Oral health services in Europe

ORAL HEAL TH SERVICES IN EUROPE WHO Regional Publications European Series No. 5 ORAL HEAL TH SERVICES IN EUROPE by J. KOSTLAN Chief Research Worker, Institute for Dental Research Prague, Czechoslovakia Formerly Regional Officer for Dental Health WHO Regional Office for Europe WORLD HEAL TH ORGANIZATION REGIONAL OFFICE FOR EUROPE COPENHAGEN 1979 "Health development is essentially a political and social process that should start off with the acceptance of the social function of health and should ensure that health technology is developed and applied in harmony with this social function." H. Mahler Director-General, World Health Organization WHO Ozronicle, Vol. 31, 1977, p. 8 ISBN 92 9020 I 05 3 © World Health Organization 1979 Publications of the WHO Regional Office for Europe enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copy- right Convention . For rights of reproduction or translation , in part or in toto, of this publication application should be made to the WHO Regional Office for Europe, Scherfigsvej 8, DK-21 00 Copenhagen (j), Denmark . The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory , city, or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are dis- tinguished by initial capital letters. The author alone is responsible for the views expressed in this publication. PRINTED IN DENMARK Reissued under ISBN: 9789289023443 (print) in 2025. Originally published under ISBN-10: 9290201053. ISSN 0378-2255 (print) CONTENTS Page FOREWORD.. ... . . ..... ... ............... . ..... .. ... 7 INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 AUTHOR'S ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 11 NOTES ON TERMINOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 PART I: ORAL HEALTH CARE IN EUROPE - GENERAL REVIEW 1. THE PROBLEM OF THE ORAL HEALTH SERVICES. . . . . . . . . . . . 13 Magnitude of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Nature of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2. OUTLINE OF ORAL HEALTH SERVICE DEVELOPMENT. . . . . . . . . 20 The dental profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 The oral health services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3. DEVELOPMENTAL TRENDS IN THE ORAL HEALTH SERVICES. . . . 23 General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Private dental practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Dental health insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Public oral health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 PART II: ORGANIZATION OF ORAL HEALTH SERVICES IN THE WHO EUROPEAN REGION INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 ALGERIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 AUSTRIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 BULGARIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 CZECHOSLOVAKIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7 DENMARK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 FINLAND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 FRANCE............ . .. . ... . ........ . .. ..... . . . . .... 53 GERMAN DEMOCRATIC REPUBLIC . . . . . . . . . . . . . . . . . . . . . . . . . . 55 GERMANY, FEDERAL REPUBLIC OF . . . . . . . . . . . . . . . . . . . . . . . . 58 GREECE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 HUNGARY... . . . ... . ... ... . .. .. . . . . . . . . . . . . . . . . . . . . . 61 ICELAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 IRELAND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ITALY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 LUXEMBOURG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 MALTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 MONACO . ... . .. .. .. .. . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . 73 NETHERLANDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 NORWAY . . ........ . . . ........ .. ... . . ... . .. ..... . ... 76 5 POLAND .. . ........ . 79 81 82 84 87 89 91 93 PORTUGAL ....... .. . ROMANIA .. ... ..... . . .... . . .... . SPAIN ........... ..... .... ... . . SWEDEN ................. . .. . ....... .. ... . . . SWITZERLAND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TURKEY ................. .. .. .... ... ... . . UNITED KINGDOM (ENGLAND) .. .. . .. . ......... . YUGOSLAVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 PART lll: ORAL HEALTH CARE IN EUROPE - DISCUSSION I. BASIC FEATURES OF A USEFUL ORAL HEALTH SERVICE 2. 3. SYSTEM MODEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 General .. .. . . .. .. . . .. .... .... .... . . . . .. ..... . Availability , accessibility, and acceptability of the oral health services .. Integration of the general health and oral health services .... . A rational basis for the oral health services ... ..... . The teamwork concept in the oral health services ......... . Strategy in developing the oral health services ........... . CONSTRUCTING AND EQUIPPING THE ORAL HEALTH SERVICE FACILITIES . . ................... .. . A NEW WORKING STYLE FOR THE ORAL HEALTH SERVICES ... Chairside economy . . . . . . . . . . . . . . . . . . . ... . Dental surgery equipment and its use . ... ... .. . . .. .. . . The role of the patient . ... . .. ................. . Division of working functions. . . . . . . . . . . . . . . . . . . . . Remaining problems ................ . ....... . . 99 100 101 102 104 105 110 111 111 112 112 112 113 4. TYPES OF ORAL HEALTH PERSONNEL AND THEIR EDUCATION .. 114 Dentists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Dental auxiliaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 5. UTILIZATION OF DENTAL AUXILIARY PERSONNEL. . . . . . . . . 117 The character of oral care and its implications . . . . . . . . . . . . . . . . . 117 Utilization of dental auxiliary personnel. . . . . . . . . . . . . . . . . . . . . 119 How should professionals react to the employment of auxiliary personnel? . 120 What future developments are foreseen in dental education? . . . . . . . . . . . 120 Staffing the future oral health services . . . . . . . . . . . . . . . . . . 120 6. INTRODUCING PREVENTION IN THE COMMUNITY ..... . 125 7. The problem ... ..... ... .. .. .. . . .... . . .. . ...... ..... 125 Water fluoridation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Alternatives to water fluoridation. . . . . . . . . . . . . . . . . . . . . . . 128 Effectiveness and efficiency of prevention . . . . . . . . . . . . . . . . 129 MANAGEMENT OF THE ORAL HEALTH SERVICES .. . . . . Management policy - directing the oral health service system ... . Studying the oral health service system . . .. ............ . 133 133 135 8. THE WHO REGIONAL OFFICE FOR EUROPE ORAL HEALTH 6 PROGRAMME, 1958 - 79 . . . . . . . . . . . . . . . . . . . . . . . . . 139 Management methodology. . . . . . . . . . . . . . . . . Collection of information . . . . . . . . . . . . .. . Alternative methods for oral health service delivery .. 140 140 140 FOREWORD In European countries today some 7 - 10% of national health budgets is spent on oral health services, which engage a grand total of around 250 000 den- tists and at least as many dental auxiliaries. This is a very heavy burden for any country, but a crippling one for the poorer countries that may already be deeply engaged in establishing adequate general health care coverage for the whole population. WHO is very conscious of the need for alternative approaches to health care delivery , including oral health. Basically, these are application of preventive measures, use of the team concept of care, and adoption of rational management practices. Since 1968 the Regional Office for Europe has initiated a number of studies of different aspects of oral care and oral health services in the Region, and the results of these show that countries, if they are not already doing so, should now think of concentrating their efforts on comprehensive prevention of dental caries, effective delivery of oral care, and efficient organi- zation of services so that these will come to have a positive impact on the oral health of the population. In this way, all sections of the community can be as- sured of adequate oral care and, as prevention takes effect, the national finan- cial load can be eased. As no comprehensive study of oral health services in the European Region had been made at the time, the Regional Office for Europe in 19 74 invited all Member States of the Region to participate in a large-scale survey of patterns of the organization of oral health services as part of this Office '.s oral health programme. Countries indicating their willingness to do so were asked to sup- ply a short description of their oral health services based on a model outline, and Dr J. Kost/an was entrusted with the task of coordinating the presentation. For this he was particularly well qualified, having served as Regional Officer for Dental Health from 1963 to 1968, and in that capacity visited most of the countries in the Region to familiarize himself with the various difficul- ties the countries were experiencing in their attempts to provide adequate oral health service coverage and with the ways in which they were meeting the challenge. In 1975, after the replies were received from participating countries, it was decided to broaden the purview of the study, and Dr Kost/an was asked to make an analysis of oral health service development in the European Region based on the national responses and his own experience. Thus the present 7 publication took shape, with the country-by-<:ountry survey fo rming the core of a report introduced by a general review of the oral health services in Europe and concluding with a comprehensive examination and discussion of the key areas of growth or constraint. This is a thoughtful, and in many ways provocative, report. I commend it to the attention of governments and service organizers and planners; teachers of dentistry and oral health educators; dentists and dental auxiliaries; and the professional bodies representing these oral health workers. While the views put forward here may not find universal acceptance, I am sure that they will stimu- late healthy discussion and lead to new thinking about the conduct of contem- porary oral health services and the responsibilities and rewards of those pro- viding care. 8 LEO A. KAPRIO Regional Director INTRODUCTION At first sight, the oral health services in the WHO European Region show a bewildering degree of heterogeneity as individual countries iliffer from one another in their socioeconomic achievements, political institutions, and local trailitions; also, there are sometimes radically differing opinions within coun- tries between oral health service planners and organizers, teachers of dentistry , and officers of national dental associations regarding the main problems and appropriate solutions to these. The different approaches and points of view provide an insight into the pressures at work shaping national oral health serv- ices , and an overall pattern of European oral health care can be perceived . Countries that have achieved comparable levels of socioeconomic development encounter broadly similar constraints in the oral health services while those adopting similar political philosophies generally arrive at comparable solutions . In studying the development of oral health care systems two viewpoints are seen to be of special significance. The first is historical. Since the pace of socio- economic development varies considerably the different European countries have encountered many of the same problems connected with the provision of oral care for all members of the population, but at different times . For ex- ample , the highly industrialized nations mostly organized oral health service coverage some SO or more years ago , whereas the developing countries of the Region have only recently set about this task. Recognition of this time element simplified analysis of the oral health service systems since it became clear that these vary more in their timing than in their ultimate structure. The second important viewpoint is the continuing development of the oral health services. The thrust behind the evolutionary trend appears to derive from efforts to adjust service systems more closely to community needs. This is most apparent in service systems where an important share of the responsi- bility for the service concept could be attributed to the community as a whole. The development process has led to a certain amount of overlapping of serv- ices, while the question of making the oral health services available to the en- tire population has not been fully resolved by all the European countries. An- other problem area is how to raise the output and quality of the existing serv- ices and how to establish a rational basis for management. Working output has to be raised because populations are growing in size and the demand for oral care is increasing rapidly , and quality has to be improved because the 9 attitudes of service users towards oral care are changing from relative indiffer- ence to a lively concern for both the health and cosmetic aspects of such care. The oral health services have responded by stressing preventive measures, oral health education, and the importance of regular, comprehensive care for all members of the community, but with priority given to certain population groups such as school-age children. In addition to all this, according to the emerging philosophy of oral care the oral health care system must be founded securely on well established facts, agreed purpose, and economy of effort. This underlines the necessity of making appropriate scientific studies, of understanding the functioning of the oral health service system, and of evaluating the results obtained. Management has been developing appropriate working methodology and emphasizing the need to produce well-trained oral health service organizers before new tasks are undertaken, and progressive service organizers are engaged in studying people's attitudes and aspirations, conducting operations research, and investigating service economy. On the other hand, national dental associa- tions are striving for an acceptable interpretation of the professional status of their members in relation to current trends in oral care and the increasing use now being made of auxiliary personnel for this purpose. The development pro- cess in the oral health field will probably never come to an end; it will slowly transform the services, making them better organized, better adapted to people's needs, and more effectively administered . The dental profession will have to identify its proper role in this process , showing proper regard for the changes dictated by social pressures , helping towards the realization of stated goals, and finding on the way professional and economic satisfaction. The views expressed in this publication have the character of a working hypothesis based partly on facts and partly on personal opinion. In this res- pect the author shares the experience of every other student of the European oral health services : known facts have until now been scarce, discontinuous, and collected mostly under noncomparable conditions. Hence many gaps have had to be filled in by personal estimates and conjectures. It is hoped that recognition of the obvious deficiencies of this report will stimulate others to carry out detailed studies and undertake research where these are required . 10 AUTHOR'S ACKNOWLEDGEMENTS I take this opportunity to thank all the chief dental officers in ministries and departments of health of Member States , scientists working in the field of public oral health , and colleagues in the World Health Organization who assisted me in carrying out this study and in developing my ideas about the oral health services. I am particularly grateful to Dr Mario M. Chaves , Director of the W.K. Kellogg Foundation Programme for Latin America , Rio de Janeiro , Brazil, and WHO Consultant ; Professor Vladimir Rudko , formerly Chief Dental Officer, Dental Health , WHO , Geneva ; and Professor Geoffrey L. Slack , Profes- sor of Community Dental Health at the London Hospital Medical College Den- tal School, and WHO Consultant ; who offered much valuable advice and en- couragement during the course of the study. Professor Slack and Dr Per Bae rum, Director, Dental Health Service, Ministry of Social Affairs and Health, Norway , later reviewed the manuscript of this report , making many suggestions for amendments that I was happy to incorporate in the final draft. 11 NOTES ON TERMINOLOGY An attempt is made in this report to employ a terminology consistent with current usage; thus the terms "oral care", "oral health" , "oral health service", "public oral health service", etc ., are preferred to "dental care", "dental health", "dental health service" , "dental public health service", etc. , in recognition of modem views concerning the nature of the care provided. An exception is "school dental service", which is usually retained. "Dentist" is used here to mean a university-trained professional who treats patients and provides care and advice without supervision. However , many European countries do not generally employ this term, professional personnel being called " dental surgeons", "stomatologists", etc. In several countries " dentist" (i.e., dentisten) refers to a class of personnel licensed to treat patients without having received a university education ; this is indicated in the country- by-country descriptions . Such personnel , though still found practising, are no longer being produced or licensed in any European country _a Auxiliary personnel are classified into two main groups : operating auxil- iaries and non-operating auxiliaries. The operating auxiliaries , who work with patients under the supervision of a dentist, are "dental hygienists" and "dental therapists" (in preference to "dental nurse"). At the present time the latter category includes "New Zealand school dental nurses" , "British New Cross den- tal auxiliaries" , and "expanded function dental auxiliaries" , the last being em- ployed mostly in the USA . Non-operating auxiliaries are "chairside assistants" ( often called "dental assistants" , "dental receptionists" , or even "dental nurses" (especially in the USA)) and "dental technicians" (formerly "dental laboratory technicians"), who assist the professional by carrying out laboratory procedures mainly in connexion with the construction of prostheses .a All personnel staffing the oral health services or providing oral care, whether professionals or auxil- iaries , are termed "oral health personnel" or "oral health workers". The term "oral health services" in the title and text is given a broad inter- pretation to include all types of curative and preventive oral health services available to the population , through public efforts or otherwise , within the context of total health services. a For further details the reader is referred to the following account of dental personnel : Barmes, D.E. Dental personnel.In : Hall , T .L. & Mejia , A. , ed ., Health manpower planning: principles, methods, issues, part IV , chapter 9 . Geneva , World Health Organization (in press). 12 PART I ORAL HEALTH CARE IN EUROPE GENERAL REVIEW 1. THE PROBLEM OF THE ORAL HEALTH SERVICES Magnitude of the Problem Provision of adequate oral health services is a major problem in European countries. The magnitude of this problem can be estimated from the scope and coverage of services, the numbers of oral health personnel in each country, or the proportion of the national health service budget devoted to these services. As a rule, oral heal th services represent the largest segment of the ou tpa tien t health services in any country . In Czechoslovakia, for example , every third out- patient treated under the national health service is a dental patient. In Europe as a whole the number of dentists is about one-quarter of that of physicians, but in some parts of Europe the proportion of dentists is even higher. In the Nordic group of countriesa the ratio of dentists to physicians is around I : 2 and in one of these, Sweden , there are 70 den tis ts per 100 physicians (Fig. 1 ). A survey of child oral health in Europe made in 1970 by the WHO Regional Office for Europeb revealed that many countries were spending about I 0% of their total health service budgets on oral health services. Within Europe there is great cultural diversity , and each country tends to find solutions to its problems , including those of the health and oral health services, within its own national context. Moreover , the study of general prob- lems relating to the oral heal th services has tended to be neglected in Europe because profound changes in the organization of oral health services in Euro- pean countries during the past 100 years left dentists and dental professional a Denmark , Finland, Iceland, Norway, and Sweden. b WHO Regional Office for Europe. Survey on child dental health in Europe: Report on a study . Copenhagen, 1974 (EURO 5501 ). 13 - "'" FIG. 1. DISTRIBUTION OF HEAL TH MANPOWER IN DIFFERENT HEALTH SERVICE BRANCHES IN THE EUROPEAN REGION IN 19658 EUROPE NORDIC SWEDEN COUNTRIES 150 C ~ 114 0 110 110 ·;; -- "' ::, a. 100 0 a. 0 0 78 0 0 ... 0 .. ~ 60 . . . . ... . . Q) . . . a. .. . . ... 50 . . ~f' . . Q) . . ..0 .. E . . 30 .... ::, II ~1 z 13 9 6 ·.·.·1 8 5 .... . . ' .. OL I L•,•,t I I .... .. ' . D ~ . t'ZZI -All physicians Dentists Paediatricians, Psychiatrists, gynaecologists neurologists a "Europe" includes all the 32 Member States of the WHO European Region. The numbers of dentists are related, on the one hand, to all physicians and, on the other hand, to maternal and child health services personnel and mental health services personnel. organizations with diminished interest in analysing and generalizing their expe- rience and in creating a sound theoretical basis for an oral health service. In the USA, on the other hand, the oral health service system and its delivery have been relatively stable, and this has facilitated the study and development of a theoretical foundation for oral health care . However, in Europe much experi- ence was accumulated with oral health service systems that provided the popu- lation with good access to oral care . This experience is increasing also in respect of service systems run by state health administrations , which have accepted the long-term goal of establishing a comprehensive oral health service for the whole community. This experience could be helpful for other parts of the world. Nature of the Problem The problem of providing a satisfactory oral health service can be broken down into three major areas: {l) biological factors (in the broad sense) that give rise to a need for oral care; (2) attitudes of users and personnel of oral health services towards oral diseases and the provision of oral care ; (3) managerial factors influencing the concept and functioning of the oral health service . Biological factors The biological factors that affect the size and character of the oral health service are the oral diseases. These influence the service by their prevalence (the proportion of individuals in whom the disease occurs) and their severity (the extent of the disease or the average number of diseased teeth per individual). The typical outpatient oral health service is concerned primarily with diseases of the teeth and supporting dental structures - dental caries, periodontal dis- ease, and the so-called orthodontic anomalies . Dental caries has spread in the European countries in pandemic frequency. In the more affluent European countries the prevalence of dental caries ap- proaches 100%, and individuals free from dental caries until an adult age are extremely rare . In the southern parts of the European Region there is probably a lower prevalence of caries. The severity of caries seems to be highest in the Scandinavian countries , lower in central Europe, and considerably lower in southern Europe (see Tables I and 2). The origin and spread of dental caries is connected with the nutritional habits of the individual, in particular with the consumption of sucrose , the trend of which in Europe is rising. Governments of European countries do not control the consumption of this food by, for example, regulating prices. As a consequence, the present trends in sugar consumption and dental caries will probably continue . 15 TABLE 1 PERCENTAGE OF CHILDREN WITH EXPERIENCE OF DENTAL CARIE!f Denmark Finland Country Germany, Federal Republic of Malta Norway Spain Sweden Turkey Age (years)b 5 12 95 100 74 99 67.9 90.6 60 41 93.4 99.7 73 88 99.3 45 a From: WHO Regional Office for Europe. Survey on child dental health in Europe: Report on a study. Copen- hagen, 1974 (EURO 5501). b Deciduous teeth at 5 years, permanent teeth at 12 years. Periodontal disease (or destructive periodontitis) is a chronic inflammation of the tissues around the tooth_ The prevalence and severity of this disease are greatest in middle and old age, but actual prevalence of this disease in the Euro- pean Region is not known precisely . Periodontal disease will have a significant bearing on the future dimensions of the oral health services because a great deal of the demand for treatment associated with this disease is at present latent in the population but will become apparent in the future. The so-called orthodontic anomalies are deviations from the normal posi- tion and alignment of teeth in the jaws. Although their prevalence in the popu- lation varies it appears that some 20 - 30% of children need an orthodontic correction; perhaps 10% of these children are now receiving treatment. A rise in the volume of the dental treatment demanded can therefore be expected in this field also. Attitudes of service users and personnel The weight of the biological fac tors in relation to the provision of oral health services depends decisively on patterns of behaviour. As already pointed out, there is close correlation between dental caries and high levels of sucrose consumption. Dental caries can to a great extent be prevented if communities agree to the fluoridation of water supplies. Regular tooth cleaning is important in the treatment and prevention of periodontal disease. Thus , certain kinds of behaviour either support or limit the influence of pathogenic factors . 16 TABLE 2 AVERAGE NUMBER OF DECAYED, MISSING, OR FILLED TEETH PER CHILD AT AGES 5 AND 12 YEARs-1 Country Age (years) 5 12 Czechoslovakia 5.2 5.5 Denmark 7 10 Finland 8 11 Germany, Federal Republic of 2.9 4.3 Malta 2.1 2.3 Netherlands 7 .1 8.9 Norway 10.1 Spain 2.5 2.2 Turkey 1.6 a From : WHO Regional Office for Europe. Survey on child dental health in Europe : Report on a study . Copen- hagen, 1974 (EURO 5501) . People's attitudes towards oral health and the oral health services have not been studied enough , but since these are of paramount importance for the de- velopment and character of the service systems such research should be en- couraged and given as much support as possible. Distinct changes in population attitudes towards oral disease treatment and prevention occurred in European countries during the last century as a result of socioeconomic development. When comparing the character of the oral health services found in Europe to- day with that of services existing 50 years ago (or existing now in the develop- ing countries of the world) , the following general conclusions are reached. Motivation in favour of a useful change in attitudes seems to depend on living standards and on educational status . With a rising standard of living opinions change about the importance of oral health for general wellbeing and comfort. Many organizers of health services do not appreciate this fact and are surprised that in developed countries with a high standard of living the oral health service often increases in volume faster than the other components of the health service. We return to this problem later. The first stage in the development of these attitudes is reflected by the developing countries . Here, the dental diseases and their sequellae have no prominent place in the life of the population. If dental disease complicates daily life , the diseased tooth is simply extracted. This attitude changes when the living standards rise . Aesthetic or cosmetic considerations are emphasized, and people begin to look for restorative and prosthetic services . This attitude prevails at the present time in all the developed European countries . 17 The third , and most advanced, step in the development of people 's atti- tudes is characterized by the fact that they come to understand how oral dis- eases develop and change their behaviour in order to prevent them . This third stage is probably spreading slowly , but steadily, in Europe . From it there will grow a pressure to transform the character of the oral health services. Biological factors give rise to an objective need for dental treatment in the population ; the factors connected with behaviour and its motivation create a demand for dental treatment. The relationship between need and demand for treatment is demonstrated in Fig. 2. In the first stage of the flow of patients from the population to the oral health service and back to the population, the need for dental treatment is limited by primary prevention. The need remains latent if the patient is not aware of it or disregards it , and is converted into a demand for treatment under the influence of motivation in favour of treat- ment. If motivation is weak conversion is slow and the store of latent demand increases. The curative service drains the reservoir of demand for treatment. Prompt treatment supports motivation and enhances the conversion of need in- to demand. The category of demand for treatment has a dynamic character. If the demand for treatment present in the population is not satisfied it intensifies the social pressure on the administration for expansion of the oral health serv- ices. If an official oral health service is not able to satisfy the demand for treatment different forms of illegal or unauthorized service may develop. An easily accessible and efficient oral health service supports the demand for den- tal treatment , whereas an inefficient service or a service that is hard to obtain limits conversion of the need for service to demand. In all of the European countries there is still a great reservoir of need for treatment not yet converted into an active demand for treatment. This con- cerns treatment of dental caries to some extent but mainly periodontal treat- ment and replacement of lost teeth . The degree to which the volume of cura- tive service provided can be expanded does not , however , depend directly on the living standards of the population ; it is limited by several factors. Under the influence of these factors the total demand for the services in the population might increase faster than the capacity of the service to satisfy the demand. Managers of oral health services in the European countries will have to find organizational means to compensate for this. Managerial factors In general , managerial factors influence decision-making in the health and oral health administration . 1l1ey can be classified as follows. (a) Conceptual factors related to questions such as the overall character of the oral health service, its connexion with the general health service , and the way it is satisfying the expectations of the population and the dental profes- sion . The oral health service concept is deeply influenced by the social and economical development of the country and by its political climate . (b) Operational factors bearing on oral health service delivery , operation , and organization. These factors influence the volume , quality , and efficiency of 18 PREVENTION '-0 FIG . 