if patients have not received another consultation during the year. In the Netherlands and Portugal emergency dental care visits as well as the other services of the vignette are not covered at all as dental services are generally not part of the statutory benefit package. However, in the Netherlands the majority of the population purchases VHI to cover part of dental care.
In regard to the alternatives of root canal treatment or tooth extraction, there is more variation in terms of coverage with respect to the treatment alternatives of tooth extraction or root canal treatment. While tooth extractions are covered nearly in full in almost all responding countries, root canal treatments are less comprehensively covered. Limited services and cost coverage for tooth extractions can be found in Estonia where it is only covered in case of emergency and in France, Lithuania and Sweden where cost-sharing is required. In Ireland, only DTSS beneficiaries are entitled to tooth extraction. Root canal treatment can be excluded from coverage, such as in Bulgaria and Ireland, or be limited to certain parts of the mouth (usually covered for visible teeth, i.e. molar to molar), as in Poland. In many countries, molar root canal treatment requires substantial cost-sharing, and it can be fully excluded from public coverage for the majority of the population, as in Ireland.
Restoration with composite material and prosthodontic treatment are less comprehensively covered overall. In Germany, there is a fixed subsidy of 60% for standard treatment of crowns or onlays, which can be increased if patients are demonstrably consistent about preventive visits. The remaining costs, as well as any difference of costs due to patients choosing superior materials than those covered by insurance have to be paid out-of-pocket (OOP). In all other countries, only a fraction of the costs for fixed prosthodontic treatment is covered by the statutory health insurance. In several countries, complementary VHI seems to play an important role for the reimbursement of dental treatments which are not or only partially covered, including prosthodontic treatment.
Vignette 2: Chronic periodontal condition
The second vignette describes a multimorbid patient with chronic periodontitis that requires a scaling and root planning and regular follow-up visits. Regular check-up visits with the dentist seem to be less comprehensively covered across countries than the acute visit in Vignette 1. In some countries, the number of dental check-ups are limited to one visit per year (Bulgaria, Ireland, Slovakia, Poland) or are subject to cost-sharing such as in Estonia and France (Table 2). Scaling and root planning are also only partially covered in many countries or limited to a share of teeth (e.g. in Poland). The number of planned follow-up visits to stop disease progression and stabilize bone-loss are again restricted in some counties (Ireland, Poland and Slovakia).
Interestingly, there is large variation in regard to coverage of periodontal probing and elimination of dental calculus which is part of periodontal treatment to prevent disease progression. The latter treatment is usually performed by a dental assistant or dental hygienist. In Germany, with comparatively comprehensive coverage for dental care overall, dental cleanings are not covered by the statutory health insurance, while in Slovakia, which has more limited coverage, the social health insurance would cover periodontal probing, and elimination of dental calculus for this patient. In general, basic dental hygiene in Slovakia is partly covered by SHI insurance twice a year in case patients attend regularly preventive check-ups. In Ireland, one scale and polish per year is covered up to EUR 42 for those who contributed to social insurance in the last three years (Dental Treatment Benefit Scheme (DTBS)), corresponding to almost half of the population. In Estonia and Lithuania some cost-sharing applies while in the remaining countries patients have to pay fully out-of-pocket for this kind of services likewise to Germany.
Vignette 3: Coverage of implant-borne restoration and prosthetic rehabilitation across countries
The third vignette describes prosthetic treatment for an older, edentulous patient who received full upper and lower dentures five years ago. Overall, the required interventions of prosthetic restoration are less comprehensively covered than services in vignettes 1 and 2. Coverage gaps exist in particular regarding the requirement for cost-sharing from the patient (Table 4). While some countries employ financial protection measures to support lower-income individuals with the procurement of dentures (e.g. Germany, Ireland, Netherlands), the OOP (out-of-pocket) cost to be borne by the patients can remain substantial. In many countries, coverage of prosthetic rehabilitation or dentures is time-bound, with coverage intervals ranging between three to five years. In Lithuania and Estonia, for example, costs for new prosthetic rehabilitation are covered up to a ceiling of EU 561 (Lithuania for pensioners, disabled and cancer patients) and EUR 260 (Estonia) every three years and if provided by contracted dentists (the exact amount covered can vary by level of bone retention). France expanded the coverage of dental prostheses (including bridges, crowns and movable prosthetics) as of 2021. In Germany, surgical implantation is only covered for patients with exceptional medical indications (e.g. jaw deformities). For prosthetic rehabilitation or fixed dentures, the fixed subsidy for dentures applies that covers 60-75 % of costs. Overall, implants are not covered by statutory insurance and are subject to full out-of-pocket in most countries.
