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Proceedings of a workshop, held in Constanta, Romania on 22 May 2014, on Oral Health of Children in the Central and Eastern European Countries in the context of the current economic crisis

  • Dorjan Hysi1,
  • Kenneth A. Eaton2Email author,
  • George Tsakos3,
  • Paula Vassallo4,
  • Corneliu Amariei5 and
  • the DPH Group
BMC Oral HealthBMC series – open, inclusive and trusted201616(Suppl 1):69

Published: 25 July 2016

The Erratum to this article has been published in BMC Oral Health 2016 16:96


This report presents the proceedings of a workshop held in Constanta, Romania on 22 May 2014. During the workshop, representatives from 18 Central and Eastern European countries gave oral presentations on the current oral health of children and young adults aged 16 years and younger. The aim of the workshop was to collect and present data relating to the oral health of children from Central and Eastern European countries and to discuss them in the context of the political changes that have taken place over the last two decades and the recent economic crisis.

The presenters had previously completed a series of questions on oral epidemiological studies, prevention of oral disease, treatment and payment, dental personnel, uptake of oral health care and other considerations and structured their presentations on these topics plus the influence of the economic crisis on oral health. It should be remembered that this paper is a report of the proceedings of a workshop and not a study. Ethics approval is not required for workshops.

After the 18 oral presentations a 90 min discussion took place during which further points were raised. The presentations, the discussion and the conclusions which were reached are reported in this manuscript.


Oral healthCentral and Eastern EuropeEconomic CrisisWorkshopProceedings


Oral health is an integral and very important part of general health [1]. Diseases originating from the mouth can effect general health and vice versa. There is documentation in the literature about prevalence of and trends in oral diseases in most of the western European countries [2, 3], where, in general, especially in North West Europe, surveillance studies seem to be well organized for collecting, analyzing and interpreting the data for oral health planning. These countries have been democracies for a long time. This might have influenced positively the oral health care systems, resulting in a reduction the prevalence of dental caries in children and young adults and an increasingly dentate elderly population. In contrast, oral health data are scarce in many Central and Eastern European (CEE) countries. There is relatively little in the literature from these countries about oral diseases prevalence, preventive programs and systems for the delivery of oral care. Furthermore, when presenting such epidemiological data, either verbally or in writing, some speakers/authors may be unable to cite appropriate references.

Since, 1990, the CEE countries have undergone political and economic changes that have affected not just their health care systems but also their lifestyles and their attempts to reach European Union (EU) standards. Some of the CEE countries have joined the EU, others are in the process and others have decided not to apply. The oral health care systems of these countries are very diverse. Since 2008, the global economic crisis has led to a general perception that budget cuts have affected all parts of the economy including general and oral health care in these countries. Because many of the citizens of CEE countries are impecunious or very impecunious, the combined effects of the economic crisis and a change in some countries, from a centralized economy to a market economy, has led to a privatization of oral care services. This has potentially created a cost barrier to seeking oral health care and, as a result, a deterioration in the oral health of many citizens of these countries.

Against this background, a workshop was planned and organized by the European Association of Dental Public Health (EADPH) and the Romanian Association of Oro-Dental Public Health. It was sponsored through the generosity of the Borrow Foundation.

The aim of the workshop

The aim of the workshop was to collect and present data relating to children’s oral health from Central and Eastern European (CEE) countries and to discuss them in the context of the political changes that have taken place over the last two decades and the recent economic crisis.

Objectives of the workshop

Within the aim there were a number of objectives, which were to:
  • Gather the most recent epidemiological data on the oral health of children.

  • Ascertain if there were any current or past national, regional or local programmes to prevent oral diseases in children.

  • Understand the payment systems for the oral health care of children

  • Ascertain the structure of the oral health workforce

  • Ascertain the uptake of oral health care by children

  • Understand the affect of the economic crisis on the provision of oral health care for children

Organization of the workshop and participants

The workshop was organized by Professor Corneliu Amariei (President of Rumanian Association of Dental Public Health) and Professor Kenneth Eaton (Chair of the European Platform for Better Oral Health in Europe). Its sessions were moderated by Dr Paula Vassalo, President of Council of European Chief Dental Officers, Dr Georgios Tsakos, President of the EADPH and Professor Eaton.

There were 18 invited participants who came from Dental Faculties, Dental Associations and Ministries of Health in Albania, Armenia, Belarus, Bulgaria, Croatia, Czech Republic, Georgia, Greece, Hungary, Latvia, Lithuania, Macedonia, Moldova, Romania, Russia, Slovakia, Turkey and Ukraine. Unfortunately, the delegate from Armenia was unable to attend the workshop. However, he submitted a report which was read on his behalf. The names of the 18 invited participants who presented data from their countries and wrote the reports that appear in the appendix to this report are in Table 1.