2 . NEED OF AND DEMAND FOR ORAL TREATMENT IN A SYSTEM OF THE ORAL HEALTH SERVICE NEED FOR ORAL TREATMENT POPULATION MOTIVATION D'EMAND FOR ORAL TREATMENT the service. Oral health service managers may find it difficult to make substantial changes in the oral health service concept, but in the operational area there is wide opportunity to initiate change, perform scientific analyses, and so on. Problems in this area are, for example, the interrelationships of curative and preventive oral health services, selection of priorities for the curative service, and effective equipping and rational management of services to raise their productivity. (c) Methodological factors. Management of an oral health service is a scientific discipline, and its methodological basis is developing rather quickly. Managers have to keep abreast of developments and accumulate the informa- tion necessary for changing the concept of the oral health service and develop- ing the methodology for planning, evaluation, and coordination of the service. Every effort should be made to base decisions in this field on better and more precise information than was available in the past, as well as to avoid traditional ways of thinking about the oral health services. Managers should adopt experi- mental methods of working and assess the effects and interconnexions of in- dividual factors that have some bearing on delivery of the service. All suggested changes in the concept and organization of the service should be introduced experimentally in pilot areas and assessed in field laboratories before being applied on a broad scale. The organization of oral health services in many European countries is undergoing rapid change and managers will find it increasingly difficult to base their decisions on traditional ideas. Without adopting a scientific methodology they will not be able to keep pace with these developments. 2. OUTLINE OF ORAL HEALTH SERVICE DEVELOPMENT The Dental Profession In the seventeenth century treatment of dental disease was provided on the one hand by surgeons, and on the other hand by traditional healers. In the seventeenth and eighteenth centuries surgery developed considerably, be- coming a recognized heal th profession. The teaching of surgery was transferred to the universities , and the surgeon's professional skill was tested by an official qualifying examination. In a similar way, the first dentists developed within the surgical profession. In the second half of the nineteenth century the number of master surgeons with experience in dentistry increased, and more examining boards were established . This process was accelerated by the development of dental education. In the second half of the nineteenth century courses were organized in many countries to prepare new dentists for the qualifying examination . Later, vocational schools for dentists were set up, and out of these grew the modern university dental schools and faculties . 20 However, the position of the dentist within the health services and his rela- tion to the physician were not established in a unified way throughout all Europe, and different types of dentist with different educational backgrounds can still be recognized. This complex question is considered again in connexion with the education of dental personnel. It is only necessary here to point out that questions relating to the place of the dentist in the health service and his professional education and status were probably discussed in Europe mainly on the basis of tradition and not of a functional analysis of the attitudes of the population towards the dental profession or the concept of integrated health care. Discussion of the problems involved was intense and there were dramatic changes in the composition of the dental manpower in the 1920s. This past experience suggests that the optimal professional profile of the dentist, the division of functions between the dentists and the dental auxiliary personnel, and the organization of the oral care team should be analysed in Europe from a functional point of view, and that it would be worthwhile verifying the con- sequences these changes are likely to have on the functioning and professional satisfaction of dentists. The Oral Health Services In the second half of the nineteenth century oral health services in Europe corresponded in their organization most nearly to present-day private practice . Since that time the organization of the oral health services has undergone sig- nificant changes in order to adapt to the growing demand for dental treatment as well as to facilitiate access of all the population to oral care. Both of these requirements gave rise, around 1880, to dental health insurance schemes . Dental health insurance These schemes first began to develop in central Europe - in the former Austria-Hungary and Germany - before and after the First World War. Between the two world wars dental health insurance systems developed in Czechoslovakia, Hungary, Poland , Romania , and Yugoslavia . During and since the Second World War such insurance spread to Belgium, Denmark , France , and the Nether- lands, and to some extent also to Greece, Italy , and Spain . Dental health insurance is a form of private insurance , being financed by contributions paid by the insured persons . At first , insurance was limited to workers only, and only persons directly insured were covered. Financial bene- fits were small , covering just an occasional inspection of the mouth and neces- sary extractions without anaesthesia. However , insurance benefits spread step by step along three different lines. First , insurance involved, successively , all categories of workers, administrative employees in both the private and the public sectors, and finally all employed persons . Secondly , benefits were offered also to the families and dependants of insured persons . Thirdly, the categories of oral care covered by these benefits were expanded to include all surgical 21 treatment and basic restorative treatment (and in some countries also certain orthodontic treatments), and , finally, at least a partial contribution was made towards the expense of prosthetic dental treatment. There are still considerable differences among European countries in the extent of benefits offered by dental health insurance organizations to their members, in the proportion of the total population covered by insurance, and in the proportion of dentists participating in insurance schemes. On the whole , however, there has been the same trend in all countries to expand the insurance and to develop a national system covering curative oral care for the whole population with the cooperation of all the dentists . Dentists at first strongly opposed dental health insurance, being afraid that it would limit the privileges of their free profession; that it would expose them to the direction and control of other dentists , or even of administrative em- ployees of the insurance companies; that the load of administrative work would increase; that their income would be limited ; and that insurance would not favour intricate curative interventions and that the quality of dental treatment would fall. These anxieties proved to be partly justified . However , there were also certain advantages in the system. A dentist working for dental health in- surance was reasonably sure of his basic income, while the growing interest of the population in receiving oral care and the rising level of community oral health contributed to the professional satisfaction of many dentists . Finally, along with generally rising living standards, contributions paid to insurance companies rose and dentists' incomes improved. At the present time the fees paid by dental insurance to dentists are satis- factory in most European countries and dentists are generally accepting this system of service without protest. Public oral health services The first rudiments of a public oral health service in Europe closely fol- lowed the start of the dental health insurance . Dentists attempted to arouse the interest of community administrators in the problem, and they succeeded, step-by-step, in obtaining support from the public budget or from charity funds for establishing public dental ambulatories, made available in the first place to schoolchildren. The first ambulatoria of this type came into being at the end of the nineteenth century and the beginning of the twentieth century in Strasbourg, Zurich , and other places. Up to the end of the First World War these developments continued com- paratively slowly, but after the war this type of oral care was extended in a number of European countries to include pregnant women and nursing mothers and , sometimes, even indigent persons . The theory and practice of incremental, comprehensive oral care for schoolchildren developed in Germany while the USSR established the first national oral health service based on public oral health care . In the post-war period, development of public oral health care continued in Austria, Czechoslovakia, Germany , Switzerland, and elsewhere, spreading also in the Scandinavian countries. After the Second World War, in the 1950s, systems similar to that provided in the USSR were established in the eastern 22 European socialist countries. In other countries also - the United Kingdom, for example - national oral health service systems were set up with goals similar to those of a public oral health service (although the organization of these service systems differed in certain respects from that). Shaping the three basic types of oral health service outlined above has not exhausted the possibilities for the development of oral health services; this is continuing. Unlimited private dental practice is becoming more and more res- tricted, while dental health insurance, at least in the countries where it has the longest history, seems to be approaching the limits of its developmental poten- tial and new types of dental health insurance are appearing that are closer to the public oral health service in character. In all oral health service systems the concept broadens along with a trend to cover the whole population; manage- ment becomes stronger, and the organization more purposeful. The change of emphasis towards prevention of oral disease becomes clearer. In most European countries national systems of oral care comprise three components: private, public, and transitional, usually represented by dental health insurance. Part II of this report, comprising brief descriptions of the oral health services in individual European countries, shows which systems are operating in the various countries. Part III deals with the characteristics of the different service components and with some major problems of existing oral heal th services. 3. DEVELOPMENTAL TRENDS IN THE ORAL HEALTH SERVICES General Every oral health care system is based on a concept that is published or whose character has to be deduced from the organization of the system, the services the system provides, the satisfaction offered to both the population and oral health personnel, and generally speaking, the developmental trends that appear within the system. Several influences act on the functional concept of each system (see, for example, Fig. 3), the fundamental influence being the wish of the population to receive oral care and treatment for the dental condi- tions that disturb normal life. The need for oral care stems from an objectively ascertainable disturbance of oral health, and the external manifestation of this need is a subjective interest in, or demand for, care. This basic desire of the population for oral care is shaped on the one hand by the dental profession and its ideas about the organization and aims of an oral health service, and on the other hand by political institutions, which strive for implementation of their policies in the health field. The value attached by the population to oral health and their ideas con- cerning the basic ways in which curative or preventive care should be presented 23 depend largely on the level of social and economic development of the com- munity. In the first stage of this development patients favour quick and radical treatment, and diseased teeth are mostly extracted. At a later stage of develop- ment the patient starts to care for the preservation of his teeth for the sake of both satisfactory mastication and a good appearance, and is then willing to undergo the inconvenience of dental treatment. In the most advanced develop- mental stage dental disease is not tolerated and people accept the limitations of a preventive regime (limiting sugar consumption, etc.) and the discipline connected with the application of preventive measures. The population seldom expresses its attitude towards oral health and oral health services directly. The established political institutions in the country interpret the attitudes of the population, translating these attitudes into polit- ical options and expressing these through their own political programmes and plans. Such plans are influenced not only by the wishes of the population but also by the aspirations of different interested groups, etc. Then , the views of dentists and other categories of oral health personnel de- livering the oral health services are expressed through their professional organiza- tions. Dental professional organizations have a strong interest in the concept of the oral health services since this is connected with economic aspirations of dentists and their efforts to ensu re a satisfactory life style, with the professional and social status of dentists, and finally with the ideas of the dental profession about the desirable organization and quality of the oral health services. Fig. 3 is a schematic representation of an oral health service and its links within the community. The health service proper is characterized by four basic parameters: the task , the resources mix, the organization, and the output. The output should balance the task and organization should optimize the use of re- sources. The system depends on inputs of requirements , information , and resources. The requirements are determined by the concept of the service (top) and influence mainly the organization . The information input relates, on the one hand, to the task of the service and arises from the need for an oral heal th service (left) and, on the other hand, to the output of the service (bottom), yielding feedback through service evaluation. The resources mix comes from the resource basis (right) and includes human , material , and technological inputs. The concept of the service stems from the population's expectations relating to oral health, which are determined by the country's level of socioeconomic development. The political institutions incorporate these aspirations into their political programmes and the state administration translates the accepted pro- grammes into the concept of the health and oral health services . Professional health organizations bear, on the one hand, on the state administration and, on the other hand , directly on the providers of the service. The organization of the service is based on a set of principles derived from the service concept. The task of the service arises from the need for an oral health service. A part of the need for service (that of the priority groups of the population) is satisfied directly, whereas the rest is satisfied only after it has converted into demand for service (see Fig. 2, p. 19). Both components join in the delivery plan, which has to correspond to the resources and organization of the services. The resources mix comes from the resource basis, which depends on the avail- ability of financial support, the production of oral health manpower , the 24 N V, FIG . 3. THE ORAL HEALTH SERVICE SYSTEM AND ITS NATIONAL AND COMMUNITY SETTING Delivery plan Organizational / methodological principles Organization X E ~ ral health ~ . service ... Output ~ CI: I I Evaluation Resource plan Socioeconomic potential Resource basis availability of material resources (equipment, drugs, etc.), and the level of avail- able technology. The service's output is evaluated and there is feedback to the delivery and resource plans as well as to the principles underlying the organization of the service. Private Dental Practice The changing role of private practice Under the private dental practice system a dentist treats a selected number of individual patients and the patients pay him a full fee for the treatment. This was the character of private dental practice at the beginning of this cen- tury. Since that time the volume of this service has been reduced and its char- acter influenced, on the one hand, directly by the public health administra- tion and, on the other hand, indirectly by the other types of service with which it coexists within the national oral health service system. Unrestricted private dental practice in the original sense of the tenn pre- vails at the present time only in some countries around the Mediterranean, but it may be supposed that this oral care service system will be remodelled in the future. When industrialization in these countries is more advanced and the number of employed persons higher, conditions will be ripe for the introduc- tion of dental health insurance. As financial resources available for the health service increase and the number of dentists rises, it will be possible to establish a public oral care service, and through it at least an emergency oral care service for the whole population. With further development, this type of service can slowly change into a restorative and prosthetic service, which will then expand to make oral care easily accessible to all members of the community. In several northern European countries - Iceland, Norway, and Switzer- land, for example - private dental practice has continued as the main system of oral care for the adult population, and until recently this was true also of Finland and Sweden. The populations of the Nordic group of countries and Switzerland have been well satisfied with private dental practice, probably be- cause in these countries the technical quality of dental treatment has always been high and probably also because the number of dentists in these countries increased relatively quickly and the gap between the demand for service and the service available never widened to such an ex tent that reorganization of the national oral health service system became necessary. The demand for oral care was more easily satisfied also because the national administrations of these countries showed at all administrative levels a sense of responsibility towards the health of individuals. As a consequence, public health service systems were built up in these countries at a comparably early stage, which helped to solve the social problems relating to the oral health service , at least as far as the treat- ment of children is concerned . At the present time, however , pressure towards a change in the existing system seems to be increasing. Finland and Sweden have changed their national 26 oral health service systems. A possible change is under discussion in Norway, and in Switzerland a referendum on the introduction of dental health insurance took place in 1975 (this change was rejected). In the Scandinavian countries and in Switzerland the trend to limit private dental practice is likely to continue and, in addition to this type of service or in its place , services will be intro- duced th_at can more easily be directed and offer greater satisfaction of people's needs . In the remaining European countries private dental practice is comple- mentary to another prevailing service system. In most western European coun- tries dental health insurance does not cover the complete spectrum of care that the population needs, and patients have to pay for certain interventions, in particular for those involving fixed prosthetics. In eastern Europe private prac- tice represents an alternative solution to the problem of oral care for certain groups of employees because this can more easily provide for the requirements of individual patients in relation to time or type of treatment or to cosmetic aspects that a national public oral health service system cannot in all cases take into account. Private dental practice of the original kind has been phased out in Bulgaria and Romania. Concept of a free profession In its original form, private dental practice corresponds to a liberal eco- nomic and political concept, having the nature of a free profession. This means that the dentist treats each case in the best interests of the patient and follows scientific principles as well as the rules of professional ethics that are controlled by special dental bodies. The country's administration sees to it that the dentist observes the legal regulations and the health administration sees to it that the practice is conducted in accordance with the general rules of hygiene, etc. However, in other respects the community does not intervene in the practice of a free profession . A private dental practitioner is not employed by anybody ; his diagnosis and treatment are based on his professional education and skills. The number of patients the dentist treats and their selection depend on his working capacity, economic aspirations, and working preferences . He selects the locality where he will settle, having regard to his personal tastes, the com- fort of his family , and the availability of good education for his children. He also expects that his practice will lead to professional satisfaction and pride based on the quality of his work and his independent professional position. This motivation is easily understood, especially as the dental schools providing professional education encourage the professional outlook just described. This concept of an oral health service is often at variance with that of modern oral health service systems. Modern service concepts are founded as firmly as possible on the consumer's point of view in order to satisfy the aspira- tions of large population groups, or the whole population, and also on the requirements for a smoothly functioning service system. These principles are observed even if the privileges of a free dental profession have to be limited . The introduction of these limitations, the struggle of professional dental organ- izations against them, and the final adaptation of dentists to their existence represent the basic professional experience of European dentists. 27 Private dental practitioners do not, of course, constitute a homogeneous group. In particular, some of the younger, dynamic members of the profession , who are confident of their abilities and are not afraid of competitive private practice but willingly accept the challenge of technical difficulties in their work, are advocates of a free dental profession. These often influence the atti- tude of the professional organizations but fail to understand that the com- munity regulates the geographical distribution of dentists in order to provide for the needs of the whole population, rural as well as urban, that it favours economical working methods and the use of dental auxiliary personnel to satis- fy the total demand for oral care, and that it supports basic restorative care for patients to save the natural teeth and avoid their extraction. On the other hand, private practice generally offers satisfactory conditions for work of good tech- nical quality and responds promptly to patients' wishes concerning the timing and cosmetic aspects of treatment and usually satisfies the dentist's profes- sional aspirations. Selection of the clientele In Europe a private dental practitioner usually treats between 800 and 1800 patients a year. The better his practice and the higher the quality of his work, the smaller, as a rule, the number of patients, and in a first class dental practice it can fall as low as 400 new patients a year or even less. The smaller the number, the more expensive the treatment is likely to be. This is acceptable because the patients are generally well off and because the cases handled in this type of practice are usually considered to be difficult and the technical quality of the treatment is high. This approach to patient selection means, of course, that the clientele of a first class private dental practitioner becomes successively limited and more exclusive. A government that is not willing to intervene but wishes nevertheless to satisfy the demands of the population for oral care has then only one way open - namely, to support the universities in raising the output of new dentists. This, however, is only a partial remedy. A private dental practitioner is not opposed to prevention, treatment of children, or to simple repetitive interventions in restorative dentistry. However, the tariff scales used in most countries make curative oral care, treatment of adult patients, and prosthetic treatment economically more advantageous. Thus, economic considerations may slow down the development of a true pre- ventive oral health service. There are both advantages and drawbacks to private dental practice in rela- tion to existing oral health service systems. These are associated with the con- cept of a free dental profession and are discussed above. A further disadvantage is that it is difficult to direct private dental practice. It is sensitive to directing interventions of the national health administration and it may be difficult to introduce in this system modern working methods such as teamwork and the regular, comprehensive treatment of children . For these reasons, evidently, in a number of national oral health service systems the role of private practice has been limited and new types of oral health service developed that do not correspond fully, or not at all , to the con- cept of a free oral healtl1 profession but ensure greater satisfaction of the 28 majority of patients ' needs and easier operation and control of oral health serv- ice development by the health administration. Dental Health Insurance The changing role of the dentist t Dental health insurance represents only a modification of private dental practice, but it is a modifica.on of such great significance that here it is inter- preted as a separate oral health service system. The dentist working for dental health insurance continues as a private practitioner, owning his own surgery , buying the instruments, drugs, and materials needed for treatment, hiring den- tal auxiliary personnel and organizing work schedules; he also selects the local- ity where he establishes his practice . Thus, many features of the free dental profession are preserved. Other features, however, are changed . At the present time two variants of dental health insurance exist in Europe . One is of the classical kind of insurance that started in Europe around 100 years ago. This was private , but compulsory, insurance guaranteeing that each person could meet the costs of dental treatment. It also diminished the health ex- penses of insured persons because employers covered part of the insurance con tri bu tions. In most European countries employers and employees participate equally in these contributions. Part of the cost of providing the health service therefore shifts to the more affluent section of the population. However, the state health administration usually does not become further involved in the development of the insurance system. Its organization , the benefits offered to the insured per- sons, and the extent of the treatment covered by insurance , as well as dentists' fees, are settled in discussions with the political parties or representatives of the population and the insurance institutions, or in discussions between the insur- ance institutions and the dental professional organizations. The government supervises these discussions and the insurance regulations adopted have legal status, but in most other respects the modelling of the health insurance is left to be decided by political pressures , the economic situation of the country, and the wishes of interested groups. The health insurance that arose in central Europe and spread to Denmark, France , Greece, Italy , the Netherlands, Spain , and Turkey was of this kind . Another variant of health insurance arose in Denmark and Sweden . In Denmark there was a transformation of the previous system of private health insurance, whereas in Sweden a new type of national oral heal th service system was introduced that substantially modified the conditions for dental treatment, as well as for the work of the den tis ts. These variants differ from the classical form of dental health insurance only slightly in respect of their financing , which in the Danish and Swedish systems is provided from the public budget. In practice , however , the difference is fundamental because through the financing the government obtains control over the ways in which the service 29 system operates, and can thus direct the work of the dental health insurance sys- tem. By changing the financial benefits for patients and the fees per item of service for the dentist, it may be possible to influence both patients' and den- tists' behaviour towards a preference for interventions of a preventive nature in addition to regular and complete dental treatment. In this way a new trend is injected into dental health insurance that was missing in the classical dental health insurance, and the state health administration is able to steer the develop- ment of the insurance system in a direction to meet the needs and wishes of the population. In this sense, this variant of dental health insurance represents a new type of service standing midway between the original dental health in- surance and the public oral health service. The general dental health service in the United Kingdom is also of this nature. It is not based on dental health insurance but represents a national oral health system accessible to every citizen, and patients enjoy substantial financial support for the expenses of dental treatment. Dentists remain private practitioners, owning their private dental surgeries and employing dental auxil- iary personnel, but they work under contract to the local administrations and are paid set fees for each item of service. This resembles the way in which den- tal health insurance pays dentists. However, the finance for these fees is pro- vided by the Department of Health and Social Security from the country's budget. The United Kingdom general dental service is, therefore, not identical with either dental health insurance or a public oral health service; it belongs to the group of national oral health service systems that serve the whole popu- lation and whose development is directed to correspond at all times to the eco- nomic status of the country and the needs of the population. The output of this system is currently being evaluated and improved by increasing coordina- tion with other components of the national health service. Support for simple restorative oral care Dental health insurance offers a basic oral health service to the contribu- tors. This service includes fillings, treatment of the dental pulp and tooth root, periodontal treatment , and usually certain orthodontic treatment and simple prosthetic treatment - mostly provision of simple, removable dentures. For dental health insurance treatment must be correctly indicated and charged. Treatment proposals are then checked and approved. Without receiving pre- vious approval, the dentist may perform only basic curative procedures. Dental health insurance pays a fee for every item of service according to a tariff that is usually settled in discussions between the dental health insurance companies and the dental professional organizations. This tariff gives preference to cura- tive procedures that correspond to the concept of dental health insurance and in this way influences the working preferences of the dentist. The dentist can, of course, recommend to the patient a construction considered to be of higher quality than that covered by the dental health insurance , an inlay rather than an ordinary filling , or a bridge rather than a removable denture, for instance, but in most dental health insurance systems these procedures have to be paid for directly by the patients, in part or in full. Many patients , however, prefer the simpler treatment and working for dental health insurance is , therefore , 30 not as rewarding financially for the