Completed vignettes were received from the 11 countries named above between October and December 2020. If answers were unclear, country experts were contacted to provide clarifications. Overall, responses varied in level of detail provided.
Some responses (in particular in Ireland and Sweden) showed the complexity of the coverage system for dental care, indicating need for further explanation. Dental services in Ireland are delivered through three publicly funded schemes: (i) the Public Dental Service (PDS), which 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) that entitles certain adults to some services free of charge, and (iii) discounted dental treatment under the Dental Treatment Benefit Scheme (DTBS) to those who have paid three years of social insurance contributions [33,34,35]. In addition, private dental care is available for patients that pay fully out-of-pocket and claim back fees of up to 20% of the treatment cost for certain non-routine procedures through tax relief .
In Sweden, dental care is free up to the age of 23 and all others receive an annual general dental care allowance between EUR 30 and EUR 60 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% (above EUR 1 470) of the reference prices. The Netherlands stands out in coverage of dental care by complementary voluntary health insurance (VHI). Most dental care services are not publicly covered but reimbursed in part by VHI plans, which are used 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 summarise results on coverage per vignette, followed by results on service access across vignettes.
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 (Fig. 1). 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 regarding 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 only covered if patients have not received another consultation that 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.
There is a lot of variation regarding coverage of treatment alternatives of tooth extraction and root canals. Limited services and cost coverage for tooth extractions can be found in Estonia, where it is only covered in case of emergency and also in France, Lithuania and Sweden, where cost-sharing is required. In Ireland, only DTSS beneficiaries are entitled to tooth extraction. Tooth extractions are covered overall more comprehensively than root canal treatments. 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 that 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-ups 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 is capped at one per year (Bulgaria, Ireland, Slovakia, Poland) or subject to cost-sharing, such as in Estonia and France (Fig. 2). Scaling and root planning are also only partially covered in many countries or limited to a share of teeth (e.g. in Poland). Moreover, the number of planned follow-up visits to stop disease progression and stabilise bone loss are restricted in some countries (Ireland, Poland and Slovakia).
Interestingly, there are large variations in 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 covers periodontal probing and elimination of dental calculus. Basic dental hygiene in Slovakia is partly covered by SHI insurance in the case patients attend regularly preventive check-ups twice a year. 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. Some cost-sharing applies in Estonia and Lithuania, while patients in the remaining countries (as in Germany) have to pay fully out-of-pocket for these services.
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 regarding the requirement for cost-sharing (Fig. 3). While some countries employ financial protection measures to assist lower-income individuals procure dentures (e.g. Germany, Ireland, the Netherlands), the OOP costs to be borne by patients can still be 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 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 fully OOP in most countries.
An exception in coverage for prosthetic treatment is 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 the repair of full dentures, with an annual deductible of EUR 385 (this deductible also applies to other health services and has to be paid by adults before the insurer reimburses). An additional fee of EUR 250 per jaw applies, though lower jaw implants are covered under certain conditions.
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 in accessing dental care (Table 2). 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. In Ireland, the number of dentists contracted to operate in the public dental scheme is rapidly declining. Almost all countries reported a shortage of dentists, particularly in rural and remote areas as well as deprived areas with impacts for waiting times, opening hours (shorter in rural areas) and travel distances. As dentists are primarily located in urban areas, physical access to dental care for patients in rural areas is often more difficult. This compounds for interventions requiring multiple visits, making waiting times a major access barrier. In Poland, for example, the average waiting time in 2020 was 16 days, but varied from six days to 41 days across regions.
Moreover, appropriate technical equipment (e.g. X-ray units) is not equally available across dental practices, necessitating referrals to other providers or laboratories, as reported in Bulgaria. Accessibility issues for people with reduced mobility in smaller and older dental clinics were reported as another access barrier in France, Lithuania and Sweden, with an example of this being dental care facilities lacking ramps or having narrow doors and thus not accessible for wheelchair users.
While the majority of physical access barriers were similar across the three vignettes, emergency care (Vignette 1) and more specialised treatment pathways (Vignettes 2 and 3) highlight access barriers specific to specialised 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 a 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 incur OOP costs, as the 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 highlighted that stomatology centres are confined to larger cities, creating access barriers for patients requiring implant-based treatments and also in Bulgaria, where very few dentists are experienced in 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. This is particularly pronounced when patients have to pay upfront for services that are reimbursed retrospectively by health insurance or cover very high OOP costs. In Lithuania, for example, the high cost of dentures (Vignette 3) implies that the intervention remains unaffordable for low-income groups. Several countries have recognised that in theory, those with cognitive impairment or mental health conditions might be less able to formulate a care request or understand the different benefits and treatment processes of alternatives, such as getting a root canal vs. an extraction. In some countries, providers might deny care due to financial reasons (related to insurance status or income level).
Across all vignettes, most respondents highlighted that patient age can inhibit access and affect outcomes, for instance by needing to travel long distances. Access barriers due to difficulties with formulating the care request may be similarly exacerbated in this patient group, particularly for the third vignette, with patients potentially finding it difficult to understand the benefits of different options and/or navigate complicated administrative processes that can help with claiming support to cover OOP costs.
Other determinants may also impact access. Evidence from Sweden, for example, 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 take advantage of cost-sharing mechanisms.
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 (i.e. being able to work 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 like hepatitis C and HIV due to the associated precautions.