It is difficult to define what constitutes Central and what constitutes Eastern Europe. Prior to 1914, Central Europe was considered by many to consist of the countries of the Austro-Hungarian Empire. However, after 1918 and again after 1945 borders were redrawn. In the early 1990s further changes occurred with the break-up of Former Yugoslavia into its constituent countries and the division of Czechoslovakia into two countries. Thus, there appears to be no clear definition of what should be considered as Central and Eastern Europe. Perhaps, of the countries who attended the workshop, those from the former Soviet Union plus Turkey could be considered to be Eastern European and the other countries as Central European. The choice of which countries were invited to take part in the workshop was relatively arbitrary and was made on the basis of the organisers’ acquaintance with senior academics and advisers to Health Ministries in the countries concerned. Representatives from all 18 countries that were invited accepted the invitation and produced reports. However, as previously stated, the representative from Armenia was unable to attend in person and his report was read on his behalf. Nine of the countries represented were Member States of the European Union (EU). They were Bulgaria, Croatia, Czech Republic, Greece, Hungary, Latvia, Lithuania, Romania, Slovakia, The other nine were not members of the EU and only three (Albania, Macedonia and Turkey) were at the time actively seeking membership of the EU. With the exception of Poland, representatives from all CEE countries with a population of more that 10 million took part in the workshop. The total population of the 18 countries is over 80 % of the total population of all CEE countries.

In January 2014, a questionnaire (Fig. 1) was prepared and sent to all delegates, who completed it and sent their answers to the workshop organisers. Their responses were published in the workshop program in advance of the workshop. The questions were structured to focus delegates on specific topics and to try to obtain comparable data. This was not a study but a workshop so ethics approval was not required.

The participants were welcomed by Professors Eaton and Amariei, who explained the aim of the workshop and the program. There were two presentation sessions followed by the discussion of the working group, a plenary discussion and conclusions.

Each country’s representative gave a 10 min presentation which focused on the points raised in the questionnaire i.e. epidemiological data, prevention, treatment and payment, dental personnel, uptake of oral health care and other considerations. The presenters also authored the descriptions from each of the 18 CEE countries; these appear in the appendix to this report.

Summary of the presentations and discussion

This section of the proceedings summarizes the presentations and the discussion that took place after the presentations. Where possible, the data that were presented are summarised in tables for the topics concerned.

Epidemiology (Table 2)

Presenters introduced data from their national or local studies. Most of them focused on dental caries prevalence of 5 and 12 years old. In general, the WHO 1997 criteria were used and caries was recorded at D3 level, by caries prevalence or DMFT/dmft indices. The data indicated that high dental caries prevalence was still the main dental public health problem in most of the countries represented at the workshop. The national mean DMFTs for 12-year-olds, which were presented during the workshop, were higher in the Eastern European countries (between 2.05 and 6.77) compared with the Western European countries (between 0.6 and 1.70) [4]. However, the variability in the methods used and the wide range of years in which the studies took place made it difficult to compare them. The methodologies used to gather the data were not consistent and comparable. Some of the studies were local and did not represent a national sample. Also training, calibration and sample selection criteria were questionable in some of the studies. For these reasons it is unwise to compare these data between countries and therefore no tables to show the different reported dmft and DMFT data are presented in this report.

Only a few data were presented about periodontal status, the need for orthodontic treatment and oral cleanliness. There was no provision for periodic national surveys to monitor oral diseases in any of the 18 countries, whose representatives attended the workshop. As mentioned in the introduction, some presenters were unable to cite references to support the data that they presented and have subsequently been unable, or unwilling to do so during the production of this report.

Prevention (Table 3)

Prevention programs which focused on dental caries were more frequently at a local rather than a national level. During the discussion, after the formal presentations, it became apparent that Romania and Bulgaria encourage milk fluoridation programs in some parts of their countries. The representative from Latvia presented a national preventive program that was very well designed and implemented. Until 2010, the Latvian program achieved a nearly 50 % reduction in the national mean DMFT score of 12 -year-olds. It consisted of several components including education, fissure sealing and the use of fluoride varnish. Most of the countries did not have preventive programs at a national level. There was a general perception that there was a need to put more effort in prevention by the health authorities (Ministries and local government), academia, the European Commission and international foundations.