dentist as private practice in the full sense. The dentist can compensate for this disadvantage by accepting a larger number of patients. In this way dental health insurance influences the motivation of both patient and dentist and directs the dentist towards performing more procedures of a restorative nature. The dentist's clientele expands and the trend towards develop- ing an exclusive practice for well-off patients is blocked. After all, with generally rising living standards contributions to dental health insurance as well as den- tists' fees increase. Dentists also become used to administrative control of their work when the dental health insurance companies improve their administative arrangements and reduce the dentist's administrative workload . Merits and drawbacks of dental health insurance Many older dentists , finding private practice too competitive, appreciate also the fact that broadly based dental health insurance in the population stim- ulates patients' interest in oral care, contributing to the stabilization of the dentist's income and the achievement of a calm and relaxed working environ- ment. Finally, many dentists feel that inexpensive procedures when well per- formed do not lower the quality of treatment. Some insurance companies have their own ambulatoria where general dental practitioners work together with certain specialists and with dental auxiliary personnel. The auxiliary personnel sometimes take responsibility for part of the treatment that was previously reserved for dentists. For many dentists this is their first experience of team- work, which the physician obtains during hospital practice. Dental health insurance has become an effective and stable system for oral care, and has spread rather widely , demonstrating its political acceptability. At the present time national dental associations in countries with a long history of dental health insurance, such as the Federal Republic of Germany, would probably protest if benefits offered to the patients were substantially reduced and the interest of the population in dental treatment fell. Dental health insurance has considerable advantages also from the point of view of national health administrations. It is not financed from the public budget and it does not, therefore , increase direct governmental expenditure or the volume of public administration. Finally, insurance changes the dentist's sty le of work to accord with the wishes of the population without using any more direct administrative pressure than regulating his income. On the other hand, dental health insurance has certain drawbacks that are felt, in particular , in advanced stages of the development of heal th and oral heal th service systems. (a) Dental health insurance has, since it began , organized a basic oral health service and opposed more complex and expensive curative procedures. Consequently, it was interested in the first place in cooperation with general dental practitioners and limited the use of dental specialists . Therefore, it did not support specialization in dentistry and has restricted the differentiation of oral health services and the treatment of complex cases. (b) The basic goal of dental health insurance was satisfaction of the de- mand for treatment by the bulk of the population and the insurance therefore 31 covered only insured persons needing treatment. Regular and comprehensive treatment of children was not included in the insurance cover. (c) Dental health insurance gave only little support, orno support at all, for primary prevention and oral health education. This is connected with the mecha- nisms used to check the treatment performed and for accounting of fees . Accord- ing to the reasoning of the insurance companies, only that part of dental treat- ment can be paid for that is of demonstrable quality . For that reason companies often hesitate to pay for interventions such as removal of dental calculus, which may be claimed for in spite of incomplete removal ; or training the patient in ef- fective tooth cleaning, which improves the patient's behaviour but may not elicit an immediate demonstrable change in the condition of the patient 's teeth ; or topical applications of fluoride - these limit the susceptibility of teeth to dental caries but it is difficult to prove by any immediate test that the treatment was given and was adequate . Dental health insurance systems experience difficulty in avoiding these draw- backs without outside pressure. The development of the oral health service , of course, continues , even after the introduction of dental health insurance. Dental health insurance expands, and the most advanced insurance systems cover prac- tically the whole population , have almost all the dentists in the country under contract , and offer the population complete dental treatment including fixed prostheses. This is the situation now prevailing in the Federal Republic of Germany. Dental health insurance follows this trend in all countries but , of course , proceeds at different speeds . In countries having the longest history of such insurance it now seems to be approaching the limits of its developmental potential . When the limits are reached further development will be restricted and it is probable that changes in the concept of dental heal th insurance , similar to those that have occurred in Denmark and in Sweden, will be made. Private insurance contributions will be replaced by support from the public budget. The tariff of fees for dentists and the benefits paid to patients will be changed in order to promote prevention and the regular, comprehensive treatment of priority population groups . The next step in the development of dental health insurance may , therefore, bring it close to a public oral health service . Public Oral Health Services° Aims of the public oral health services and dentists' attitudes The goal of dental health insurance is to remove th e financial obstacles to oral care for the whole population ; that of a public oral health service is the a A WHO Ex pert Committee repor t on planning and evaluation of public dental health services (WHO Technical Report Series, No. 589, 1976) defines public dental health services as , " . .. educative, preventive, or therapeutic services that are organized, administered , or financed by government organizations or community groups to prom ote , maintain , and improve the oral health sta tus of groups of individuals or communities". 32 attainment of higher levels of oral health. The target groups of public oral health programmes are determined by age (schoolchildren, for example) or health status (pregnant women, nursing mothers , the physically or mentally handi- capped), and all members of the target groups are equally eligible for services provided by the public oral health programme. The public health dentist therefore cannot exercise his own judgement in providing treatment or base his efforts on his working capacity, limiting his task by treating only a section of the target groups. Often he is responsible for treating a group of patients , the size of which he did not decide himself, and in spite of that has to meet his obligations to provide oral care, and he must therefore modify his working methods and find an app roach that will enable him to do this. He will soon realize that his work will be more effective when planned and more efficient when preventive measures are adopted and dental auxiliary personnel used. Since he is using public funds , he is obliged to prove through evaluation of the public oral health service that his expenditures are necessary and his working methods efficient. The goals , the nature of the responsibilities , and the working methods of a public oral health service produce den tis ts a long way from the type of dentist with whom the dental health services began. The system within which the dentist works dissociates him from local traditions and calls for his careful evaluation of the professional policy of the national dental organiza- tion. The oral health service dentist will give much thought to his function, and he will become interested in the rational management of oral health care. Variants of public oral health services There are three variants of public oral health services in Europe at the present time . The first is represented by the oral health service system estab- lished in the USSR and in the eastern European socialist countries . It is based on a state-organized service financed from the state budget , and its develop- ment is planned within the state-wide economic plans. Basic management is in the hands of health ministries. Services opera te in coopera tion with regional , district , and local heal th administrations. Eastern Europe health service systems are based on the principle that every citizen has a right to health and to health care . The oral health service is an integral part of the general health service, which , in principle, is free of charge and is delivered in public health centres where both basic and special health services are available. In connexion with the planned development of the service, a unified sys- tem for undergraduate and postgraduate education of all health personnel has been established. These personnel are employed by the state health service and receive fixed salaries. Much effort is made to achieve a balanced development of the system in relation to population growth and economic development of the country. The unified management ensures the availability of care of com- parable quality service areas. Regular and comprehensive services for priority population groups (mainly children) differ in size in the individual countries , depending on the economic situation and population density . Considerable emphasis is placed on prevention. Finland also is planning to establish in the near future a public oral health service as its national system. Basic legislation related to this role was adopted 33 and the service system will be built up step by step through the national 5-year plans. Oral care will be transferred from private surgeries to public oral health centres , and the long-term goal is to include the whole population within a comprehensive oral care service . First, an oral care service will be organized for children and adolescents, and successively higher age groups will be included. In the meantime, before the service system reaches its final form, most of the adult population will be treated by private dentists under the control, and with the financial support, of the state administration. The Finnish oral health serv- ice system strongly emphasizes prevention based on an extensive plan for water fluoridation throughout the country . In Norway and Sweden, which have both large territories and an uneven population density, the public oral health service took over the task of com- pensating for an insufficient number of private dentists , especially in the northern half of each country. The goal of this oral health service system was the prefer- ential , regular , and comprehensive treatment of schoolchildren, but for a lower cost it treats also preschool children and adolescents and accepts adult patients, who pay the full fee for treatment according to a tariff that is lower than that in private practice. Dentists employed in these service systems spend more than one half of their working time in treating schoolchildren, but part of their time is made available for other age groups , as described . These systems ensure good working conditions for dentists and treatment of good technical quality. Public oral health service systems in the remaining Scandinavian countries stemmed from a concept of priority oral care for schoolchildren. In Denmark and Iceland they still have this character and treat schoolchildren in public oral care centres located in or near the schools . This system of service is administered and financed by local administrations, possibly with participation by the national governments . The task of the public oral health service in the Netherlands is also to treat schoolchildren. The service is financed through the sickness funds and partly supported by local administrations and patients' contributions. The administra- tion is managed by a special institution that is supported by, but not directly subordinated to , the Ministry of Health. This service system covers a smaller segment of schoolchildren than in Norway and Sweden and makes use of several different types of treatment - for example, transportable dental equipment is often used . The United Kingdom public oral health service or school dental service system also must be mentioned in this connexion. It represents a system con- trolled by local administrations serving schoolchildren, preschool chil dren , pregnant women , and nursing mothers . The service is delivered in public oral care surgeries or centres, which are often located in the schools, and by dentists who receive a fixed salary. In recent years, coordination of this service system with the other two oral health service systems in the United Kingdom (the general oral health service and the hospital dental service) has been im- proved. The oral health service in Switze rland stands close to the public oral health service systems of the Scandinavian countries as regards its significance and pre- ventive efforts. The service in Switze rland is organized by the cantons and depends mostly on the initiative of local administrations. Towns and villages 34 either build public oral care centres, or the local administration arranges a contract with a local private dental practitioner to provide regular and compre- hensive treatment of children; this often covers also orthodontic and pros- thetic treatment. Treatment is either free of charge and is paid in full by the public budget or parents contribute to the cost. The extent and management of this type of service is not coordinated at the federal government level, but in certain cantons oral care spreads through the life of the community , making use , fo r prevention, of water supply systems, salt production facilities, and also schools. The children's oral health services in these cantons are among the most active and prevention-oriented in Europe. In Austria and the Federal Republic of Germany public oral health service systems were established for the preferential oral care of schoolchildren, and stemmed from the idea that a systematic oral health service must start where dental disease starts - in childhood. For different reasons the extent of these services was limited to preventive dental examinations, oral health education, and primary prevention, the extent of which, however , is uneven. Dental treat- ment proper is either not performed by this service system or performed to only a limited extent, and children found to need dental treatment are referred to private dental practitioners , who are contracted to treat these children on a dental health insurance basis. This oral health service system was introduced in both Austria and the Federal Republic of Germany in several provinces ( or federal states). Its aim is to complement the broad dental health insurance serv- ice system by means of systematic dental control and oral health education of children. The same child is examined , if necessary, several times a year , and parents are notified that the dental treatment has not yet been carried out. Unfortunately, in some provinces/states the oral health service system examines only certain classes of children. The public oral health service system in Italy also depends on the initia- tive of local and urban administrations, and some towns have public oral care centres where children are examined, sometimes treated, and receive oral health education. In France, a preferential oral health service for children is comparatively small in extent. The health administration requires only oral inspections of schoolchildren by school physicians. However,certain professional dental groups are also involved , offering active prevention and oral health education of school- children. In addition, certain dental health insurance companies in France have special oral care centres for treatment of children and for orthodontics. The different forms of oral care described as belonging to the second variant of a public oral health service are, therefore , centred largely on children, ensuring for them a more or Jess comprehensive and regular oral health service including prevention and oral health education. These arose through the initia- tive of local administrations of villages and towns , and in a number of countries they remain at this stage of development. In other countries, financing and administration of oral health services was tranferred to regional administra- tions , and this has made it possible to establish broader coordination within these systems. The third variant of a public oral health service is represented by systems established in countries having a low density of dentists . The public oral health 35 service in these countries comprises a network of public physicians or dentists working in hospitals or public health outpatient centres. In certain instances they work only part-time, receive a fixed salary, and deliver an emergency den- tal service for indigent members of the population. This is the character of pub- lic oral health in, for example, Malta, Spain , and Turkey . In Algeria the work- ing capacity of the service system was considerably broadened by requiring each dentist to work full-time for the public oral health service system for a certain period after qualifying and part-time for the rest of his professional career. Developmental potential of public oral health services The main achievements of a public oral health service are to implement primary preventive measures , introduce comprehensive and regular treatment for children and other priority groups, and manage the service system in a rational way . Provided such a service system has at its disposal all the financial and manpower resources needed it will be capable of transforming into a com- prehensive dental service for the whole population. Extension of the curative oral health service to cover the whole population and its transformation into a comprehensive, regular service is only one of three potentials for development embodied in a public oral health service. The other two are the transformation of the oral health service from a primarily curative into a predominantly preventive one and in its integration with community life , and the adoption of rational management of the oral health services. It seems highly probable that a public oral health service can realize these developmental goals more easily than other oral health service systems. Changing the character of the oral health service from primarily curative to predominantly preventive and integrating the preventive service with the community life cannot be fully implemented at tl1e present time, or even in the near future , but these are not unrealistic aims. Their achievement requires, in fact , only the implementation of those principles of prevention that the oral health services have been advocating for a long time. For example, limiting sugar consumption is in the interests of the whole population , not only in rela- tion to dental caries but also to other health problems such as obesity. Com- munity action in this regard is therefore desirable . The sale of sweetmeats in schools should be prohibited and the school authorities might limit the con- sumption of sweet dishes in school meals. The community could also monitor commercial advertising likely to stimulate a high sugar consumption. In the in- terests of health , many countries have imposed restrictions on the advertising of cigarettes and tobacco . Similar action aimed at tl1e prevention of dental caries might be considered. Another change would be the transfer of oral health education and of cer- tain primary prevention activities to nurseries , kindergartens, and schools. Pri- mary preventive measures such as distribution of fluoride tablets or supervised self-application of fluoride solutions to the teeth tend to have a low efficiency in groups of children if provided through the oral health service. Supervised use of preventive measures is easier in schools since the children are all present at the same time. In order to make this organizational change the communal 36 institutions such as the schools or school authorities would have to agree to ap- propriate extension of the school programme. This may be acceptable in future if the community accepts the principle that prevention of disease is a service to the population and that the cooperation of all the communal institutions con- cerned is necessary . Health education in general, as well as oral health education such as training in tooth cleaning , could become a part of the school programme because children need this information and teachers, who are trained educators, can deal with this goal more effectively than oral health personnel. Other types of communal institution that have to be involved are water- works, where water fluoridation can be effected, and in some countries also salt factories that are controlled by the community and could produce fluoridated salt. These activities may be extended to the commercial distribution of fluori- dated nutrients, depending, of course, on the economic organization prevailing in the various respective countries. In short, all ways and means available to the community should be used in these activities and their efforts coordinated. Integration of prevention with community life can be realized also in another way - namely, the training of lay personnel, mothers of children, or pensioners, for example, to supervise the self-application of fluoride solutions, to give training in oral hygiene and so on. Persons with only primary education can easily perform these tasks; the training courses might be free and the trained personnel could work in the oral health service for a short time, possibly on a voluntary basis. They could then be used in schools and parents' associations, as well as in the oral health services. Use of these personnel would not only expand the dental manpower in an economically advantageous way , but the knowledge they gain would directly benefit their children and families. If most of the mothers in the community received this training the practical effect of preventive measures would be greatly enhanced . As far as rational management of the oral health services is concerned, this is already emphasized in present public oral health service systems. Manage- ment is easier in the public oral health service and there is greater adaptability. For these reasons it is assumed that this type of service has a greater develop- mental potential than other service systems. Imperfections of existing public oral health services It does not follow from what has been said that existing public oral health service systems are ideal or are working in an optimal way . Many of the regula- tions are based on tradition rather than on exact knowledge. For optimal perfor- mance these service systems must apply scientific measurement and analysis far more frequently than they have so far; they will have to operate more efficiently and extend their use of experimental working methods by incorporating various organizational measures in service models and evaluating them in pilot areas and field laboratories for experimental studies on service delivery. In this way public oral health service systems may become more attractive for the European countries. 37 PART II ORGANIZATION OF ORAL HEALTH SERVICES IN THE WHO EUROPEAN REGION INTRODUCTION In 1973 the European Regional Office of the World Health Organization organized a study of oral health service systems in the European Region, and offered all Member States of the Region the opportunity to participate and to submit brief descriptions of the organization of their services. In order to harmonize these descriptions a model description of one country's service was prepared in the Regional Office and submitted to the 28 countries that elected to take part in the study. The descriptions of service systems given in this report reflect the state of these systems in 1973. The contributions mostly begin with a brief historical introduction; they then explain how, and to what extent, the oral health serv- ices are managed, how the services are provided for, and how they are delivered, give the numbers and density of dental manpower and the categories of dental auxiliary personnel employed, describe which preventive measures are being used in practice, and, finally, discuss the country's main problems and future plans in the field of oral health. All these descriptions were officially approved for publication by the country concerned. Several countries have allowed the name of the author of the contribution to be given. ALGERIA0 Introduction In Algeria the practice of dentistry remained a private enterprise with fee- paying patients until 1962. Oral care was provided by dentists holding degrees a Statement prepared by Professor M. Bouchouchi, Director , Department of Dental Surgery, Institute of Medical Sciences, Algiers. 39 from French universities. In 1950 the Algiers Institute of Odontostomatology was created to provide education in dentistry within the faculty of medicine. In 1962, after the massive departure of European dentists, independent Algeria was confronted with a scarcity of dentists and had to face two main problems : the training of the future dental health personnel, and the organi- zation and management of dental service systems. Training of personnel and organization and management of the oral health services Training for dental health personnel is provided by the Department of Dental Surgery in the Institute of Medical Sciences . This training, including studies and instrumentation, is free , and each student receives a study grant serving as a pre-salary . At the end of his studies, the graduate is required to undertake 2 years' national military service , 18 months of which is devoted to practising his profession either in a hospital or a state polyclinic. After that he must fulfil the obligation to undertake state civilian dental service for a period of 5 years (Ordinance No. 71 - 78 of3 December 1971). From 1962 to 1 January 1974 there were three types of dental service in Algeria. (a) Private dental practice with fees paid entirely by the patients. Patients affiliated to a social security fund received some reimbursement of fees. (b) The medicosocial centres of large nationalized enterprises , which pro- vided oral care for those affiliated to them. The latter paid only a part of the fees (ticket moderateur) . (c) Dental clinics of hospitals or dispensaries: every hospital of a region, or wilaya (there are 17 wilay a in Algeria) , has one or more units providing oral care . These units are staffed by full-time dentists paid by the state . Patients contribute a modest amount towards the cost of this care. For certain patients (those ill in hospital and indigent persons) the service is completely free. An ordinance of 6 April 1966 deals with the status of dentists, (I) requiring every dentist in the private sector to devote six mornings a week to the public service; and (2) regulating in relation to the private sector the status of dentists work- ing either full-time on a permanent basis (i.e. , state officials) or full-time in a "regulated" way that governs the amount of time devoted to private work by teachers in the university hospital centres to one or two after- noons a week . The oral health services as from 1 January 1974 Ordinance No . 73 - 65 of 28 December 1973 instituting free medicine in the health sectors came into force on 1 January 1974. On that date the number of dentists in Algeria was 445, i.e. , 1 dentist for 33 707 population. The num- ber of dental students was 609 . Private dental practice, entirely paid by the patients, is still in existence as a result of a national agreement between the social security funds and the state, 40 which fixes the tariffs. However, authorization to start a new private practice is subject to the approval of the Ministry of Public Health. Approval is strictly reserved for Algerian nationals; it can only be obtained after carrying out the 2 years' national service and the 5 years' civil service, and is given only for "de- prived" areas, large towns being excluded. The Minister of Public Health has at his disposal 238 oral care units dis- tributed between the hospitals, polyclinics, and dispensaries of the wilaya. The whole of the population has the right to preventive and curative care in these units. Care is provided by dentists paid by the state or in half-time practice. All state societies and organizations are required to have an oral health care service, and this is free . The teaching of dentistry underwent reforms in 1972, and these will produce their full effect from 1975 onwards. Education now includes training in epidemiology and social odontology; already there are two teams with mobile equipment applying in the field methods recommended by WHO. The education of dental technicians has been organized since 1966 by the Department of Dental Surgery. Up to the present 228 dental technicians have been trained in addition to those trained through practice in private surgeries before the existence of official training. Main current problems and future plans In the medium term, Algeria must solve two important problems. (a) Scarcity of dental personnel. This problem will eventually be solved by the creation of three new departments of dentistry in the institutes of medical sciences within the universities. This makes it possible to face an in- creasing demand for care from the rapidly growing population. (b) Health education and oral public health. The greater part of the popu- lation still does not know the principles of public oral health. The state pro- poses to set up facilities for disseminating knowledge of the oral diseases and teaching the rules of oral hygiene, including school programmes, education by radio and television, and itinerant teams with mobile equipment to reach the most distant territories. In the long term the programme of oral hygiene and oral health is intended to achieve the following goals. (a) To include an oral health page in the health booklet issued to each person; (b) to introduce obligatory preventive visits for certain age groups: (1) during maternal and child health care visits (pregnant women, babies, and children of preschool age); (2) at the time of school entry; (3) on starting employment in all agricultural and industrial occu- pations; (c) to follow preventive visits with curative care provided by state dentists in the hospitals or polyclinics, the priority groups being at present children and old people; 41 (d) to attack the endemic fluorosis that is widespread in areas of the Sahara, affecting a million people; and (e) to organize hygiene and prevention campaigns at the national level to combat caries and periodontal disease. Thus, Algeria hopes progressively to extend its various programmes of oral hygiene and social odontology for prevention and curative care completely and regularly to the whole population. AUSTRIA Introduction The bulk of the oral health services in Austria are based on dental health insurance, which has a long tradition in that country. Serious conditions of the mouth and jaws have been covered by health insurance since 1888. Dental treatment proper was included in 1908, at first only for persons who were directly insured and later, in 1917, also for their family dependants. Since that time the insurance has spread steadily and after the Second World War over 90% of the population was covered. Private dental treatment paid in full by patients without any support is comparatively limited in scope , and so is the public sector (school dental service). Management of the oral health services The development and delivery of the oral health services in Austria are not subject to any systematic management by the government; political and health administrations supervise only legal aspects of specific segments of the health servi2e. The rights and duties of dental manpower are defined by laws govern- ing the activities of physicians and dentisten (see below) and by related regula- tions. Questions of professional responsibility and ethics are under the control of official nongovernmental organizations (so-called physician chambers). Benefits offered by the dental health insurance are outlined in various laws. Finally, public oral care for schoolchildren is based on regulations of individual provinces (federal states) or cities . Provision of oral health services The aim of the oral health services in Austria is to prevent oral disease and to treat manifest disease as early as possible. Dental health insurance extends to practically all employed people and their families, and most dental practi- tioners work for insurance schemes. These are financed by contributions from the insured persons and their employers . 