An exception in coverage for prosthetic treatment are the Netherlands where general dental care is usually excluded from the broad benefit package for adults. The Dutch statutory basic tariff, however, covers the cost of full dentures at a reimbursement rate of 75% for new prothesis and at 90% for repair of full dentures with an annual deductible of EUR 385 (lower jaw implants are covered under certain conditions) and with an excess to be paid by the insured person of EUR 250 per jaw. The annual mandatory deductible applies not only to dental care costs but also other health care costs (except GP care, maternity care, district nursing) and has to be paid by adults before the insurer begins to reimburse for services.
2. Service access: physical availability and other determinants
The results reported in the three vignettes also show that patients may experience very different kinds of physical barriers to access dental care (Table 5). The most important barriers reported in all three vignettes across countries relate to the availability of dental care providers, be that due to a general shortage of professionals contracting with public payers or regional variation. In Estonia, for example, the number of contracted dentists per capita is very low and represents the major limitation for access to dental care. In Ireland, the number of dentists contracted to operate in the public dental scheme is rapidly declining. Almost all countries reported shortage of dentists in particular in rural and remote areas as well as deprived areas with important implications on waiting times, opening hours (shorter in rural areas) and travel distances. With dentists primarily being located in urban areas, physical access to dental care for patients in rural areas is often more difficult. Especially for interventions that require several visits, waiting time constitutes a major access barrier. In Poland, for example, the average waiting time in 2020 was 16 days, but varied from 6 days to 41 days across regions.
Moreover, appropriate technical equipment (e.g. x-ray units) is not equally available across dental practices which makes referrals to other providers or laboratories necessary, such as in Bulgaria. Accessibility issues for people with reduced mobility in smaller and older dental clinics were reported as another access barrier such as in France, Lithuania and Sweden; for example, dental care facilities are not accessible for wheelchair users due to lack of ramps or narrow doors.
While the majority of physical access barriers were similar across the three vignettes, emergency care (Vignette 1) and more specialised treatment pathways (Vignette 2 and 3) highlight access barriers specific to specialized services and providers. Emergency dental services and out-of-office hour dental care in general are often only available in large cities in some countries (Vignette 1). The unequal distribution and/or lack of specialised dentists as well as dental hygienists constitute major barriers in many countries. In Ireland, dentists with a special interest in endodontics are generally confined to more urban areas. In Slovakia, the lack of specialists on periodontal conditions results in low quality of care for these patients (Vignette 2). Lithuania experiences a lack of dental assistants in facilities contracted by the statutory health system. As a result, patients have to pay out-of-pocket as services of dental assistants are only covered if they are employed in a contracted facility. Moreover, the lack of specialists in rural areas has become a main barrier for access (Vignette 2). For Slovakia, respondents highlight that stomatology centres are confined to larger cities which create access barriers for patients requiring implant-based treatments and also in Bulgaria, very few dentists are experienced in the area of dental implantology as it is a relatively new specialty (Vignette 3).
The socioeconomic status of patients was reported as the main determinant of access to dental care in nearly all countries. In particular when patients have to pay upfront for services which are reimbursed retrospectively by the health insurance, or cover very high OOP costs, socioeconomic status is crucial. In Lithuania, for example, the high cost of dentures (Vignette 3) implies that the intervention remains unaffordable for low-income groups. Several countries recognized that in theory, those with cognitive impairment or mental health conditions might be less well placed to formulate a care request or understand the different benefits and treatment processes of alternatives, for instance root canal vs. extraction. In some countries, providers might deny care due to financial reasons (related to insurance status or income level).
For all vignettes, most respondents highlighted that patient age can inhibit access and affect outcomes, for instance by complicating long distance travel. Access barriers due to difficulties with formulating the care request may be similarly exacerbated in this patient group, particularly for the third vignette, patients may find it difficult to understand the benefits of different options and/or navigate complicated administrative processes that would have helped with claiming support to cover OOP costs.
Other determinants may also impact access: for instance, evidence from Sweden identified female gender, higher educational levels, and native status as drivers for seeking care for chronic conditions – men, less educated people and foreigners are less likely to seek care. Foreigners and the less educated are also less likely to make use of cost-sharing alleviations.
The question on the role of provider attitudes was the one most frequently left without adequate responses due to lack of relevant evidence. However, several countries reported indicative reasoning for motivating factors. Most frequently, care denial was driven by insufficient coverage (either because public coverage tariffs are too low or because patients are deemed unable to cover OOP costs) or insufficient skill on the side of the practitioner, for example for working with children, cognitively impaired patients or individuals living with a mental disorder. One country also mentioned dentists refusing care to patients with chronic infectious diseases, such as hepatitis C or HIV due to for example required efforts to practice standard precautions.