Treatment and payment

Some countries indicated that free treatment was provided by their dental public services for the age group 0–16 years and it included fissure sealing, fluoridation, scaling and polishing, extractions and fillings. In Croatia there was a comprehensive free service for children which included prosthetic and orthodontic treatment. Treatment in the private dental service was not free except in countries where the state insurance scheme covered prevention and some other procedures e.g. in Macedonia. In other countries, parents and caregivers had to pay for all dental treatment provided in the private dental clinics/offices/practices. No one presented data concerning toothpaste sales and oral health expenditure.

Dental personnel (Table 4)

Dental treatment for children was always performed by a dentist, except in Latvia where dental hygienists are an important part of the team. In most countries, general dentists were the main providers of oral health care. One clear exception was Georgia where every dental graduate underwent further education and became a specialist. In many of the 18 countries, dentists work solo and without chairside assistance. Only six countries - the Czech Republic, Hungary, Latvia, Russia, Slovakia and the Ukraine- train and employ dental hygienists. Many countries had declined to train dental hygienists because they had un- or under-employed dentists and were continuing to overproduce dentists. Some of the speakers expressed a fear that the opening of new dental faculties, often as private schools without state funding, was having a great impact and was leading to the graduation of too many dentists, who had been trained to a lower standard. Another concern expressed was the risk of overtreatment in countries where there are insufficient patients for the dentists. Speakers, from countries with this problem, indicated that the main reasons for this chaotic and “ridiculous” situation were a lack of workforce planning and inappropriate politics. In many of the 18 countries, access to oral healthcare was difficult in rural areas, since dentists tend to migrate to urban areas. The Latvian speaker explained that in her country this problem had been addressed by the use of mobile dental clinics which travel to remote rural areas. During the discussion it became apparent that only Latvia and Slovakia had data on migration of dentists to other countries.

Other considerations

Many of the countries indicated that the economic crisis in the last 6 years had negatively influenced the provision of oral health care. There had been budget cuts and reductions in the public dental workforce responsible for oral health care of children. However, there were exceptions, such as in Croatia where there have been no cuts and all children and young people can still obtain all oral health care free of charge until they are 18 years old.

The situation does not seem to be improving. There was agreement on the need for a wide coalition to make oral health an important issue not only to the local and national governments but also the European Commission.

During the discussions, after the oral presentations, it was agreed that:
  • There is a need to improve the quality of oral epidemiological data through better study design, applying consistent methodologies and, if the WHO oral health assessment criteria are used, to employ WHO 5th edition Basic Methods for Oral Health Surveys [5]. In the future, the International Caries Detection and Assessment System (ICDAS) Epi version could be used.

  • Special attention to training examiners in epidemiological surveys should be consistent and contribute to high levels of intra and inter examiner consistency.

  • A simple questionnaire should be given to people who are subjects in epidemiological surveys to obtain a snapshot of the their awareness of the need for oral health care and their socio-economic status.

  • There was a need for a workshop on epidemiology of oral health to minimize the inconsistencies and to improve their knowledge toward survey methodologies.


The aim of the workshop had been to bring representatives from 18 CEE countries together to compare the current situation with regard to the oral health of children in their countries and the impact of the economic crisis on the provision of oral care.

The reports, which each representative produced, gave an overview of the situation in their country and enabled them to share good practice. The workshop provided a great opportunity to meet colleagues from CEE countries and discuss different experiences and problems. It seemed that all had common problems as well as some that were unique to individual countries. It is clear that a great deal of work needs to be done towards improving the prevention or oral diseases, oral epidemiological surveys and the systems for the provision of oral care in all the countries represented at the workshop.

All those who attended the workshop expressed their gratitude to the organizers, the EADPH and the Romanian Association of Dental Public Health, and to the Borrow foundation for their generous sponsorship, without which the workshop would not have taken place.




The authors thank all the other members of the Dental Public Health group listed in Table 1, who prepared and presented country reports, and the Borrow Foundation for funding the workshop.


Publication of this supplement was funded by the co-author Kenneth A. Eaton.

Authors’ contributions

DH produced the tables and the first draft of the report, KE designed the questionnaire and the programme for the workshop and revised and edited all drafts of the report, GT and PV facilitated workshop sessions, led the discussion and corrected all drafts of the report, CA was the local organiser for the workshop and contributed to the design of the questionnaire, the report and its editing. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interest.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

Albanian Dental Association, University Dental Clinic, Tirana, Albania
European Platform for a Better Oral Health in Europe, Old Saddlers, London, United Kingdom
European Association for Dental Public Health, London, United Kingdom
Council of European Chief Dental Officers, Valletta, Malta
Romanian Association of Oro-Dental Public Health, Constanta, Romania


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© The Author(s). 2016