42 The insurance covers surgical and conservative dental treatment and part (40 - 80%) of the expenses of prosthetic and orthodontic treatment. Special treatment such as gold inlays or metal crowns and bridges is paid in full by the patient directly to the dentist. Poor persons who are not covered by dental health insurance can obtain comparable financial support from the social serv- ices of the local or provincial administration. Dentists are remunerated according to a tariff for each item of service, which is regularly adjusted in cooperation with the insurance companies and the Austrian Dental Association . A school dental service is organized only in some provinces and large towns . In most instances its aim is to examine schoolchildren in certain school years and to refer those in need of oral care to private dentists. In three pro- vinces, however , all children are examined every year (twice a year in Vienna) , and in certain instances (e.g., in Vienna) free dental treatment is available to children on demand in public polyclinics . This service is financed jointly by the provincial and local administrations. Preventive oral care is financed by contributions of the Federal Ministry of Health and Environmental Protection, the provincial governments, and the Austrian Association for Oral Hygiene. Delivery of oral care Basic and special oral care are delivered in private surgeries of dentists , in the dental polyclinics of insurance companies, and in public children's poly- clinics. Insurance benefits also cover dental treatment given by the university dental clinics or hospitals (maxillofacial surgery departments and dental poly- clinics). Oral health manpower Oral health manpower consists of stomatologists, Dentisten ( dentists), den- tal technicians, and chairside assistants . Other categories such as dental hygien- ists and school dental nurses have not yet been introduced . The ratio of profes- sionals to population is I : 2300. Stomatologists (Fachzahniirzte) , of whom there are 1500 altogether, are physicians with a complete medical education and a 2-year specialization in dentistry . Specialized training is given in the den- tal clinics belonging to three university medical schools (Vienna, Gratz , and Salzburg). Dentisten (1570 altogether) are primarily dental technicians who have fulfilled certain conditions (mainly related to practice) and have received vocational training at a subuniversity level. At the present time training of Dentisten has been discontinued. Dental technicians are organized as craftsmen . Chairside assistants are about as numerous as the dental professionals and are mostly trained by the professionals themselves. There are no recognized dental specialties in Austria. Postgraduate dental training is organized by the Austrian Dental Association and by the university dental clinics. 43 Prevention of oral diseases Prevention of dental caries is based on regular distribution of fluoride tab- lets to schoolchildren through the schools on a nationwide basis . Water fluori- dation has not been introduced. Oral health education is organized by the Austrian Association for People's Health in cooperation with the school and health administrations. In all schools having compulsory school attendance a "dental health day" is declared every year and instructions for the prevention of dental caries are given to all children . Children entering primary schools receive a set of oral hygiene utensils, to- gether with an informative leaflet, free of charge. Main current problems and future plans At the present time the main problem of the Austrian Dental Service is the lack of dentists . The number of training posts must be increased and the establishment of a new university clinic in Salzburg is under consideration . Prevention will also continue to be based on fluoride tablet distribution, and a broad information campaign on a national basis is under preparation to stimu- late the interest and motivation of the population in prevention . BULGARIA Introduction The first written records on dental care in Bulgaria date from the early nineteenth century (1824) . The dental profession has been recognized since the regulations of 1880. The first odontological society was established in 1905 and in 1911 a journal, Review of dentistry, began to appear. In 1942 a section of dental education was set up within the medical faculty of Sofia University, and in 19 SO the name was changed to "Faculty of stoma tology " . Up to 1944, 90% of oral care was provided by dentists in private practice . Since then free oral care has expanded continuously . In 1972 the State Council completely abolished the system of private medical and dental practices. At the present time all oral health pe rsonnel work only in state public health institutions and serve the whole population. Management of the oral health services These services are an integral part of general preventive and curative health care within the public health system. The management of the oral health serv- ice network is undertaken by the Ministry of Health , which has a department of oral health care . In the chief town of each region (okrug) there is a regional 44 oral health polyclinic, which includes departments for operative, children's , prosthetic, and surgical stomatology, and specialized surgeries for orthodontics, periodontology, and physiotherapy. The chief of the medical service, as well as the heads of oral health departments and surgeries, serve as advisers in matters of organization and methodology for medical and dental care in the regions. In the chief towns of the districts (rajon) there are oral health departments in the hospitals. Department heads have a similar advisory responsibility for oral care in the dental surgeries of the rural preventive and curative centres of the dis- tricts. Dentists receive a fixed salary. Provision of oral health services The entire population is entitled to free oral care but a small charge is made for prosthetic treatment, excluding inlays and orthodontic appliances. Senior teachers of stomatology and specialists, whose services are in great demand, see patients on request in separate surgeries outside their regular working hours. They receive additional salary for this work but the service is free of charge for patients . Certain population groups are covered by regular preventive "dispensary" oral care. These are "captive " 0 children in the age range 3 - 7 years, schoolchildren, pregnant women, adolescents of pre-military age , patients with certain chronic diseases, and people working under conditions that present risks to health. All large factories and other undertakings have oral care surgeries providing for dental examinations and treatment of workers . Delivery of oral care Oral care is delivered by personnel working in state facilities. In the oral health polyclinics of the chief towns of the regions specialized care (operative , prosthetic, surgical, orthodontic , and periodontal) is delivered on the basis of the sector (ucastok) princip e.b For delivery of inpatient care use is made , when necessary, of regional hospitals. In the oral health departments of district hospitals and in the oral care surgeries of the rural curative and preventive heal th centres polyvalen t services are available; here , the sector principle does not apply . Oral care for children of preschool age attending a kindergarten , and for schoolchildren, is delivered in school dental surgeries or in institutions for general oral care. For specialized treatment of both groups of children there are children's departments in the oral health polyclinics. In addition to children's and school dentists, other dentists also are used to maintain scheduled pro- grammes when this is essential for improving the oral health of children. In isolated regions full use is made of mobile units for this purpose . However, various difficulties are experienced in connexion with the coverage of "non- captive" children of preschool age. a Children attending kindergartens, etc. b This principle allocates one dentist to eac h sector of the population in order to ensure uniform availability of the service. 45 The Ministry of Health provides supplies of both human and material resources for the oral health services, and directs their use . Oral health manpower Oral care is delivered by dentists (stomatologists) and dental auxiliary per- sonnel. The country has, on an average, 1 dentist to 2750 population . Newly qualified dentists are assigned to oral health facilities by the Ministry of Health . After three years they can specialize in one of the following specialties : general stomatology, children's dentistry, prosthetics , orthodontics , operative den- tistry, and surgical stoma tology. While undergoing specialist training den tis ts receive payment at the full rate. The Ministry of Health plans and guides all activities relating to the post- graduate education of senior health staff. The Medical Academy directly con- ducts and coordinates postgraduate education, using its own technical and manpower resources and those of the Public Health Service network. Prevention of oral diseases Prevention is achieved by the comprehensive use of fluoride tablets, fluori- dated mineral water, toothpastes containing fluoride, topical applications of fluoride , and regular hygiene of the oral cavity together with rational nutri- tion. A programme to introduce water fluoridation has been approved and will be implemented in the near future. A certain proportion of the working time of every dentist is devoted to preventive measures and oral health education. Main current problems and future plans An important problem in the Bulgarian oral health services is a shortage of oral health personnel in relation to the continuous growth in demand for oral care and the increase in the numbers of people receiving regular dispensary treatment. Also important are the shortage of auxiliary personnel and the im- provement of the material resources of the services. The Ministry of Health developed a programme for improving oral health in Bulgaria in the period up to 1980. This includes : (I) reducing dental morbidity, introducing an integrated system for pre- vention of dental caries, and creating optimum conditions for raising the qual- ity and quantity of preventive and curative work ; (2) increasing the number of oral health personnel, raising their level of education, and optimizing their distribution throughout the country; (3) improving the material and technical supplies and the equipment pro- vided for oral care; (4) improving the cons truction of oral health units. 46 CZECHOSLOVAKIA Introduction The practice of dentistry as a health profession began in the mid-nineteenth century in areas now forming Czechoslovak territory. The first teachers of dentistry appeared in the medical schools in about 1860, the first dental associ- ation was created in 1896, and the first dental journal was published in 1900. Before 1900 dental services were provided by private practitioners, the full fee being paid by the patients. Later, and until 1948, most practitioners worked for private dental health insurance. In 1948 National Health Insurance was introduced. The present dental service system was introduced in accordance with the Law on Unified Preventive and Curative Health Care of 1951,and with the Law on Health Care of the People of 1966. Oral health services are of a socialist type, covering the whole population and organized by the state health administration. Management of the oral health services Overall planning and coordination of the oral health care services is the responsibility of the national ministry of health , whereas operation of the ser- vice is a matter for the regional, district, and municipal (local) health adminis- trations , acting in collaboration . Chief stomatologists at the republic , regional, and district levels advise the health administration on methods of delivering oral health care or control the services provided at the lower levels of adminis- tration. All oral health personnel are employed by the health administration and receive fixed salaries. Provision of oral health services The aims of the oral health services are to serve the bulk of the population on a "demand for service" basis and to organize comprehensive, regular care for priority groups (mainly schoolchildren, expectant mothers , military recruits, patients with certain systemic diseases , and those exposed to risks while at work). The whole population is eligible for preventive and curative oral care, which is delivered free except for small charges for crowns, bridges , and expen- sive types of denture. However , children, adolescents, and priority groups of adults are exempted from these payments . Private dental ca re, where the patient pays the full fee, is available but very limited. Delivery of oral care Basic oral care is delivered in dental surgeries belonging to local community health centres. One dental practitioner is allocated to each "health area". The patient can choose either a dentist working near his home or one working in the enterprise where he is employed (or a wider choice of dentist is available 47 at the patient's request). In towns, oral care for a number of health areas is usually concentrated in polyclinics controlled by the District Institute of National Health and staffed by an appropriate number of dentists. Specialist oral care (in particular, dental surgery, prosthetics, and orthodontics) is also available in these district polyclinics or at the regional institutes of national health, where all types of specialized care are provided. The regional institutes have both outpatient and inpatient facilities. Around 45% of the total popula- tion utilizes these services every year. The so-called dispensary (i.e., priority) oral care for children is delivered either in school dental surgeries or in facili ties for general oral care, which, on certain days, treat only children. This care is not compulsory for children but the great majority of them receive it. About 95% of all schoolchildren are examined, mostly at school, and treated regularly once or twice a year. This dental service is considered as part of the school programme. Comprehensive, regular treatment is given to about 25% of preschool children and 60% of adolescents only, mainly because of the relative difficulty of reaching these age groups , but the volume of care provided is expanding wherever conditions of service permit. The average dentist to population ratio is 1 : 2600. Dental manpower con- sists of graduate dentists (stomatologists), dentists without university educa- tion, and dental auxiliaries. The stomatologists comprise either physicians specialized in stomatology (the minority) or dentists receiving 5 years' training in 11 dental departments of medical schools (the majority) . Dentists without university education are no longer being produced . After graduation, a stoma- tologist chooses a post from those available in the basic dental services net- work. After another three years he undergoes an "attestation examination" and can either specialize (in maxillofacial surgery, children's dentistry , ortho- dontics, or periodontology) or receive training for higher posts in the dental health administration . Refresher courses are available to all dental practitioners at the district and regional institutes of national health. Postgraduate education is free of charge and is planned and coordinated by the national institutes for post- graduate medical training. Dental auxiliaries comprise chairside assistants and dental technicians, both being about equal in number to dentists. Auxiliaries with duties similar to those of dental hygienists are rare, but at the present time the output of these personnel is being speeded up . School dental nurses of the New Zealand type do not exist in Czechoslovakia. Prevention of oral diseases Fluoridated drinking-water is available to about 10% of tl1e population and fluoridation schemes are steadily expanding. Fluoride tablets are distributed to about 30% of preschool children through creches and kindergartens. Some 10% of schoolchildren receive topical applications of fluorides . Every dentist en- gaged in child oral care is required to spend one hour a day on oral health education work. This is supported with the appropriate educational material by the district departments of health education . 48 Main current problems and future plans The major problem of the Czechoslovak oral health services is the relative shortage of oral health manpower , caused mainly by the rapidly increasing demand for oral health services and by wastage due to retirements . Future plans concern primarily an increase in oral health manpower output and a cor- responding extension of facilities fo r oral care. In the longer term it is hoped to extend comprehensive and regular oral care to include all preschool children and adolescents , and to increase the comprehenisve oral care coverage of the adult population. DENMARK Introduction Examination of dentists in Denmark was e~tablished in 1873 at the Medical Faculty of the University of Copenhagen; the Danish Dental Association was founded the same year. Dental education in a dental college commenced in 1889. Dental manpower has developed as follows: Year No. of dentists Population 1945 1 600 4 045 000 1955 2000 4448000 1965 2900 4 768000 1970 3627 4 921 000 1971 3800 4 950000 Management and provision of oral health services The Danish National Health Service includes an oral health section. The national health service has an obligation to supervise the functions of practising dentists and the public oral health services, and to advise the government, the ministries, and the regional and local health and social welfare administrations (counties and municipalities) in public health matters. Up to 1973 the oral health services for the major part of the popula- tion (i.e. , for adults and preschool children) were based mainly on national and private programmes of dental health insurance. Contributions were paid directly by insured persons to the local insurance boards and benefits were offered as a partial or total reimbursement of the fees paid to private dental practitioners. The proportion of the cost reimbursed depended on the income of the patient. Prosthetic treatment was , in general , paid for in full by the 49 patients. Schoolchildren in many localities had access to a free school dental service run and financed by the community administrations. On 1 April 1973 a new Public Health Services Act was adopted. Under the provisions of this Act the expenses of adult patients and preschool children for oral care are reimbursed from the county health administrations, whose budget is based entirely on national taxes. Support is given for dental examinations, X-ray examinations, scaling, amalgam and silicate fillings, root-fillings, and ex- tractions. Altogether, 67% of the costs are paid by county health administra- tions . Persons 16 years old and persons born later than 1944 can take part in a regular oral health scheme. This scheme ensures, and requires , that participants have two oral examinations annually . County health administrations pay 100% for regular oral examinations and 75% of the cost of subsequent treat- ment is refunded to the patient. The dental service for schoolchildren is based on the Child Dental Health Act, which came into force on 1 August 1972. Pursuant to the Act , all muni- cipalities must set up clinics and employ dentists and auxiliaries. Free preven- tive and therapeutic dental care, including orthodontic treatment , is offered to all schoolchildren (7 - 16 years). The Child Dental Health Act imposes on the National Health Service the responsibility of continual evaluation. A data recording system was developed and started to operate at the beginning of the 1972 school year. National, regional, and municipal statistics are available every year. These encompass oral hygiene, den ta! caries , gingivitis, malocclusion, dysfunctions, and oral pathological conditions. Oral health manpower and delivery of oral care The oral health services for schoolchildren are provided by 500 municipal child dental clinics. This part of the oral health service is delivered by 650 den- tists employed full-time and 350 employed part-time. About 450 000 children are treated in the clinics annually. There are 2000 private dental clinics wi th 2700 dentists, and about 700 pri- vate denturists. 0 Auxiliary dental manpower consists of dental technicians (700), chairside assistants (5000), dental preventive workers (mostly chairside as- sistants with an additional training in preventive procedures),and dental hygien- ists, training for whom started in 1974 . Specific institutions for the physically and mentally handicapped have established dental clinics with state-employed dentists . Prevention of oral diseases Water fluoridation has not been implemented on account of legislative obstacles . The main preventive method used by the school dental service is rinsing with O .2% solution of sodium fluoride at intervals of 2 weeks. a Denturists are practising dental technicians who are allowed, without any specific authorization, to treat patients and insert full and partial dentures. 50 Future plans It is planned to ex tend the Child Dental Health Ac t to comprise also children aged 0 - 6 years, and to extend financial support under the Public Health Security Act to periodontal tre.atment and dental prosthetics. FINLAND0 Introduction The education of dentists in Finland began in 1892, and the Finnish Den- tal Society was founded the same year . The first dental journal was published in 1904. The school dental service started on a local authority (commune) level in 1909 and gradually developed into an organized school dental service cover- ing, by 1972 , the majority of schoolchildren. Organized oral care was also given to some extent to students, military conscripts , handicapped persons , and other institutionalized people (e.g., geriatric patients). Oral care for other age groups was provided by private dentists and the cos ts were paid by the patients in full . There was no dental health insurance in Finland . Only in cases where dental treatment was necessary as part of medical trea tment were costs refunded by the national sickness insurance according to an established rate. In 1972, however , a new system of organizing both the general health and the oral health services was adopted on the basis of the Public Health Act. At the present time the oral health services scheme is being reorganized. Parts of the previous system, described above, will continue to exist until comprehen- sive oral care for the enti re population is developed under the public health programme. Management of the oral health services The public oral health services will be put into effect according to the national 5-year plan and evaluated annually by the National Board of Health on the basis of annual reports made by local health authorities . The National Board of Health operates under the supervision of the Ministry of Social Affairs and Health. All public health work will be carried out at the health centres , serving a population of approximately l O 000 , that are run by the communes or federa- tions of communes under the supervision of the local board of health . Each health centre has a responsible dentist in charge of oral care. In future, the a Statement prepared by Dr H . Nordling, Chief, Office of Dental Health , Na tional Board of Health , Helsinki. 51 public oral health manpower will increase to match the expected increase in volume of the public oral health service. Provision of oral health services Systematic, free oral care for the whole population will be introduced gradually. The first aim was to provide by 1976 systematic oral care including dental examinations and treatment, instruction in oral hygiene, dietary advice, and rinsing with, or topical applications of, fluoride solution for all persons less than 17 years of age (i.e., 30% of the population). In the transitional period all persons over 17 years of age are charged for oral care in public health centres, as provided for in public health legislation. This charge is considerably less than that for private dental care and in future it will be reduced further through a subsidy paid to the communes out of national sickness insurance. To cover the total expenditure for public health, including oral health, the communes receive state subsidies of 39-70% of the total ex- penditure, depending on the financial situation of the commune. Delivery of oral care The public health centres will provide the basic oral health service whereas a special oral health service will be included in the national plan for hospital services. The Public Health Act places emphasis on prevention, on the one hand, and on development of outpatient services, on the other. Consequently, the oral health service being developed according to the new concept emphasizes preventive programmes. These are directed primarily towards expectant moth- ers and young children and their parents. Oral health manpower Dental manpower in Finland consists of dentists (3136), chairside as- sistants (1311 ), and dental technicians (545). Among the dental technicians is a group of "special laboratory technicians", numbering 197 persons, who are en- titled through training and examination to work directly with patients, for whom they make whole dentures. The "dental hygienist" and "dental therapist" categories of dental auxiliary personnel have not yet been established . The dentist to population ratio was 1 : 1500 on 1 January 1974. The total number of dentists in active work is 2700, of whom 1100 work in the health centres. The majority of dentists still work as private practitioners, and they are mostly located in urban communes . Specialization in dentistry is under consideration and, in the near future, a new category of auxiliary called "special dental assistant" will be trained. Their training programmes and work specifications have not yet been clearly defined. Prevention of oral diseases In 1969 a recommendation was made by the National Board of Health concerning the use of fluorides in the prevention of dental caries . According to 52 this recommendation the communes are entitled, with the permission of the National Board of Health, to introudce fluoridation of drinking-water. In prac- tice, only one town (Kuopio, with 60 000 inhabitants) has introduced (in 1959) fluoridation of public water supplies. Investigations of the natural fluoride con- tent of drinking-water have also been carried out in other localities. Sodium fluoride solutions (0.2% or 0.05%) are used as mouth-washes for schoolchildren, and topical application of fluorides is perfonned by dentists or chairside assistants. Sodium fluoride tablets are distributed free of charge in con- junction with dental health education in the health centres. A limited amount of fluoridated kitchen salt is produced and consumed in the country. Main current problems and future plans The main problem for the oral health services in Finland is shortage of oral health manpower, especially in health centres where the demand for dental treatment is increasing rapidly . Expansion of education for oral health man- power and enlargement of preventive programmes as well as services in the health centres are the main plans for the Finnish oral health services for the future. FRANCE0 Introduction Up to I 892 the practice of dentistry was free. The law of November 1892 restricted the practice of dentistry to physicians and dental surgeons in pos- session of a diploma after studies completed in a state establishment pro- viding higher education . The first dental school was set up in Paris in I 880, the first dental association in 1879 , and the first dental review was published in 1887 . Dental services are provided by private dentists whose fees, up to I 930, were the sole responsibility of the patients. At this date the social insurance funds were created, which participated in the reimbursement of the cost of dental care to the most underprivileged social category. The present system is based on the Ordinances of 1974 setting up the social security system and now applies to practically the whole of the French population. Dental care, pros- theses, and dentofacial orthopaedics are reimbursed to the extent of75% on a scale fixed as a result of an agreement between the social security funds , the public authorities, and the professional associations. a Statement prepared by Dr L. Hanachowicz, Dental Adviser to the Director-General of Health, Ministry of Public Health and Social Security, Paris. 53 Management of the oral health services There is no planning system for the oral heal th services in France. The only planned aspect at present is the number of dental SUigeon diplomas to be awarded annually in order to meet the needs. The acce pted figure is I dentist with university training for I 500 persons. There is no body of public health dentists. Provision of oral health services Dental fees cover regular and complete ca re for the whole of the popula- tion, without priority groups. Charges for costly prostheses (bridges , precious metals , ceramics) remain the responsibility of the insured persons. Dentofacial orthopaedic costs are reimbursed to the extent of I 00%, like those for treat - ment of all long-term diseases coming within the social security system. In France there are collective organizations for oral care managed by the municipalities , the social security funds, and the mutual funds. They utilize salaried dentists, who at present amount to 15% of all dentists in practice. The greater part of the oral health services (85%) is provided by private practitioners, but prevention of oral conditions is not at present covered by the social security organizations. Delivery of oral care Where the private practitioners work is entirely a matter of their own choice, and this leads to a certain lack of balance in the nationwide distribution of oral care. The socially insured patient is free to choose his dentist and his treatment. There are , however , private and public dispensaries linked with factories, muni- cipalities , social security, and various mutual funds (for example , those of stu- dents and public servants) . Some of these specialize in the treatment of children, but they are few in number. Oral health manpower In 1974 there was an average of I dentist for 2000 population. The oral health personnel included: (I) medical stomatologists (about 1100) ; (2) doctors of dental surgery with 5 years' specialized training in any one of 14 university centres (about 27 000) ; (3) chairside assistants qualified since 1967 - these are not authorized to work within the mouth (about 3500); ( 4) dental technicians who have technical training. There are no dental hygienists or school dental nurses , and there are no plans to train these personnel. 54 Prevention of oral diseases The regulations concerning a preventive oral health service provide for an annual case-finding system based in principle on the school physician . Owing to lack of credits and means, it is not much practised. Certain departmental committees of the French Union for Education in Bucco-Dental Care organize free case finding for children aged 6 - 9 years . Since 1968 this professional group has been organizing annual campaigns for oral heal th education, and so far 600 children aged 6 - 13 years have benefited from these lessons which are given in the schools and followed by the distribution of teeth-care kits. Main current problems and future plans A very large epidemiological survey, limited, however, to the compulsory school population (6 - 16 years), was carried out in 1974, with the aim of as- certaining accurately the oral health needs of this age group. As an experiment a complete cycle was undertaken in two French departements : oral health edu- cation and free systematic case finding for children aged 6 - 9 years (omitting the 25% partial payment normally charged to the insured person), accompanied by free choice of practitioner. The public authorities will draw conclusions from this experiment after it has been in operation for 2 years. An important problem remains to be solved: that of dentofacial orthopaedics, the benefits of which do not seem at present to be proportional to the expenditure involved. GERMAN DEMOCRATIC REPUBLIC Introduction In 1945 after the end of the Second World War, the preconditions for oral care had to be recreated in the territory of today's German Democratic Repub- lic . In the political sense, a basis of trust was established to enable full integra- tion of dentists practising privately into the new, state-organized health services in which particular emphasis was placed on the development of the oral health service system . Every year new state polyclinics and "ambulatoria" (smaller outpatient facilities comprising at least two special departments) are established . All new university graduates in dentistry work in the state public health serv- ices . The number of dentists having private dental surgeries is at the present time around 1500 only. On 29 September 1977 the Government of the German Democratic Republic and the Confederation of Free German Trade Unions adopted a Joint Decree specifying that every citizen of the German Democratic Republic has the right to oral care based on modern dental science and delivered free of charge. 55 Management of the oral health services The planning and coordination of oral care are carried out by the Ministry of Public Health according to state health-political directives. Responsible for the implementation of this care are the county and district health officers together with the county and district councils. The number of new dentists and other oral health personnel needed is determined by the Ministry of Higher Education in coordination with the Ministry of Public Health. The establish- ment of new surgeries , both in polyclinics and individual locations (state dental surgeries) , is the responsibility of the county councils , which coordinate their plans with the Ministry of Public Health . Provision of oral health services Every year 50% of the population consult a dentist. Because the oral health services are free the demand for dental treatment in general and also for crown and bridge work, metal inlays, etc. , as well as for the necessary metal alloys, has risen steeply. At present, curative treatment is in the foreground but the systematic development of preventive and rehabilitative care is given particular attention and particular importance is attached to fluoridation of drinking-water, which began in 1959. At present, about one million inhabitants of Karl-Marx-Stadt, Magdeburg, Plauen, Cottbus , and other municipalities and rural communities are supplied with fluoridated drinking-water but in 1985 about 50% of the population of the German Democratic Republic will be included. Since 1961 child dentistry has been considered as a specialty within oral care, showing that much attention is devoted to the care for children. All infants having harelip and cleft palate are registered and cared for by a special dispensary unit that determines the time for operating and starting speech therapy education . When school begins for these children afflicted with con- genital fissures all are rehabilitated . Further attention has also been devoted to the development of oral care for factory workers . These services are provided free by factory den tis ts, but where treatment is provided at private dental surgeries , it is also free of charge. Delivery of oral care At present (1974), the average dentist to population ratio is I : 2200. The local differences that still exist (coverage is better in towns than in rural areas) are being eliminated as planned. Patients have a free choice of dentists and physicians. In the larger towns there are polyclinics where patients are cared for by several specialists. In the smaller towns and in rural areas the individual surgery of the general practitioner is usual, all difficult cases calling for specialist treatment being referred . For schoolchildren there is a dispensary system that provides for regular examinations and treatment by a child dentist. In the larger towns there are you th dental clinics caring exclusively for children. The aim is to provide regular 56 oral examinations and, where necessary, dental treatment, for all children of preschool age. Particular attention is devoted to oral health education for citi- zens of all ages. Oral health manpower The oral health team consists of a dentist educated at university level , a dental nurse (dental therapist), and a dental technician ; the latter two receive medium-grade medical education. After 5 years' study every dentist undergoes another 5 years' compulsory specialist training. The oral health specialties are general stoma tology, orthodontics, children's stoma tology, and oral surgery. No Dentisten (dentists without university education) have been trained in the German Democratic Republic for 20 years and existing Dentisten have been given an additional 2 years' training to qualify as dentists. At the conclusion of his university studies a dentist receives a diploma. Subsequently, he may extend his professional qualification to "doctor in den- tal medicine" (Dr.med.dent.), for which a scientific thesis is required, or pre- pare himself for an academic career. In the latter case he must graduate as "doctor in medical sciences" (Dr.sc .med.) . After finishing medium-grade medical training , dental technicians may qualify in various special fields such as ceramics, restorative prosthetics of defects, highly specialized prosthetics, etc. Dental therapists have various pos- sibilities for specialization, and increasing attention is being devoted to pre- vention. Education at both universities and medium-grade schools is free of charge. Most students are awarded scholarships by the state. Postgraduate training is also free . The arrangement of postgraduate training curricula for dentists and their supervision, and the preparation of guidelines concerning their implica- tions are the responsibility of the Postgraduate Medical School of the German Democratic Republic, which comes under the Ministry of Public Health. The postgraduate training of dentists is also the task of the Stomatological Society of the German Democratic Republic, which comprises 11 regional societies and 6 specialized societies (of prosthetic dentistry, orthodontics, periodontology, conservative stomatology , child dentistry, and oral and facial surgery). For dental technicians and dental therapists there are also regular training events, and they become members of the Stomatological Society . Main current problems and future plans - Increased education of dentists, dental technicians, and dental thera- pists to guarantee that up to I 985 there will be a dentist to population ratio of I : 1800, and that there will be I dental technician and 1.5 dental therapists for every dentist. - Introduction of modern and efficient methods of work leading to better results being achieved by existing personnel. - Making better use of the latest research results in everyday den ta! practice. 57 - Further improvement of preventive measures and health education for the whole population in order to decrease the demand for treatment of dental caries and periodontal diseases . - Steady improvement of the qualifications of all members of the oral health team within the framework of a coordinated system . Above all , further clinics are needed . FEDERAL REPUBLIC OF GERMANY Introduction The practice of dentistry as a health profession has a long tradition in the Federal Republic of Germany. The first dentists were recognized in the first half of the nineteenth century, and in 1875 some 500 were already in practice . Their number doubled before the end of that century and increased again five times within the next 50 years. The first dental health insurance was introduced at the beginning of this century and the dental health insurance programmes increased steadily both in numbers of insured persons and scope of benefits offered. At the present time oral health services are provided primarily through the dental health insurance system and delivered in private dental surgeries. Also , the public dental service for schoolchildren started in German territory very early (the first school dental clinic in Strasbourg was opened in 1902), and after the First World War well-known schemes for organizing incremental dental care of children were drawn up. Provision of oral health services The dental health insurance programme covers 97% of the population. Numerous heal th insurance companies are managed on a local basis by guilds or by factories and offices and organized on a state or federal level by associations protecting their general interests . The benefits cover all surgical and conservative dental treatment and a part - usually one -third - of prosthetic and ortho- dontic treatment, with little variation in coverage offered by different insurance companies. The volume of financial benefits paid to patients increased six-fold within the last 20 years; reimbursement for prosthetic treatment alone increased by 50% during the last 10 years. The public oral health programme is limited to child care and is concerned almost exclusively with examinations, referral of those in ne.ed of treatment to private practitioners, and prevention. Practically no treatment is given. This pro- gramme is managed by the federal states without coordination on the federal level. One of 10 federal states has a dental officer at the ministry level, and in another the public oral health programme is based on a law. In two of the federal states the programme covers all schoolchildren (North Rhine-Westphalia 58 and Hessen). One dentist examines up to 20 000 children a year. Evaluation surveys show that only about 5% of children neglect their teeth completely; over 60% of children are treated comprehensively and another 20% partially. Delivery of oral care Dental treatment is performed in private surgeries. Public oral health poly- clinics are rare and are usually not concerned with dental treatment. Oral health manpower In the Federal Republic of Germany today there are around 30 000 den- tists, and the dentist to population ratio is approximately 1 : 2000, ranging from l : 1600 to 1 : 3800 in different parts of the country. Dental auxiliaries are represented by dental technicians and chairside as- sistants . The dental technician to dentist ratio is about I : 3 and that of chair- side assistants to den tis ts nearly 1 : 1. Both categories of auxiliaries are trained through apprenticeship combined with special schools. No other dental auxil- iaries are used in practice . Prevention of oral diseases The Federal Republic of Germany introduced water fluoridation in 1952, and was the first country in Europe to do so. Later, this had to be discontinued owing to changes in legislation. At the present time the main emphasis is placed on distribution of fluoride tablets, topical application of fluoride, oral hygiene, and rational nutrition. Main current problems and future plans Oral health care in the Federal Republic of Germany seems, at the present time, to be well balanced . No substantial structural changes in the provision or delivery of oral care are expected in the near future. It is evident, however, that the main emphasis in the future development of the oral health service will be placed on improving the dentist to population ratio, evaluation of the effec- tiveness of the service by systematic collection of statistical data, and on preventive programmes . GREECE Introduction Regulation of the dental profession in Greece stems from a decree of 1834 that restricted the practice of dentistry to holders of an official diploma awarded on the basis of an examination by the Medical Council. 59 The University of Athens was created in 1837, but a dental section was not included because of the small number of dentists in Greece . However, a dental school was set up in 1911 within the framework of the Faculty of Medicine; in 1921 this became autonomous, and the duration of studies was fixed at 4 years. In 1952, the dental school again became attached to the uni- versity as a section of the Faculty of Medicine . In 1970 it became a Faculty of Dental Medicine. Management of the oral health services The oral health services come under the Ministry of Social Services. Oral care is provided by the odontological sections of the hospitals, state polyvalent clinics, dental dispensaries of the social security organizations, and centres of the National Foundation for Maternal and Child Care (PIKPA). Dental educa- tion is controlled by the Ministry of Education. Organization of the oral health services About 80% of persons in need of oral care are treated by the private sector. The providers of oral care are linked by a convention mainly with the social security organizations - namely , (a) the Fund of the Banks, the Telecommuni- cations Organization of Greece (OTE), the Public Electricity Enterprise (DEH), the Fund for the Organization of Rural Health Insurance (OGA) , the Fund for State Civil Servants , etc., and (b) the Social Security Foundation (IKA), which runs dental care dispensaries . (I) OGA covers the whole of the rural population ; oral care is provided free in the odontological sections of the hospitals and the state polyvalent dispensaries. (2) The Fund for State Civil Servants provides oral care through private practitioners adhering to the convention. Insured persons pay a contribution amounting to 50% for prosthetic work only . (3) IKA extends the benefits of its dental insurance to a large part of the population by using its own odontological dispensaries. It reimburses the whole of the costs of surgical and conservative treatment and the greater part of the costs of dentures. Crowns and all prosthetic work, with the exception of den- tures in general, are paid for by the insured person. In Athens and Salonika, the IKA hospitals also have services for maxillofacial surgery. In Athens an emer- gency dental service is available on Sundays and public holidays. (4) The school dental service is operated by five odontological dispen- saries located in Athens , Salonika , Larissa , Kalama ta, and Piraeus. The odonto- logical sections of state hospitals serve schoolchildren in the other parts of the country. (5) The National Foundation for Maternal and Child Care covers the oral health needs of the child population through 18 dental units (3 of which are mobile) providing preventive examinations for children in the rural regions and the appropriate treatment where necessary . 60 Delivery of oral care Oral care is , in general, provided by private dentists , the various social security funds, the National Foundation for Maternal and Child Care , and the social security foundation. In Greece there are over 230 odontological clinics which employ more than 700 dentists. The oral health service , supported by IKA, performs in total about 1 600 000 interventions per year . Oral health manpower Greece has about 4500 dentists, i.e ., 1 dentist to 1800 population. More than half of them work in the Athens and the Piraeus areas. Den ta! specialties are not recognized . Postgraduate training is provided by seminars organized by the state health services, the universities, and the faculties of dental medicine. It does not have the character of postgraduate studies but of completing train- ing in developments in dental science. The number of dental auxiliary personnel is still low. The proportion of dental technicians to dentists is about 1 : 3 .5. There are few chairside assistants. Technicians and assistants are trained by apprenticeship. There are no other kinds of dental auxiliary . Prevention of oral diseases Prevention of oral conditions, essentially based on the topical application of fluorides, is practised on a limited scale by the oral health services of the Ministry of Social Services , assisted by dentists of the National Foundation for Maternal and Child Care . A programme for water fluoridation has been officially approved and will be applied as soon as the necessary preparations have been completed. Main current problems and future plans At present the main problems are the limited number of properly trained oral heal th personnel, the prevention of den ta! diseases , and the education of the population in oral hygiene. It has been decided to introduce , in the future , odontological sections in hospital institutions and to create centres for the oral care of children. An effort is needed in this respect in order to improve the oral health services offered to the population. HUNGARY Introduction The practice of dentistry as a health profession started in Hungary at the end of the eighteenth century. The Medical Faculty of the University of Budapest has conferred dental diplomas (Magister artis dentariae) since 1799 . The first 61 chair of dentistry was established at that university in 1844, and the first uni• versity dental institute was opened in 1909 . The Hungarian Dental Association was created in 1878, and the first dental journal, The odontoscope, was pub- lished in 1892 . Social health insurance was introduced in 1870 and has provided for the oral health services since 1891 . In 1948 the National Council of Trade Unions took over the administration of health insurance until the Jaw on public health , introduced in 1973 , ensured, for all Hungarian citizens, the right to medical treatment , including dental treatment, free of charge. Management of the oral health services The Ministry of Public Health is in charge of overall management and co- ordination. In special questions related to the organization and methodology of the public health service, the Ministry cooperates with national institutes struc- tured according to specialized branches of the health service. A special profes- sional board of the Central Institute of Stomatology in Budapest functions as a consulting body in the field of oral health. This Institute is in direct professional contact with chief dental officers managing oral care in the counties and cities. These managers are located in the centres for basic oral health and report twice a year on the oral health services in their respective areas. Provision of oral health services The aim of the oral health services is , for the time being, to serve the ma- jority of the population on a "demand-for-service" basis. Priority oral care is reserved for limited population groups such as schoolchildren, expectant mothers, military recruits, and industrial apprentices; these receive regular care. The whole population is eligible for free dental treatment except that nominal fees are paid for inlays, bridges , and dentures as well as for gold alloys used in treatment. Dentists working full-time (6 hours daily) in state facilities and retired den- tists may be permitted to practise privately. In private practice the patient pays the fee in full to the dentist. Dentists working in the state facilities are employees of the local authorities and receive a fixed salary. Delivery of oral care Basic oral care is delivered in dental surgeries belonging to local community heal th centres. These are responsible for an area with around 3 800 - 4000 in- habitants. Specialized oral care is available in the dental outpatient depart- ments of the regional health institutes. These institutes comprise also inpatient dental departments and are centres for the organization and management of oral health in the regions. Dental services for children provide comprehensive oral care in Budapest and in cities having more than 30 000 inhabitants. Children are examined and treated, where possible, twice a year. In rural areas, den tis ts belonging to the area treat children in the public oral health care facilities on certain days of the week. 62 Oral health manpower The average dentist to population ratio in Hungary is now 1 : 4000 . In the state health service there are three categories of dental professionals : (1) physicians (6 years of basic education in medicine) specialized in odontostomatology (3 additional years of postgraduate study); (2) doctors of dental surgery (5 years' undergraduate university training) who can specialize or continue their postgraduate studies for 2 years after graduation ; (3) a certain number of dental technicians trained at a sub-university level and passing a state examination; training of this category of personnel is at present discontinued. A major part of the dental laboratory work is carried out by the State Dental Technical Enterprise, a special institution run by the Ministry of Health . Nearly 70% of all den ta! technicians are employed by the Enterprise, and its facilities are fairly evenly distributed over the country. A few den ta! labora- tories are run by the regional administrative councils and about 20% of dental technicians work for the private dental practice sector. There are also chair- side assistants, who are abo ut as numerous as the dentists. Postgraduate dental education is compulsory for all den ta! practitioners , who are expected to attend every third year. These courses are organized by the Institute of Postgraduate Medical Education and are free of charge . Main current problems and future plans The main problem of the Hungarian oral health services is the relative short- age of oral health manpower. It is hoped that the number of dental schools can be increased in the future . In the long term it is hoped to extend comprehensive and regular oral care to all preschool children and children in the 14 - 18 years age range, as well as to groups of workers exposed to professional risks and later to the whole population. For prevention of caries use of fluoridated salt seems to be the most suitable method in Hungary, and the aim is to make this available in all parts of the country . ICELAND° Introduction The practice of dentistry as a health profession sta rted in Iceland around the turn of the cen tury . In 1922 a limited dental service for schoolchildren was a Statement prepared by Dr 0. Hoskuld sson , Assistant Professor of Pacdodontics, University of Iceland. 63 started in Reykjavik . Since then it has gradually expanded and spread to some of the larger towns in the country . The Icelandic Dental Association was founded in 1927 and the first dental publication appeared in 1933 . In 1941 the first teachers of dentistry joined the Faculty of Medicine of the University of Iceland. It can hardly be said that the delivery of oral care is based on any specific legislation in Iceland; it has simply grown into its present shape . Management of the oral health services Oral health services for schoolchildren are operated by local authorities and financed through taxation, and are thus free of charge to the immediate recipients. Services are planned to some extent but have not yet been evaluated. In Reykjavik today they cover about 50% of the needs of children aged 6 - 14 years . Dentists delivering this care receive fixed salaries plus a specified fee for each treatment given . Provision of oral health services The aim of the dental corps is to provide complete and regular treatment for all persons. However , at present the population generally receives service only on demand, the only existing priority group being cleft lip and palate patients whose treatment is paid in full by the public health insurance. With the exception of this group and schoolchildren all dental fees have to be paid in full directly by the patients. Delivery of oral care Basic oral care is delivered in private dental surgeries by private practi- tioners and their staff - namely, chairside assistants and dental technicians . Dental hygienists do not exist in Iceland but it is planned to train these per- sonnel. There are no New Zealand type school dental nurses . Specialist care is almost exclusively on a private basis. At present the fol- lowing specialties are available : prosthetics , orthodontics , periodontology , endodontics , and paedodontics (one dentist is employed part-time by the school dental service) . Schoolchildren receive treatment in surgeries located in the schools . Cleft lip and palate patients who are not of school age receive treatment privately. Oral health manpower The average dentist to population ratio in the country is 1 : 1600 but is improving steadily , albeit slowly . It should be noted, however , that in the Reykjavik area the ratio is 1 : 1200 , leaving the rural areas with a ratio of 1 : 3700. Six dentists graduate annually fr om the University of Iceland following a 6-year course, but it is planned to increase this number in a few years to 8 per annum after a course lasting 5 years . In addition , a few dentists graduate from foreign dental schools. 64 Prevention of oral diseases Fluoridation of drinking-water was started on 11 December 1971 in one community (population 5000) , only to be disrupted in January 1973 by a vol- canic eruption. In some schools children brush their teeth regularly with I% sodium fluoride solution. Sodium fluoride tablets are distributed to children in some kindergartens. Oral health education is included in courses for expectant parents. School- children receive this education from both their teachers and the school den tis ts , and are instructed in home dental care by personnel specially trained for this purpose. The public in general is exposed to oral health education through regular radio and occasional television programmes organized, delivered, and sponsored by the Icelandic Dental Association. Main current problems and future plans The main problem facing the Icelandic dental corps is the volume of oral disease and the lack of public understanding and interest. A stepwise socializa- tion of oral health, starting with the younger age groups, the handicapped , and pregnant women is now being prepared. IRELAND Introduction The earliest legislation aimed at controlling the practice of dentistry in Ireland was the Den tis ts Act of 1878. That Act made it an offence for any per- son to use the title "dentist" , or any similar title , unless he was registered un- der the Act. It was not , however, an offence for a person to practise dentistry if he were not so registered . The Den tis ts Act of 1928 superseded the earlier legislation and has since controlled the practice of dentistry in Ireland . That Act established the Dental Board , which is responsible for maintaining the register of dentists and dealing with matters of a disciplinary character affect- ing the profession. Under the l 928 Act it is illegal for anyone other than a reg- istered dentist (or a registered medical practitioner) to practise dentistry in Ireland. Management of the oral health services The public oral health service originated with the Public Heal th (Medical Treatment of Children) Act of 1919 . That Act imposed on local authorities the obligation of providing for the medical inspection of children attending national (i .e., primary) schools and for having their physical health attended 65 to without direct charge. Oral examinations, usually of a perfunctory nature , were carried out by the school medical officer but dentists were later appointed for the treatment of schoolchildren. The Health Act of 1953 specifically pro- vided for local authorities making available dental services for primary-school children and preschool children referred for treatment following child health examinations. The 1953 Act also provided for local health authorities making available dental treatment and appliances for persons who could not reasonably afford such services from their own resources . The provisions of the Health Act of 1953 relating to oral health services were re-enacted in the Health Act of 1970 , which set up eight area health boards to administer the health services, including the public dental service, for eligible persons . Overall planning and supervision of the dental services for eligible persons are the responsibility of the Minister of Health. The dental services, free of charge to eligible persons, are financed from general funds made available to health boards from local and central sources for the purpose of financing the health services. Provision of oral health services The total population of the Republic of Ireland is approximately 3 000 000 . However , only certain categories of persons are eligible for dental services pro- vided by health boards - namely , primary-school children and preschool children referred for dental treatment under the Child Health Services and per- sons who have full eligibility for health services, i .e., persons unable to provide for such services from their own resources without undue hardship . The aim of the public dental service is to provide comprehensive oral care for all eligible persons. Because of the shortage of dental personnel and the high incidence of dental caries the oral health services provided by health boards are inadequate for the needs of all persons at present entitled to them. Consequently, it has been necessary to apply a system of priorities in these services. First priority is given to children referred for dental treatment under the Child Health Serv- ices. Next are persons with full eligibility for health services who require den- tal treatment for medical reasons. There are 500 000 children enrolled in pri- mary schools and about 100000 preschool children (3 - 5 years age group) eligible for oral health services free of charge. About one-third of these children receive dental treatment yearly. In addition , there are about 500 000 adults with full eligibility for free oral health services. About 10% of these receive dental treatment, mostly extractions and dentures, each year. Apart from those eligible for oral health services from health boards , approximately 780 000 per- sons insured under the state social welfare code are eligible for dental treat- ment under the Treatment Benefit Scheme administered by the Department of Social Welfare. This scheme operates on a demand-for-service basis, treatment being provided by private dentists under contract with the Department of Social Welfare . These dentists are remunerated on a fee -per-item basis , and treatment is free of charge to the patient except for dentures, crowns, inlays, and bridge work, for which the Department of Social Welfare pays part of the cost and the insured person the balance. Treatment may be obtained by an insured person from any of the 550 dentists on the Department's panel. About 66 25% of insured persons avail themselves of this service annually. Thus, almost two-thirds of the total population is eligible for oral health services, free of charge in most cases. Delivery of oral care Under the public dental service treatment is provided mainly by dentists employed full-time by the health boards . These den ta! officers are paid fixed salaries and normally each is provided with a chairside assistant by his health board. In most areas the full-time staff is supplemented by the part-time em- ployment of private dentists. Each health board area is subdivided into two or more local areas, a senior dental officer (full-time) being in charge of the public dental service in each local area. In addition to performing clinical work, the senior dental officer organizes and supervises the operation of the public dental service in his area. Each local area has a main centre with facilities for all forms of dental treatment and also a number of subsidiary centres where all but major forms of treatment can be provided. Primary schools are visited by full- time health board dental teams, who examine the dental status of the children and refer them for treatment at clinics arranged by the health board. Some health boards operate mobile dental clinics where treatment is given at schools for pupils during school hours. Children requiring specialized treatment (ortho- dontic treatment, for example) are referred to dental specialists under arrange- ments made by the health board. The majority of persons in the general population still receive dental treat- ment privately or as insured workers from general dental practitioners in the dentist's own surgery. Oral health manpower All dentists in private practice and in the public service are university trained. The number of dentists on the dental register is now 826, representing a ratio of 1 dentist to 3500 persons. This ratio is steadily increasing. Prevention of oral diseases In developing the public oral health service it was realized by the Depart- ment of Health that available resources of manpower and finance would be in- sufficient in themselves to control dental disease in Ireland. Consequently, special legislation was enacted in the Health (Fluoridation of Water Supplies) Act of 1960, which provides for the fluoridation of public piped water supplies specified in regulations made under the Act. Fluoridation commenced in I 964 and to date 120 supply systems serving 1 56 7 000 people (52% of the general population) have been fluoridated. Included among the communities so served are all the cities and the larger towns. In some areas where , for technical reasons, fluoridation of water has not been possible , a fluoride mouth rinsing scheme using a 0.2% solution of sodium fluoride has been introduced for schoolchildren . The Dental Health Education Committee of the Irish Dental Association (the dentists ' professional body) , in cooperation with the Department of Health 67 and the health boards, mounts each year a national oral health campaign aimed at promoting among the public, and particularly the children, a better apprecia- tion of the importance of good den ta! health and oral hygiene. Main current problems and future plans A major problem affecting the public dental service is the shortage of full- time staff. Recruitment is , however , improving and there has been a 50% in- crease in the number of dental officers employed in the health service over the past 5 years. It is the policy of health boards , with the Department's approval, to con- tinue to expand their full-time dental staffs, supplemented where possible by private dentists , to ensure that all children now eligible for oral health services will receive a good standard of oral care. Consideration is being given to ex- tending the public dental service to include children receiving second-level education and to improving the services for adults with full eligibility for health services. ITALY General information Dentistry in Italy is considered as a branch of general medicine and not as a profession per se; there is no separate dental health service. Out ofapproxi- ma tely 107 000 physicians in Italy about IO 000 practise dentistry full-time and about 2000 part-time. The majority of these are medical specialists in stomatology and have passed the 3-year specialized postgraduate course organ- ized by medical faculties or their stomatological clinics. However , this speciali- zation is not a necessary condition for admission to dental practice . Any phy- sician having completed his medical education is allowed to practise dentistry. Specialization is needed only for practising under social security contracts and for employment in a hospital. The accepted professional philosophy in Italy favours intimate connexion between general medicine and surgery, on the one hand , and pathology of the oral cavity, on the other. However , the present professional training of stoma- tologists is time-consuming and arrangements conce rning admission to dental practice may give rise to difficulties in exchanges of dental professionals be- tween Italy and other European Economic Community countries. The Govern- ment of Italy has proposed, within the framework of the pending bill for the establishment of a national health service, that faculties of dentistry should be established in de pendent of medical faculties after the first two years in common. 68 Dentists are sharply divided from dental technicians , who belong to the category of dental auxiliary personnel and who, in principle , work only in den- tal laboratories and deal with technical dental work without any direct profes- sional contact with patients. This arrangement is necessary in order to prevent dental technicians from establishing unauthorized and illegal dental practices. Provision of oral health services and delivery of care A major part of oral care in Italy is provided for by dentists without any financial support for the patient. This is true in spite of the fact that 95% of the Italian population is compulsorily insured against illness , mainly because the benefits offered to insured persons are relatively limited (mostly about one-third of the expenses for extractions and fillings and less than one-fourth of the cost of dentures) and because most patients treated under the social security programme receive their treatment in the crowded clinics of the sickness funds, which perform mostly ex tractions and conservative treatment of dental caries. This situation is due to the lack of dental manpower , the dentist to population ratio in Italy being 1 : 5000 or 6000, or about half that in most European countries. Public dental treatment for children is comparatively little developed . In most instances it is limited to periodical inspection of the child's teeth by the school health service and referral of those in need of service to a dentist. In the Italian children's dental service programme only about 300 dentists are deliver- ing conservative treatment and dental health education to schoolchildren. Another segment of the public oral health service is represented by muni- cipal dental clinics administered and financed by the local communities, where people registered as indigent (4% of the total population) may obtain extrac- tions and fillings free of charge, or possibly partially supported prosthetic treatment. The dental polyclinics of the sickness funds usually form part of large health polyclinics with facilities for various medical specialties. Their dental personnel total 1800 stomatologists. Many private dentists work in private group practices together with other general dental practitioners or de facto specialists. In a few places, in hospitals, a well-organized oral health care team can be found consisting of dentists and dental auxiliaries working closely together. As far as emergency dental treat- ment is concerned, this is assured only in the public dental hospitals in a few large cities. Water fluoridation has not yet been introduced in Italy, and the main preventive methods are distribution of fluoride tablets and topical applications of fluoride solutions. Main current problems and future plans In the long-term plans for the oral heal th services that are now under dis- cussion in Italy consideration is being given to the national health service system including comprehensive and free oral care. Much effort will be needed before these plans come to fruition . In the first place , it will be necessary to 69 increase dental manpower and to introduce new categories of dental auxiliary personnel such as dental hygienists, especially for the school dental service . In view of this , the short-term plans envisage the establishment of dental facul- ties in the universities. Later , in the future local health units , it will be neces- sary to establish emergency and regular oral health services and to enforce prevention of dental diseases through compulsory distribution of fluoride tab- lets in the kindergartens and schools and through organized oral health educa- tion and reduction in sugar consumption in school canteens. LUXEMBOURG Introduction The practice of dentistry in Luxembourg is reserved for Luxembourg citi- zens holding either a Luxembourg state diploma of "doctor in dental medicine" or a higher foreign diploma of dental medicine that has received official ap- proval from the Minister of National Education of Luxembourg. Since Luxem- bourg does not have a national university the _professional studies for obtaining these diplomas are carried out abroad, particularly in Belgium , France, the Federal Republic of Germany, and Switzerlan d, and they must meet various conditions as to duration and con tent. Management of the oral health services The intervention of the state in the oral heal th services is confined to the establishment of legislative conditions regulating the right to practice, the organization and financing of the social security system, and the school dental inspection service. The Government of Luxembourg does not specifically regu- late the practice of dentistry as a private profession . Provision of oral health services Practically the whole of the population now receives sickness insurance benefits. In 1974 a new law reformed the system in force with a view to har- monizing the benefits paid by the majority of sickness funds. Generally speaking, medical and dental procedures provided by physicians and dentists are paid by the sickness funds at tariffs fixed by collective conven- tions. If a differentiation is made in any of these tariffs in accordance with the income of the insured person , payment is made at the minimum tariff. Dental prostheses are paid by the sickness funds to the extent of 80% of the tariffs described above except for restorative maxillofacial prostheses for which the funds contribute 100%. Furthermore, the personal participation of 20% is not required from insured persons , or those co-insured , if every year for at least 2 years they have visited their dentist for preventive purposes. 70 There is no public oral health service for schoolchildren. Since 1958 the latter have undergone an annual examination, the results of which are notified to parents . The state of the teeth of each child is registered on a card, and those needing treatment are referred to their private dentists. The school den- tal inspection service is financed by the state. Delivery of oral care Dental treatment is provided by private practitioners. There is now l den- tist for 3245 persons. Most dentists follow postgraduate courses in foreign uni- versities but the Society of Medical Sciences in Luxembourg also organizes cycles of conferences in Luxembourg City. Long-term future plans Luxembourg should increase the number of its oral health personnel and augment the volume of care provided , particularly in the field of prevention . In the future , preventive activities will be supplemented by the extension of dental examinations to the preschool and postschool age groups and , above all, through the health education system, which will emphasize the need for tooth brushing, rational nutrition, and early case finding of dental caries and ortho- dontic anomalies. MALTA0 Introduction The practice of dentistry as a health profession started in Malta around the beginning of this century. Formal teaching in dentistry leading to a diploma in dental surgery commenced in 1933 at the Royal University of Malta within the Faculty of Medicine, and since 1954 has continued in the separate Faculty of Dental Surgery which awards the degree of Bachelor of Dental Surgery (B.Ch.D). The practice of dentistry is regulated by the Medical and Kindred Professions Ordinance, while discipline within the profession is con trolled by the Medical Council . The Dental Association of Malta was established in 1947 . Management of the oral health services Oral health services are provided through two distinct systems, the private general dental practitioner service and the government dental service . A measure a Statement prepared by Professor G.E. Camilleri, Senior Dental Surgeo n, St Luke's Hospital, Malta. 71 of control over the private dental service is exercised by the Chief Government Medical Officer , acting in conjunction with the Advisory and Executive Board , the membership of which includes a dentist elected by secret ballot by the dentists ordinarily resident in Malta. The overall planning and coordination of the government dental service is the responsibility of the Chief Government Medical Officer of the Ministry of Health , acting on the advice of the Senior Dental Surgeon and Professor of Dentistry at the Royal University of Malta. Provision of oral health services (a) Private general dental practitioner service. A wide range of routine and specialist dental treatment is available on a fee-for-item basis . The full fee is paid by the patient; there are no insurance schemes covering dental treatment by private practitioners. (b) Government dental service. This service operates in two sections, (1) the government dental clinic at the dental department of St Luke's Hospital, which is the island's main hospital, and (2) the school dental service. Delivery of oral care There are 32 dentists practising in Malta (dentist to population ratio of 1 : 10 000) of whom 6 are in full-time salaried service (government or univer- sity) and 26 have private dental surgeries (5 of these also have part-time govern- ment or university appointments). Regular dental treatment is supplied mainly by private dentists . Patients who have an income below a ce rtain level and are eligible for free treatment at government hospitals can obtain comprehensive treatment at the government clinic . Schoolchildren attending government-run schools are eligible for com- prehensive treatment at the school dental clinic in Valletta. There are at present 3 dentists catering for over 40 000 schoolchildren. Specialist treatment in oral surgery and maxillofacial trauma is available for all the population at the government dental clinic. The dental clinic of the Faculty of Dental Surgery , Royal University of Malta, is also situated at St Luke's Hospital and offers specialist services, which it expects to expand, to the public . Postgraduate training in the specialties is normally received abroad, usually in the United Kingdom. The use of auxiliary personnel such as chairside assistants and dental tech- nicians is fully accepted by the profession and administration . The utilization of dental hygienists is being developed but at present they are used only in the government dental clinic. The possibility of running a training course for den - tal hygienists is under active consideration. Main current problems and future plans The two main problems are dental heal th education of the population and the application of modern methods for prevention of dental and oral diseases in the community. 72 Improved organization and trammg of the oral health team (dentist, hygienist, chairside assistant, and dental technician) to deliver oral care more efficiently and cheaply is an immediate problem requiring the combined efforts of government, university, and professions for a satisfactory solution . The col- lection and evaluation of epidemiological data is an essential prerequisite for applying preventive dentistry at the community level with the most rewarding results . MONACO Management of the oral health services Management of the oral health services in Monaco is limited to regulations setting, on the one hand, conditions for admission to the practice of dentistry and, on the other hand, for preventive oral examinations of schoolchildren. Admission to the dental profession is based on the law of 24 July 1938 stating that dentistry may be practised by citizens of Monaco as well as by foreign nationals provided they hold the French state diploma in dentistry or other diploma of comparable status. Provision of oral health services The whole population is covered by social security, which includes oral health. Patients pay for treatment by dentists of their own choice and their expenses are reimbursed to the extent of 80 - 100% (more for surgical and con- servative treatment and comparably less for prosthetic treatment , especially in the case of expensive types of dentures) . Oral care for schoolchildren is limited to regular examinations and referral of those in need of treatment to private practitioners. These examinations are free of charge. There is no public oral health service providing dental treatment. Delivery of oral care All curative oral care is delivered in the private surgeries of the 17 dentists practising in Monaco. Future plans No substantial changes in the present system are being considered at the present time. 73 NETHERLANDS Introduction So-called dental masters and dental surgeons were registered in the Guild of Surgeons in the eighteenth century; in 1800 they were officially recognized after having passed an examination . A scientific periodical devoted to dentistry has been in existence since 1894. In 1895 the first clinic for training dentists was established, and in 1908 this was incorporated into the medical faculty. Since 1913 the practice of dentistry has been restricted to physicians and den- tists . Also in 1913 the Dutch Association of Dentists was formed. Since 1947 the education and training , as well as the examination, of dentists have been undertaken by the dental subfaculty of the medical faculty. There are now 5 dental subfaculties with a total intake of about 400 students a year. Until 1940 oral care was , by and large , provided by private practitioners except in a few instances where health insurance covered elementary dental services. At that time the school dental service was only in the first stage of development. In 1942 legislation for health insurance was introduce d covering about 70% of the population . From 1945 onwards school dental services ex- panded rapidly. Management of the oral health services The direct responsibility of the cent ral government for oral health is laid down in a number of legal provisions concerning the professional duties of the dentists (conditions for admission to the prac tice of dentistry, practice of for- eigners, etc.) as well as the financing of dental services through health insurance where the approval of the Minister of Public Health and Environmental Hygiene is required . There is an oral health section in the Inspectorate-General of Health , at present staffed by two dental health officers who advise the Minister of Public Health and Environmental Hygiene on the organization and financing of the oral health services. Provision of oral health services The aim of the oral health services is to ensure that adequate oral ca re is available for every citizen and that the delivery of care is organized efficiently. The oral health services are mostly provided for on the basis of dental health insurance. In addition to the 60% of the population for whom this insurance is compulsory, another 10% are insured on a voluntary basis . The remaining 30% are not insured and are treated by private dental practitioners , paying the full fee. Under the sickness fund scheme dental patients are charged a fee for initial dental treatment (children under 6 yea rs of age are exempt) and become eligible for dental health insurance benefits provided they take regular care of their teeth and see a dentist twice a year. The benefits cover in full extractions , 74 dental fillings and pulp treatment, removal of dental calculus, orthodontics, and oral surgery. As regards prosthetic treatment, the insurance contribution covers about one-third of the cost of acrylic dentures. Crown and bridge work are paid in full by patients . The 100 individual sickness funds are supervised by an autonomous body, the Council of Social Security . The school dental health services are organized collaboratively by mu- nicipalities, local health insurance agencies, and the Dutch Association of Dentists. In a few cases only , the services are organized by the municipal health services alone. The services are run by voluntary corporations (foun- dations for social dentistry) that are organized on a territorial basis . There are about 120 of these foundations covering the whole country. The finan- cing of the school dental services is provided by the sickness funds (75%) and the municipalities and, to a limited extent, by contributions from partic- ipants . Delivery of oral care A major part of oral care in the Netherlands is delivered in the private surgeries of dentists. Most of them accept sickness fund patients. In the large towns the sickness funds operate a limited number of dental polyclinics that treat , altogether, about 15% of the insured persons. School oral care is delivered by the local foundations for social dentistry, which buy the dental equipment and employ dentists and other personnel. In some cases the service may consist of examining children and referring those in need of treatment to family dentists , but mostly regular full treat- ment is performed in mobile units of oral health centres. Some of the founda- tions equip local school polyclinics and employ full-time den tis ts on a fixed- salary basis. Most school dentists , however, work part-time and are paid on a daily basis. About 50% of the insured persons eligible for oral care are under regular control and about 50% of primary-school children participate in the school dental service (800000 children). Oral health manpower On 1 January 1973 there were 3750 dentists for a population of 12.5 mil - lion. Of these, 2853 were in general practice, 390 in the school dental service, and the remainder were working in dental schools, institutions for the handi- capped, in military service, or functioning in a supervisory capacity. There were 150 specialists. The dental auxiliary manpower comprises chairside assistants (about as numerous as dentists) , dental technicians, and dental hygienists . There are now 4 training institutions for dental hygienists and the training course lasts 2 years. About 70 dental hygienists are working in general practice, dental schools, the school dental services, sickness fund clinics, and in the military dental serv- ice . In addition, the use of New Zealand-type school dental nurses is now being studied on an experimental basis. 75 Prevention of oral diseases Fluoridated drinking-water is available to about 20% of the population. As in some other European countries, there is some opposition in the Netherlands to the fluoridation of water. Relevant legislation is now before parliament. In the rest of the country fluoride tablets are distributed , especially by the youth dental services. The use of fluoride-containing dentifrices is also increasing. Main current problems and future plans The greatest problem at the present time is the shortage of dental man- power. There is now I dentist to 3700 population. With the present intake of dental students it can be expected that in about 10 years' time the dentist to population ratio will be I : 2000. Training facilities for dental auxiliary per- sonnel will probably be expanded also . In the organization of oral health services priority is being given to extend- ing comprehensive and regular oral care to children, including preschool children. This care will be delivered through the youth dental service, which will have to be strengthened . Emphasis will be placed on preventive care, including appli- cations of fluoride, early X-ray diagnosis of dental caries, and oral health education, in order to motivate children towards good oral health behaviour. Oral health services provided by the sickness funds will be extended towards more comprehensive oral care, assuming, of course, that adequate manpower and finance are available. The dental subfaculties are rapidly developing facilities for postgraduate education and training, with special emphasis on the public oral health service. Finally , efforts are being made to study the oral health situation through use of epidemiological methods, and to evaluate the results of oral care. NORWAY° Introduction The practice of dentistry in Norway began about the middle of the last cen- tury . An Act of Parliament of 1852 provided for the holding of examinations for candidates intending to practise dentistry, but the first examinations were not arranged until 1859. The Norwegian Dental Association was founded in 1884, and formal teaching of dental subjects, on a limited scale, commenced in 1893 . Private practitioners were the only providers of dental care until about 1910, when some municipalities began to provide free dental treatment for primary- school children in publically owned clinics. Free oral health services are at a Statement prepared by Dr 0. Haugejorden, Directorate-General of Health , Oslo. 76 present available under the school dental service, the public oral health service, and the dental services for the armed forces, while preschool children and adults depend mostly on the services of private practitioners for treatment . Management of the oral health services The school dental service is run by the municipalities. The intention is , however , to replace it gradually by the public oral health service. The public oral health service is coordinated at national level by the Ministry of Social Affairs , but its operation is delegated to the counties and dental districts . Den- tally qualified personnel are employed at each administrative level to supervise and operate the service and to give professional advice on dental matters . The dental officers of the school dental service are employed by the munici- palities and receive a fixed salary, while dental officers of the public oral health service are employed either by the counties or by the central government . Dental officers employed by the counties receive a fixed salary, while those employed by the central government may choose either a fixed salary or a combination of a salary plus 50% of the fees paid for treatment by nonpriority patients . Provision of oral health services The aim of the public oral health service is to provide free comprehensive oral care, including preventive services, on a regular incremental basis for all those between the ages of 6 and 17 years. Surgical and prosthetic treatment are provided to the extent they are needed while orthodontic treatment is limited by the time available for such care after other necessary treatment has been provided . Treatment facilities of the school dental service for the 7 - 15 year age group may vary from one municipality to another , but the scope is approx- imately the same as under public oral health service arrangements. Parents and guardians of children of priority group age may choose whether or not to take advantage of the services offered by the school dental service or the public oral health service. If they decide against obtaining treatment for their children under school dental service or public oral health service arrange- ments, they assume full responsibility for, and bear the whole cost of, dental treatment provided by private practitioners . In addition to free treatment for the priority group (6 - 17 years), the cost of which is shared by the state , the counties, and the municipalities, public oral health service dental officers may spend about one-third of their annual work- ing time treating nonpriority patients at standard fees fixed by the Ministry of Social Affairs. Treatment provided on demand for nonpriority patients , either by dentists in private practice or by public oral health service officers , is paid for by the patients . The heal th insurance does , however , reimburse part of the fees for surgical treatment including extractions , subgingival scaling when this is part of a comprehensive treatment plan , dental examinations of expectant mothers, restorative treatment for persons suffering from haemophilia , and treat- ment of den to facial anomalies and more severe malocclusions . The health insur- ance financed 7% of the estimated total cos t of oral ca re in 1972 (37 million kroner out of a total of 530 million kroner). 77 Delivery of oral care The oral care provided by the publicly financed school dental service and public oral health service is given in clinics built and maintained by the muni- cipalities. The public oral health service is fully operational in 6 of the 19 coun- ties and is at present being introduced in another 8. Each county is divided into dental districts with one or more dental officers, depending on the size of the population (priority group). Although the public oral health service provides some care for nonpriority patients , the majority of preschool children and adults visit the surgeries of private dental practitioners for treatment. Treatment coverage of the school dental service and public oral heal th service priority groups is usually over 80%, but there is some variation accord- ing to age and county. The oral health facilities are least satisfactory for pre- school children and the handicapped . The magnitude of this problem has not yet been adequately defined, but the oral health status of these groups is now receiving increased attention. The findings of an interview investigation of den- tal visiting habits indicated that about 58% of persons aged 15 years and older had visited a dentist during the 12 months from February 1972 to February 1973 but what proportion receives regular incremental care is unknown . Oral health manpower The dentist to population ratio was l : 1060 in January 1974. Recognized types of dental auxiliary personnel are dental hygienists, chairside assistants, and dental technicians . Dentists obtain their basic qualification after a course lasting 5 years. In Norway there are 2 dental faculties with a combined annual capacity of about 130 graduates . Both faculties provide postgraduate education leading to higher degrees or specialist qualifications. Refresher courses are arranged jointly by the dental schools and the Norwegian Dental Association . About 140 dental hygienists have qualified since formal training started in 1925 , while the estimated number of chairside assistants is approximately the same as the number of dentists . Chairside assistants are commonly trained in service, but formal training at vocational colleges is becoming more readily available. Finally, there are about 700 dental technicians whose training generally consists of a combination of vocational college education and an apprenticeship. There are no New Zealand-type school dental nurses in Norway . Prevention of oral diseases Only about 7000 people in Norway are supplied with naturally fluoridated water containing more than 1 part per million of fluoride . An Act of Parliament is needed before the municipali ties may adjust the flu oride concen tration of domestic water supplies to the optimum level. Fluoride tablets are, according to sales statistics, taken by 12 - 15% of children younger than 12 years. Furthermore, it has been estimated that be- tween 66% and 75% of primary-school children participate in organized tooth brushing or mouth rinsing with weak fluoride solutions at school. Sales of 78 fluoride dentifrices account for about 80% of all dentifrices sold, and increasing attention is being given to oral health education of expectant and nursing mothers and preschool and primary-school children. A State Advisory Board for Preventive Dentistry was established in 1971 to advise the Ministry of Social Affairs on matters relating to preventive den- tistry. Main current problems and future plans A shortage of oral health manpower, including specialists, and uneven geo- graphic distribution has been a major problem, but the situation is now improv- ing in most parts of the country. There has been in recent years considerable activity in the field of preven- tive dentistry. The most important task in the future will be to expand existing programmes and to develop and start new ones. The oral health services are at present inadequate to meet all the treatment needs of the population, but the demand for care is reasonably well covered . The efficiency of the services could be improved by taking full advantage of existing knowledge concerning the use of dental auxiliary personnel and by implementing the cheapest and most effective method of caries prevention , i.e., water fluoridation. The central health authorities have taken the initiative to gain recognition for organized teaching of community dentistry in the universities at the under- graduate and postgraduate levels in order to facilitate the establishment of an adequate oral health service commensurate with socioeconomic and profes- sional developments in Norway . POLAND Introduction The development of dental care in Poland started in the eighteenth and nineteenth centuries in Cracow , where dentistry was taught in the medical schools in courses of surgery. The first doctoral thesis in dentistry was written in 1817. In the second half of the nineteenth century Warsaw became the centre for dental science, and in 1898 a journal , Dental review, and a handbook, Course in dentistry, were published . The first institute of stomatology was es- tablished in 1903 . The Polish Stomatological Society was founded in 1951 . Management of the oral health services Oral health services are provided by the state as an integral part of primary health care, which also covers general, gynaecological, obstetric, and paediatric 79 care. The main directions of development of oral health care are determined by the Ministry of Health and Social Welfare, which is also responsible for increas- ing the numbers of oral health personnel and the provision of funds . Within the Ministry there is a division of stomatology dealing with related problems. Human and financial resources for the 22 provinces (voivodships) are divided centrally. In each voivodship there is a dental outpatient clinic comprising a curative department and a department for methodological and organizational management. The voivodship dental clinic is the highest authority in questions of organization, operation, and provision of oral health care . These clinics cooperate with the dental institute of the nearest medical school in questions of epidemiological research, training of personnel, and treatment of difficult special cases. In each voivodship there are a number of counties each having specialized outpatient dental clinics , which form part of the county health service com- plexes. These dental clinics are responsible for the standard and organization of the work performed in all dental outpatient clinics in a county. They supervise the functioning of the outpatient clinics providing basic oral care in the field. Planning for the development of oral health care is based on directives, observing the amount of dentists' and dental technicians' working time avail- able daily for 1000 persons. At present the optimal rates are fixed as follows: 252 minutes daily of dentist's time and 186 minutes daily of dental technician's time. The actual working time available in 1972 in the dental service amounted to 150 minutes daily of dentist's time and 50 minutes daily of dental tech- nician's time. Provision of oral health services Oral care, including all forms of prevention, treatment, devices , and den- tures as well as special examinations, is provided, in principle, free of charge for the whole population . Priority oral care is provided for children, students , and industrial workers. Forms of oral care complementary to the state-run care are dental coopera- tives and private practice , which , however, is limited in extent. Patients pay for these services. Delivery of oral care Basic oral care is delivered in dental oupatient clinics , paedodontic school, interschool, and student clinics for children and young people , and in industrial plant or interplant clinics for workers. Children, students, and workers may also obtain oral care at ordinary outpatient clinics accessible to the entire population. In many towns children in kindergartens are covered by a mobile oral heal th service. Specialized oral care is rendered by specialized outpatient clinics in county health service complexes. Specialized se rvices available are dental surgery , orthodontics , prosthetics, period ontology, children's stomatology , preventive stomatology, and X-ray diagnostics . All technical dental work is done by dental technicians in dental workshops that form part of the dental outpatient clinics. 80 Oral health manpower The present dentist to population ratio is 1 : 2800. Over 31 % of the den- tists work in outpatient clinics for children and young people, about 25% of them in clinics for general dental care , and 17% in industrial health services; the remainder work in specialized oral health services. The optimal ratios through- out the services would be 1 dentist to 1000 schoolchildren or 2000 industrial workers or students. Dental studies in the stomatological institutes of medical faculties last 5 years. After a further 5 years' work in the field dentists may specialize in 1 of 10 stomatological specialties or in 1 of 6 general medical specialties. Two higher degrees are available in these specialties. Postgraduate training is compulsory for all oral health personnel (including dental auxiliary personnel). Dental auxiliaries comprise chairside assistants and dental technicians , who must have completed their secondary education and a special 2-year course. In 1972 schools for dental hygienists were opened for students who have com- pleted a secondary education. Prevention of oral diseases Fluoridated drinking-water is available to over 5% of the population. Around 30% of preschool and school-age children receive fluoride tablets or clean their teeth with fluoride solutions . Lectures on oral hygiene are given throughout the country . Future plans The main plans for improvement of oral health relate to implementation of water fluoridation and other forms of prevention of dental caries ; extension of regular oral care for children , adolescents, and industrial workers;extended use of dental auxiliary personnel; and establishment of large dental workshops for technical dental work . A long-term plan for development of oral care has been prepared up to 1985. PORTUGAL The present system Oral health care is provided in hospitals and in the dispensaries of the national insurance and social security systems of the districts and in private surgeries . Efforts are being made to extend dental assistance to the whole coun- try through health centres. Dentistry is practised almost exclusively by physicians specializing in stomatology . This specialist qualification may be gained either through an 81 examination by the Order of Doctors or by in-service specialization in the hos- pitals. There still exists a group of dentists (odontologists) trained in a school that came under the Lisbon Faculty of Medicine ; this has been closed for several years. Future plans Within the framework of the public health policy adopted in 1970, and to deal with the growing need for oral health care and the present lack of physi- cians specialized in dentistry, the Ministry of National Education has announced the creation of a new Faculty of Odontology. In parallel with this , in order to speed up the reform and the development of the dental assistance system, a course for dental auxiliary personnel began in May 1974 at the National Institute of Health under the fourth development plan. This course lasts 18 months (6 of which consist of practical training) and is designed to prepare persons who have completed their secondary education to work under the direction of physicians and to help them with various aspects of public health work. The Institute is also studying the case of Portuguese citizens holding dip- lomas or certificates issued by recognized foreign schools of dentistry with a view to allowing them to practise after undergoing an examination in the official national schools. It is also possible that, in the future, agreements of reciprocity with certain countries will be made to recognize the qualifications of dentists and their right to practise. The new health policy at present gives priority to the problems of providing oral health care throughout the country as there are serious shortcomings in this area in Portugal. The new efforts added to those already mentioned should contri- bute to progressive improvement in the oral health of the whole population. ROMANIA Introduction The beginnings of dental care in Romania go back to the second decade of the twentieth century ; the first specialized dentists were trained immediately after the First World War. During the period that followed, oral care was pro- vided concurrently by physicians specialized in stomatology and by dentists without university education working within the framework of social insurance and in most cases in a private surgery . In 1958, by a decree of the Council of State, ratified by later decision of the Council of Ministers, oral care was placed , as were other forms of heal th care, under the control of the state health administration, and its benefits were extended to the whole population. 82 Management of the oral health services The planning and coordination of the oral health seivices and their organi- zation are undertaken by the Ministry of Health in collaboration with the departmental health administrations. The financing of oral health services is shared between the Ministry of Health, which provides the installations and the major equipment, and the departmental health administrations, which finance the personnel, instruments, consumable material, and medicaments. Auxiliary personnel employed in the oral health services are remunerated on the basis of fixed salaries. Provision of oral health services The intention is to provide complete oral health care, both in urgent cases and on request, through the various dental services described below, priority being given to certain groups (schoolchildren, pregnant women, sick persons suffering from diseases of occupational origin). The means employed differ in the towns and rural areas. In the towns oral care is provided in dental surgeries grouped together with laboratories for dental techniques and located in polyclinics where, in addition to stomatology, various other medical specialties are represented. Priority is given to prosthetic work in cases of total or extensive loss of teeth. Besides these grouped services, independent surgeries without laboratories for dental techniques operate in the urban medical dispensaries and in a large number of schools. These surgeries deal with all urgent cases and provide part of the treatment on request; in addition they undertake the systematic dispensary treatment of oral conditions in children referred from the school surgeries. In rural areas oral care is provided by dental surgeries which are inde- pendent of other medical services; they treat both adults ( 66% of the time) and children (33%). Prosthetic work represents a little less than one-third of their activities. Oral care of a preventive nature (consultations, extractions, X-rays, fillings of all types, orthodontic apparatus) is free; for prosthesis patients must pay a minimum amount though in certain cases they may be exempted. Extent of oral care In conformity with present legislation, each dentist/stomatologist is responsible for 3500 persons in rural areas and 2500 persons in towns with a population of less than 50 000 ; in towns with a population of more than 50 000 this figure is reduced to 2000. The oral health personnel comprise stomatologists, dental practitioners and technicians (without university training), and dental auxiliaries . The first type may be either physicians specialized in stomatology (a small number) or stomatologists proper who have trained for 5 years in the five faculties of stomatology (the majority) ; their frequency for the whole of the country 83 is 1 to 3700 population. After receiving their diploma and following a 6'.rhonths' obligatory postdiploma course, stomatological physicians must undertake a supervised stage lasting 3 years, after which they can specialize in maxillo- facial surgery (3 years) or in child stomatology (2 years). Both stomatological physicians and dental technicians working in a surgery or a laboratory (the numbers are approximately equal) must undertake regular refresher courses in the large departmen ta! units or in the university centres. The training of medical assistants for stoma tological prophylaxis (i.e., dental hygienists) has been started. The organization of oral health care (like that of other types of health care) is on an area basis ; however , the patient is given the opportunity to choose his dentist from among those working in the polyclinics serving the area where he lives. Prophylactic periodontological and oncological consultations are com- pulsory, and so is their recording with mention of the treatment carried out. More than half the total population uses the oral health services . The number of consultations and treatments provided in 1973 exceeded 25 million. Preven- tive services for children are a priority problem. About 70% of children of school age are examined each year. Prevention of oral diseases In addition to the dispensary treatment of oral conditions in the schools , 90% of primary-school children receive fluoride tablets or topical applications of fluoride . All stomatological physicians must undertake health education in oral hygiene. Main current problems and future plans The double problem to be solved in order to satisfy the growing demand for oral health care is the lack of dentists and dental surgeries . By 1980 it is hoped to reach a dentist to population ratio of 1 : 2700 , as a result of which complete and regular oral care will be available to all children of school age and 50% of adults. SPAIN Introduction In 1968 and 1969 the Director-General of Health organized an epidemio- logical survey of the oral health of schoolchildren and adolescents up to the age of 15 years. On that occasion a study was also made, at the national level, of the concentration of fluoride in drinking-water. The purpose of the survey was to collect data that would permit a more systematic organization of oral health services in the country. It revealed that nearly 75% of schoolchildren 84 suffered from dental caries, that 10% of them suffered from malocclusion, and that about 1.5% had signs of gingivitis . The proportion of teeth with caries was not very high: 3 pennanent teeth p-er child. These data are comparatively favourable. Nevertheless, the demand for oral care is relatively low in Spain. The survey showed that only 1032% of affected teeth were treated, and only 27% of the necessary fillings were carried out. In order to practise dentistry in Spain, it is necessary to hold a degree in medicine (given after 6 years o( medical studies) and to have followed post- graduate courses of specialization in odontostomatology for 2 years at the School of Stomatology in the Faculty of Medicine in Madrid. This School was set up in 1945. Management of the oral health services The state does not intervene directly in the management of private dentis- try and oral health care provided within the framework of social insurance. It is , however, responsible for the network of public oral health services that is organized on two levels : a corps of specialists of the national service of health ( odon tology branch) , which comes under the Director-General of Heal th ( each of the capitals of the 50 provinces has an odontologist belonging to this corps), and a network of local public oral health services directed by the local administra- tive authorities of the provinces. This network includes 75 dental posts in the secondary centres of rural hygiene , together with 1 dentist in each urban centre of IO 000 inhabitants and above. Provision of oral health services Oral health care is mainly provided by private practitioners , about half of whom are entirely remunerated by the patients. The others generally work part- time for the dental insurance system or for the public oral health service . Social insurance at present covers about 65% of the population in Spain, and is responsible for dental treatment justified by a general health problem (in case of infection of the buccal mucosa, a wound, or a tumour of the jaw, for example). The cost of dentures is partly reimbursed when these are made necessary by jaw surgery. As for dental treatment proper , only extractions are performed free. The public oral health services of the provincial capitals and the secondary centres of rural hygiene are concerned chiefly with oral health care for the young. They perform oral examinations of schoolchildren and treat children at risk of inflammatory complications as a result of dental caries. Fillings are made to save the first permanent teeth, but extractions are still very frequent. When necessary, the mouth is cleaned and inflammation of the gums treated. Occlusion troubles are recorded, and parents are notified and advised to take the child to a private dentist for treament. The second priority group for the public oral health service is that of preg- nant women who attend the secondary centres of rural hygiene for prenatal consultations. 85 Finally, in the public oral health surgeries of communities with at least 10 000 inhabitants other adults also are treated and emergency care is given to the indigent. A similar oral health service also exists in most of the general hospitals. Delivery of oral care Private dental practitioners carry out their work in their own surgeries. Services covered by social insurance are also mostly provided by dentists under contract with the fund concerned; however, in the big towns part of this serv- ice is provided by the dental units of polyclinics belonging to the social insur- ance system. Public oral health sector dentists generally work part-time , either in surgeries reserved exclusively for oral care or in premises shared with other medical specialists (ophthalmologists, otorhinologists, etc .). Oral health manpower In Spain there is 1 dentist to about 10 000 population. The countrywide density of dentists is not regulated , with the result that there are more dentists in the towns than in rural areas. The Madrid Dental School trains around 130 - 150 dentists a year and also arranges postgraduate training courses. A second dental school is to be opened shortly in Barcelona. Specialization in the different branches of dentistry is not yet recognized but many dentists, in fact if not in name, concentrate on specific fields such as orthodontics or oral surgery. Dental auxiliary personnel consist of chairside assistants and dental tech- nicians, but these personnel are still few in number. Dental technicians have the status of artisans and are trained by apprenticeship. The training of chairside assistants is the responsibility of individual dentists. Prevention of oral diseases Fluoridation of the water is being studied and an experimental programme for the distribution of fluoridized kitchen salt is under way in one province. The principles of rational nutrition and good oral hygiene are taught as part of health education. Future plans These concern primarily the use of fluoride compounds for the prevention of dental caries, and the training of dentists and dental auxiliary personnel. In the public oral health sector the number of posts for dentists will be increased in both the basic and the orthodontic services. 86 SWEDEN'7 Introduction Official examination of the dentist's abilities took place for the first time in 1799, and organized dental education began in the second half of the nine- teenth century. The first professional organization was the Dental Society of Stockholm, founded in 1860. In 1881 this became the Swedish Dental Society, and in 1908 its trade union section (Swedish Dental Association) was founded. The first law relating to the public oral health service in Sweden was adopted in 1938 . This granted priority dental treatment for children in the 6 to 1 S years age range . In 1965, 16-year-old adolescents were included. In 1973 the Swedish parliament adopted the Law of General Dental Health Insurance , which came into force on I January 1974. This Law makes the den- tal service more easily accessible from the financial point of view, and struc- tures the benefits so as to ensure priority for prevention and for treatment of cases where the patient's general health is at risk. It also regulates dentists' fees by imposing a state-approved tariff scale in both the private and the public dental services. Management of the oral health services Private dental practitioners representing 45% of the dentists in active serv- ice are free to establish their practices where they wish. However , the National Board of Health and Welfare supervises the quality of their work and , from 1974 on, the National Office of Insurance deals with certain administrative aspects. The public oral health service is planned and managed by the different county councils and their health committees , and is supervised by the National Board of Health and Welfare . Provision of oral health services The ultimate goal of the oral health services is to make adequate preven- tive and curative care available to the whole population . On account of prac- tical limitations this goal has not yet been achieved . For children and adoles- cents the services are planned on the basis of their needs. The adult population, aged 20 years upwards , is served on the basis of demand for oral health care and is covered by dental health insurance granting equal benefits to all citizens. The patient is charged according to the state-approved tariff scale for each i tern of service delivered . The patient pays his share of expenses (to a maximum of 50% of the total cost) and the difference is paid to the private dentist or the county council a Statement prepared by Dr E. Bohlin , Dental Officer, Dental Division, National Board of Health and Welfare, Stockholm. 87 from the insurance fund , which is financed from national taxes . Higher benefits (75% of the cost) are offered for all preventive dental services and to patients needing a full upper and/or lower denture. Further, 75% of all dental expenses exceeding 1000 Swedish kronor are reimbursed. The public oral health service sector takes care, in the first place, of its target group (the 3 - 19 years age group). This service is basically free of charge for the patient but, in the present transitional period, the 17 - 19 years age group is treated according to general dental health insurance system regulations. A free oral health service is also granted to those in military service, especially during their first period of service , and also to all patients (including adults) with congential or other facial or jaw malformations, and to all hospitalized patients. Regular oral health services, including examination and treatment, are pro- vided once a year in full for the age group 6 - 16 years, and to some extent for the age groups 3 - 6 and 17 - 19 years. Emergency dental care is provided by both the public oral health service and private practitioners. However, for organizational reasons , this care is offered mostly by the public oral health sector. Delivery of oral care Basic oral care is delivered , on the one hand , by private dental practitioners in their own surgeries and, on the other hand , through the public oral health service, mostly in public dental polyclinics . The size of these polyclinics de- pends mainly on the number of children in the district. According to current arrangements , 1 dentist takes care of about 500 children . Specialized oral care is delivered mainly through the public oral health service sector and by the dental schools. The four main specialties are paedo- dontics, orthodontics, periodontology, and oral surgery . Oral surgery is mostly available in specialized dental clinics at the main county hospitals . Further specialized services, for endodontics, X-ray diagnosis, or diseases of the oral cavity, for example, are available in the dental schools. Oral health manpower The average dentist to population ratio in Sweden is 1 : 1073. In 1972 there were about 7600 dentists in Sweden and 2800 of them were working in the public oral health service . The dental auxiliary manpower consists of dental technicians , chairside assist an ts , dental preventive workers , and dental hygienists . No school dental nurses of the New Zealand type are in practical use . Prevention of oral diseases The preventive programme has been developing under the public oral health service for many years. The new Law on Dental Health Insurance places strong emphasis on prevention . Preventive programmes, planned and supervised by the National Board of Health and Welfare, start with mother and newborn child in children 's welfare centres , and are based on oral health education , dis- t ribution of fluoride tablets , and , in preparatory and primary schools, supervised 88 mouth-rinsing with weak fluoride solutions twice a month. Experiments are continuing with professional tooth cleaning executed by dental preventive workers (i.e., specially trained chairside assistants). Water fluoridation is at present not allowed in Sweden. Main current problems and future plans In spite of the relatively high density of dentists in Sweden the dental manpower is inadequate to cover completely the existing need for oral care. In particular, public oral health service manpower needs to be enlarged. In future, the main investments in dental services will have to go, on the one hand, to the public oral health service and, on the other hand, to the preventive oral care programme in order to ensure comprehensive oral health care of a high standard for the whole population. SWITZERLAND Management of the oral health services The Federal Government intervenes in oral health matters only with regard to the obligatory insurance for working premises, the payment of pensions to patients with congenital or acquired diseases (including marked deviations in the occlusive or craniofacial relationships), military accidents , subsidies to the sickness insurance bodies, and legislation concerning the use of fluoride for pre- vention of dental caries. Cantonal administrations undertake the surveillance and regulation of the tariffs for dental treatment. In principle, problems of health, including oral health, and the actions to be taken to solve them are the responsibility of the communities, which have often brought into being, in the absence of any cantonal legislation, school dental services. The organization of oral health services and delivery of care Oral health care for adults is mainly provided by private dentists whose fees are paid entirely by the patients. Those who have dental insurance can be reimbursed by the insurance companies but only a small part of the population is insured. There are four public dental clinics (Bern, Geneva , Lausanne , and Zurich) where adults having low incomes can receive treatment at a very reduced cost. In Switzerland about half the children under 16 years are treated by pri- vate practitioners under contract with the communities ; the other half are treated by school dentists (144 full-time dentists in 1960, 230 in 1968, 260 in 1974). Care can be provided in the dental surgeries of the schools or in the 89 private surgery of the dentist; this is sometimes a matter of free choice. The school dental service also covers accidents and urgent cases , and makes ortho- dontic treatment accessible to about 50% of the children. In most cantons restorative treatment is applied also to the deciduous teeth . In most of the school dental services parents are required to pay part of the cost (between 10% and 90% according to the income of the family) to the community , which remunerates the dentist in accordance with a can tonal scale; this may be lower than the federal scale . Certain legal provisions make it pos- sible to extend school dental service benefits to children of preschool age, the same subsidies being given. Oral health services for adults at present cover about 10% of the young people between the ages of 16 and 20 years . They comprise an oral examina- tion completed by radiography and an estimate of any treatment that may be necessary. Subsidies may be granted for the treatment of adolescents belonging to the lowest income group. Oral health manpower The great majority of dentists have received university training and hold a federal diploma . There are still a very few dentists without university training but with cantonal approval to practise. In 1970 there was 1 dentist to 2500 population. About 150 new dentists graduate from the Swiss dental schools each year. Prevention of oral diseases The following main methods are used for prevention . (1) Fluoridation of drinking-water; this covers 4% of the population . (2) Fluoridation of salt at a rate of 90 parts per million of fluoride ; this salt is consumed by 70% of the population. (3) Fluoridation of salt at a rate of 250 parts per million of fluoride ; at this dosage rate the urine contains a fluoride concentration comparable with that caused by the consumption of fluoridized drinking-water . This salt is con- sumed by 8% of the population . ( 4) About 7 5% of schoolchildren receive fluoride tablets to be taken every day, or brush their teeth (under supervision) with fluoride solutions, or are treated by a combination of these two methods. All these four measures are applied without charge. Main current problems One of the current problems for the oral health services is the unequal distribution of dentists . In the east of the country (800 000 inhabitants) there is 1 dentist for 4800 population and , if anything, the situation is becoming worse. 90 The use of dental hygienists is limited to certain urban areas. Until 1974 all received their training abroad . The first group of dental hygienists trained in Switzerland completed their studies in 1975. The financing of oral health care also gives rise to problems, and a reform of the law to considerably increase dental health insurance is at present under study. With regard to the prevention programmes, progressive development at the cantonal and community levels is envisaged. TURKEY Introduction The organization of dental education in Turkey goes back to the middle of the nineteenth century . Teaching was given in the schools of medicine and the first physicians to graduate from these schools were also responsible for the care of teeth. From the time of the Ottoman Empire, dentistry was carried out by surgeons or by certain self-taught persons. Later, the right to practise became subject to obtaining a surgeon's certificate, originally given by the medical director of a hospital but later awarded after a practical examination by the Facu:ty of Medicine. The Istanbul Dental School was set up in 1909. The school of higher den- tal studies of the Faculty of Medicine of the University of Hacettepe was opened in 1963 and this was followed in 1964 by that of the Faculty of Medicine of Ankara University. The Faculty of Dental Medicine at Izmir was established in 1968 and that of the Atatiirk University in Erzurum in 1970 - 71. There are also 4 high schools of dental medicine attached to the faculties of medicine, 2 in Ankara, 1 in Izmir, and 1 in Istanbul. Dental studies last 5 years ( or 6 at the University of Hacettepe ). Management of the oral health services Intervention of the state in the management of health services is limited to the sector subsidized from the state budget; this is associated with the general hospitals. The private practice of dentistry is not directly regulated. Dental social insurance comes within the framework of the general regulations con- cerning sickness insurance , which define the financing and administration of this insurance and lay down the benefits for insured persons. Delivery of oral care The largest part of oral care is provided by private practitioners entirely remunerated by the patients themselves. Dental insurance of industrial workers 91 and employees covers about 2 million families. It provides for free dental, sur- gical, or repair treatment. Dentures are not provided free except within the framework of dental treatment following an accident; in other cases all pros- thetic treatment is paid for by the patient. Certain sectors of industry, the rail- ways, for example, have their own system of insurance that provides higher benefits for the participants. The oral health services organized by the state are provided in the state- owned hospitals. About a fifth of all the hospitals have small dental polyclinics. Patients with an income below a minimum level (about one-third of the popu- lation) are treated free; others must pay part of the cost. Demands for urgent treatment are still the most frequent. Oral care for children is also provided in the hospitals or their dental poly- clinics. Since 1960 all the hospitals have been required to treat school-age children free of charge . To supervise this measure the Ministry of Public In- struction employs several dentists established in main towns. Provision of oral health services In addition to the dental polyclinics of the hospitals, there are also in the main towns several dental polyclinics coming under the dental insurance com- panies. Treatment is also provided at a modest cost in the polyclinics of all the dental schools. Private practitioners have their own surgeries, but as the num- ber of these surgeries is not regulated dentists in the private sector are distrib- uted very unequally over the country. In the province of Istanbul there is 1 den- tist for 1700 population, in Ankara 1 for 3400, and in Tun~eli only 1 for 154 175. Oral health manpower In 1973, Tur key had 3 8 7 4 den tis ts for a population of 3 7 800 000, i.e., an average of 1: 9757. Nearly all dentists practise general dentistry; the number of specialists is very limited and the only recognized specialty is orthodon- tics. The number of dental auxiliary personnel is also small. Dental technicians are artisans trained by apprenticeship. Courses have also been organized for training this category of personnel in certain hospitals coming under the Minis- try of Health and S9cial Welfare . Dental laboratories function only in 18 hos- pitals. Prevention of oral diseases The fluoridation of drinking-water has not yet come into force in Turkey . Health education in oral hygiene is essentially designed for pregnant women and mothers attending maternal and child health centres. Pupils of primary and secondary schools also receive oral health education through dentists employed by the Ministry of Public Instruction. Prevention has been integrated into this programme in so far as the number of personnel allows this. 92 Future plans Confronted with the clear necessity to enlarge the oral health services in Turkey, it is proposed to promote the training of personnel while at the same time improving standards of training. It will also be necessary to increase the proportion of oral health personnel working in the institutions attached to the Ministry of Health and Social Welfare, the existing numbers (270 dentists out of a countrywide total of 3874) being far from satisfactory. Finally, it is in- tended to pursue research on the optimum concentration of fluoride in drinking- water. UNITED KINGDOM (ENGLAND) Introduction Examinations in dentistry were introduced under the Medical Act of 1858, and in 1921 the practice of dentistry by unregistered persons was prohibited . The first public dental clinic was established in 1907 for the treatment of schoolchildren ; by 1918 local authorities were obliged to provide treatment for primary-school children and could treat expectant and nursing mothers , and other children . Between 1923 and 1926, 12 million members of the public be- came entitled to receive dental insurance benefits from private dentists . The 1944 Education Act obliged education authorities to dentally inspect and treat all children in publicly maintained schools and, under the National Health Service Act of 1946, comprehensive oral health services for the whole population were provided through public authorities, whose administration was unified by the National Health Service Reorganisation Act of 1973 . Necessary dental treatment is available to the whole population of 46 million through gen- eral dental service practitioners working in their own surgeries under National Health Service (NHS) arrangements. Alternatively, in local clinics , treatment is available to schoolchildren through the school dental service, and, through the priority dental service, for expectant and nursing mothers and children below school age. Specialist support for all these systems is provided by NHS hospitals . Management of the oral health services The Department of Health and Social Security, under a government minis- ter, and with lay and professional staff, is responsible for the central strategic planning, monitoring, and financing of the public oral health services. It deter- mines the scale and balance of services and guides , supports, and , as required, controls regional and area health authorities. Surveys and research are organized centrally, and statistics relating to treatment, costs , and staffing are collected and evaluated. 93 Altogether, 14 regional health authorities and 90 area health authorities in England, composed of unpaid members and served by professional advisory committees and salaried staff, plan, supervise, and control services at their own levels and employ, on a salaried basis, staff in hospitals and in school and prior- ity service clinics. The family practitioner committee of each area health au- thority, with the assistance of the Dental Estimates Board , administers the arrangements for general dental service practitioners working in their own sur- geries and pays their fees. Community health councils are given the specific function of representing the views of the public to area health authorities. Provision of oral health services The aim of the dental service system is to make available to all persons normally resident in England all the treatment, including orthodontics, they need to make them dentally fit. Anyone may seek an appointment with any general dental service practitioner, regularly or whenever he desires treatment. The provision of certain crowns, dentures, and other appliances and some treat- ments is subject to the prior approval of the Dental Estimates Board. The patient pays half the cost of treatment up to a maximum charge of £10, but examinations, arrest of bleeding, and repairs to dentures are free . Children and expectant and nursing mothers are not charged, and persons who cannot afford the charges are assisted financially. Priority dental service clinic treatment for expectant and nursing mothers and young children is free . Children in schools maintained by the education authority have an oral inspection normally every year and are referred to the school dental service clinic or to the general dental service for necessary treatment. Treatment outside the NHS is also available to those who wish it from private fee-charging dental practitioners. Any patient may be referred to hos- pital for specialist services, which are free of charge. Delivery of oral care Most oral care in England is provided through the NHS general dental services by dentists under a contract for service. A dentist may decline to accept a particular patient but must render dentally fit any patient he has accepted. The fees paid for the more usual items of service are determined by a group composed of representatives of the central departments and the profession under an independent chairman. The Dental Estimates Board considers any proposals from the practitioner for less usual treatments re- quiring prior approval or special approval of fees , and subsequently authorizes payment of the fees due, less any charges due to be paid by the patient. The Board also reports any suspected breaches of contract. Some health centres have been developed by local authorities where salaried dentists provide general dental services. The school oral heal th services inspect, usually on school premises , the 95% of the child population attending state-maintained schools. About 60% are 94 inspected each year and approximately half require treatment. Over 2000 sur- geries in fixed or mobile clinics are situated mostly in educational catchment areas . The priority dental service for expectant and nursing mothers and young children is provided in conjunction with the school dental service, usually in the same surgeries. The dental specialist service provided in teaching hospitals and dental departments of general hospitals is used by any dentist who wishes to refer a patient for a consultant's advice or any necessary advanced treatment. The armed forces have their own dental services. About 11 000 dentists in England provide National Health Service gen- eral dental services but some work part-time in other services . The school and priority dental services employ the full-time equivalent of about 1550 den- tists, and the hospital services about 850, one-third of whom are of consultant status. Dentists qualify after 4 or 5 years' full-time study at university level. Re- fresher training is available to all dentists and some study for higher academic qualifications, which are essential for hospital consultants. The General Dental Council maintains the Dentists Register and is responsible for supervision of training standards and professional discipline. About 225 enrolled dental therapists in clinics and hospitals conserve and extract deciduous teeth and carry out simple fillings in permanent teeth under dentists' direction and written prescription. There are about 450 enrolled den- tal hygienists who may work also in the general dental services . Under the direc- tion of dentists, they clean, polish, and scale teeth, apply prophylactic solu- tions, and give oral hygiene advice . Oral health education is undertaken primarily by local authorities with the assistance of the Health Education Council , which produces leaflets and posters , spending over £20 000 annually. A limited amount of oral health instruction is given in some schools. All National Health Service general dental service prac- titioners give necessary advice to their patients during the initial diagnostic examination. Fluoridated water is supplied to about 3 .5 million people and a further 500 000 receive water with an adequate natural fluoride content. Main current problems and future plans A high level of oral disease is experienced. There is a shortage of dentists, particularly acute in some regions owing to uneven geographical distribution and also wastage of practising female dental auxiliary personnel. It is planned to continue to increase the overall level of oral health manpower. It is hoped to use opportunities provided by reorganization of admin- istrative structures to coordinate and improve dental service provision and planning. There remains the problem of fluoridating drinking-water, some of which is piped to areas of minority opposition . 95 YUGOSLAVIA Introduction The dental service as a health profession started in the middle of the last century in Serbia (Belgrade , 1844). In the other parts of Yugoslavia (those that were under Austro-Hungarian rule) it started towards the end of the century (Zagreb, 1893). The first book dealing with dentistry was published in 1904. In 1923 professional dental training started fo r physicians following completed medical studies. In 1927 the Yugoslav Society of Dentists was formed, and in 1932 the first journal was published (there are now four). In 1933 the first Congress of Yugoslav Dentists was held and was attended by 53 dentists from various parts of the country . In 1948 the first School of Dentistry (Faculty of Stomatology) was opened in Belgrade. Today there are seven dental schools. Before the Second World War there was practically only private practice in dentistry with some services provided under the social insurance system in the larger towns. After 1950 private practice was reduced and this service now operates under legal regulation and solely under the social insurance system in most of the Yugoslav republics. In some of the republics private dental practice is allowed but is practised only by a small number of dentists. Management of the oral health services The services are entirely the responsibility of, and fall under the compe- tence of, the community. Oral health planning is the object oflegal provisions passed by the federal and republic legislative assemblies as well as those of the two autonomous provinces. Services are implemented by the local institutions concerned and managed by the insured persons' assemblies , this being a specific feature of Yugoslav self-government. Provision of oral health services Oral health care is accessible to all Yugoslav citizens according to the demands for service. There are legal provisions to regulate the tendency towards ever-expanding coverage of priority groups : children and young persons under 16 years, pregnant women (entitled to free care), etc. All those employed in the field of public service and members of their families are entitled to free oral care . Adult farmers pay part of the cost (0-50%) of the services provided to them, depending on the commune from which they come. Delivery of oral care Basic oral care is delivered by the communal network of outpatient units. The principle of free choice of dentists and institutions is fully applied. Special- ized services (e.g ., prosthetics , orthodontics, child and preventive dentistry , 96 diseases of the mouth and teeth, and oral surgery) are available in all larger towns through the health centres. In the main towns of the republics, as well as in some larger centres , there are dental clinics for maxillofacial surgery for both inpatients and outpatients. Child oral health services are organized in various ways in the country: in child health clinics, in school health services, where they form an integral part of the school health clinic, in the health centres that exist in each commune, and in outpatient clinics for adults (in the smaller localities). This type of care is not compulsory. Systematic oral care for preschool children is carried out to a very limited extent only in larger centres. Systematic school oral care is also restricted to dental units in schools, child health clinics, and health centres . Roughly speak- ing, the proportion of schoolchildren examined systematically is around 20%, and that of schoolchildren systematically treated about 5%. Oral health manpower Dental professionals are (1) physicians who graduated before the Second World War and specialized in oral and dental diseases after completing their medical studies (a small number); (2) dentists trained in 5-year dentistry courses (most existing professional personnel); and (3) dental therapists with various types of training but no university degree. The number of dental therapists is steadily declining as this type of training has been discontinued. In 1970 there were 2862 university graduate dentists and 1623 dental therapists without a university degree. The total number of practising profes- sionals in 1974 is 4485 . There are 3120 dental technicians, and the total num- ber of chairside assistants is 3930. There are 2382 dental clinics. Chairside assistants who previously attended I-year courses are now receiving additional training. There are no dental nurses of the New Zealand type. After graduation and the compulsory I-year internship, dentists are free to work wherever they find a post. Vacancies are advertised in the press , and for this reason there is a tendency for dentists to concentrate in large centres . Refresher courses lasting 1 - 3 weeks are held by the dental schools once or twice a year and are open to all practising dentists. Curricula for these courses are circulated in advance to all health institutions , which , according to their needs, bear the expenses of professional staff attending a course. Special- ized training is available in all fields of dentistry. Applicants must have a uni- versity degree in dentistry , and have successfully completed the I-year in tern- ship and professional examination. In addition they must have spent 3 years in dental practice. This type of training lasts 3 years, and deals with orthodontics and child and preventive dentistry , oral surgery, oral and dental diseases, and prosthetics. Specialized training in maxillofacial surgery lasts 4 years. Prevention of oral diseases Drinking-water is not fluoridated, but one republic has adopted legislation requiring this to be done . Fluoride tablets are distributed to schoolchildren by outpatient units on an individual basis . Larger numbers of children are provided 97 with these tablets only in certain centres. About 2-3% of schoolchildren bene- fit from topical applications of fluoride. Limited health education is carried out by school dentists and those attached to child health clinics. Oflate ,efforts are being made by the Faculty of Dentistry and the Institute for Health Educa- tion to intensify dental health education and to conduct appropriate activities in that field. Main current problems and future plans There is an inadequate number of oral care outpatient units , especially school dental units , and an inadequate number and uneven distribution of dentists. Plans have been made to increase the number of oral health care institu- tions, implement the fluoridation of drinking-water, distribute fluoride tablets, and in general to change the emphasis from curative to preventive activities. It is also planned to expand systematic oral care for particular population groups - school oral care coming first - and to expand and improve coverage for an ever-increasing number of preschool children, along with care for employed adults. 98 PART III ORAL HEALTH CARE IN EUROPE DISCUSSION 1. BASIC FEATURES OF A USEFUL ORAL HEALTH SERVICE SYSTEM MODEL General A model of an oral health service system that could satisfy the expecta- tions of the population better than some existing systems is described here. Be- cause one of its basic features is steady development, this model will hardly ever achieve a final stage where all problems are solved and all expectations ful- filled. All service systems are basically unstable because the aspirations of the population in relation to a health service are continually evolving. Development of a service system is never regular, proceeding quickly at certain times but more slowly at others, and the concept becomes changed. Every change in the concept should make the system more acceptable to the population and improve its functioning. Every beneficial change of concept in the system creates new possibilities for expansion of the system or improve- ment of its quality. The quiet periods of development offer organizers an op- portunity to study the system and its dynamic components, to update their in- formation about the population's attitudes towards oral health and to consider and analyse alternative solutions to organizational problems and verify these in field laboratories and pilot areas. In every service system factors that speed up its development are in steady competition with those that slow it down. The most important factors in the first category seem to be the economic potential of the country and the stan- dard of living of the population. Another factor encouraging development is the degree of responsibility accepted by the community for the general and oral health of the population , and a fourth is the rapid progress made in dental science and the possibility of applying this knowledge in practice (i.e ., the methodology of oral health service system management). This last factor 99 could also be described as a rational approach to the system's function. Among the limiting factors the most important is perhaps lack of economic resources. However, very important also is a tendency to yield to accustomed ways of thinking and to accept opinions based on faith or on tradition and lacking a rational foundation. Also, the special interests of the dental profession or pro- ducers of dental equipment , or of the institutions organizing the oral health service, can hamper the functioning of the system. In this connexion it is necessary to say something about the points of view of dental professional organizations. A national dental association can have a stimulating, as well as a retarding, effect on the development of a national oral health service system. It has a duty to protect the requirements and expecta- tions, professional and personal , of dentists. This is understandable ; the just expectations of the dental profession must be satisfied in order to ensure that the service system functions smoothly. On the other hand, the historical develop- ment of the oral health service in certain countries demonstrates that the national dental association has sometimes had hard views about the new forms of oral health service being introduced . In more than one instance it became clear that the reservations and anxieties of the national dental association were exaggerated and that the members of the professional organization could find economic and professional satisfaction in the new form of service. Therefore, while it is necessary to take the professional organization's views into account when changing the concept of the oral health service, the organizer of the service must interpret the intentions and formulations of the national dental associations cautiously, evaluate them correctly, and establish a balance between the aspirations of the profession and those of the population at large. During the historical development of oral health services in Europe the dental profession has shown an admirable degree of elasticity and adaptability when facing sometimes quite abrupt changes in the oral health service system. The organizer of the oral health service may confidently count on the coopera- tion of the dental profession at all times . The role of the International Dental Federation (FOi), the only profes- sional dental organization in official relations with WHO , must be mentioned in this connexion. The FOi represents a large number of national dental organiza- tions and assists them in solving common problems. The ways and means it uses are analogous to those employed by WHO . The Federation has a tradition for strong, dedicated, progressive leadership , and has given considerable help to the dental profession all over the world in identifying its role in the develop- ment of a healthy society and in solving major professional problems . Availability, Acce~ibility, and Acceptability of the Oral Health Services In highly developed European countries oral health services of comparable quality are now usually available in urban and rural areas. In the developing European countries tl1e situation is not yet so favourable. Differences in the density of dentists between the urban and rural areas remain very great, and 100 in some of these countries the concentration of dentists in towns is 150 times higher than that in the country areas. Countries with a progressive concept of the oral health services have recog- nized the right of all citizens to have access to oral care . Acceptance of this broad responsibility has a very beneficial effect on the development of the oral health service system; it helps to increase the volume of care delivered and to improve the quality of care through expanding preventive programmes and treating more of the population completely and regularly. This is the develop- mental concept of progressive oral health service systems, and in the future the populations of the highly developed European countries will hardly be willing to accept less. It is understandable that the oral health of the population can only be realized by making heavy demands on costly material and manpower resources. In this respect, therefore, the country will always depend on a sound economy and will be constrained by lack of resources . However , acceptance of this responsiblity gives health administrations good grounds for demanding new resources and also stimulates the economic utilization of available resources . Integration of the General Health and Oral Health Services An oral health service is undoubtedly a part of a general health service and should be integrated with it in all respects . Good oral health is necessary for normal functioning of the body and also for mental wellbeing and successful social adjustment. The second aspect of oral health is often overlooked. All the basic oral health needs and demands of the population should be satisfied, as well as those relating to general health. The oral health services should therefore be planned in much the same way as the medical services. No doubt the oral health service will always be primarily a large outpatient service, but it must have facilities for treating hospitalized patients (offered either by the oral health service or the medical service) and the means to develop special- ists in fields where difficult cases occur that are beyond the experience of the general dental practitioner. It has been felt in some countries for a considerable time that in the under- graduate dental curriculum the teaching of biological subjects should be ex- tended to the detriment of technical subjects, in particular the properties, pro- cessing, and use of dental materials. Also, the biological aspects should be iden- tified in the so-called cosmetic treatment demands of patients ; these require- ments are psychologically motivated and connected with the patient's mental wellbeing, and they should therefore be satisfied even when simple, functional treatment is planned . They should be part of, and not an alternative to, func- tional treatment as used to be the case in some dental health insurance schemes . On the other hand , cosmetic considerations should not be accepted as an op- portunity for applying special technical skills and collecting high fees. Like the medical services, oral health services should make good use of the possibilities offered by scientific advances and be ready to treat all cases de- serving of treatment as well as to prevent all disease that can be prevented. This 101 development will be constrained by competition with other health disciplines for available resources. Health service organizers should understand that the expectations of the population with respect to mental and social wellbeing are rising together with living standards. Development of the oral health services may proceed at a faster rate than would seem to be justified by a strictly medical point of view. This is a characteristic feature of an oral health service and it should not be disregarded by any organizer wishing to satisfy the health requirements of the population as defined in the Constitution of the World Health Organization. Again like the medical services, oral health services have to use a team approach to the work. Medical personnel learn this approach in the hospital service that most physicians experience after their graduation. Dentists might learn the same lesson in teamwork while working in oral health centres . How- ever, this is possible only in certain countries since oral care is mostly delivered in the isolated surgeries of dental practitioners and organizationally it is often detached from the medical services . That is why the dentists in some European countries do not fully realize how far the use of auxiliary medical personnel has progressed. Within the last 50 years a number of independent health pro- fessions have developed in which auxiliaries have a considerable responsibility. Utilization of auxiliaries extends both the curative and preventive potentials of the health service without limiting the quality of care and without constrain- ing the function of the physician or his professional status . The oral health services should learn from this development in medical care. The profession cannot insist that all procedures forming a part of dental treatment be executed by a dentist with university training. A dental hygienist removing dental calculus or a dental therapist preparing a cavity for placing an amalgam filling is not bearing any greater responsibility than a medical nurse working in an intensive care unit. The fears about professional status that are limiting the use of dental auxiliary personnel in the oral health services pre- clude expansion of output to meet the demands made on the service. Thus integration of the general health and the oral health service systems could have a far-reaching influence on the development of oral health care. A Rational Basis for the Oral Health Services In a well-functioning oral health service system the management and con- trol activities are placed on a rational basis . Such a system has, in the first place, to define its goals as clearly as possible, and it should have at its disposal a sufficient amount of reliable information on the working output of the sys- tem and on important factors influencing the work. The results of the service are evaluated and monitored tq determine whether and how fast the final goals are being achieved. This also means that the concept and organization of the system must be carefully considered and matched to give optimal support to the functioning of the system. Both concept and organization should be free from internal 102 contradictions, and procedures based on tradition, accustomed ways of work- ing, or group interests should be examined and corrected if necessary. When discussing the concept or organization of an oral health service system based on rational principles, the organizer should always be willing to admit that he does not know the answer to all problems that arise. He should insist, however, that the question be decided on the basis of facts ascertained by experiment, and further that the facts ascertained are to be accepted by all those participating in the discussions. Present oral health service systems are far from being managed on a rational basis, and frequently their goals are not clearly defined in their concept. As a basis for planning services they use the suggestions and opinions of one or several experts instead of a thorough situation analysis, and in evaluating the results obtained they unintentionally or consciously avoid certain questions. This ab- sence of rational management slows down the development of the oral health service. The way towards rationalization of present oral health service systems be- gins with the information available about the working of the system. In the report on child oral health services in Europe issued by the WHO Regional Office for Europe in 1974a information provided by participating countries was critically analysed, revealing that some national oral health service systems lack certain basic information and the information available is frequently in- complete. The reliability of routine on-service data is not checked through epidemiological and other control surveys. Epidemiological surveys that are made are rarely based on representative samples of the population or on ran- domly selected groups, and in the results of these surveys there are surprising differences that have not been explained. Many important questions related to the evaluation and economics of the oral health services, their efficiency and cost/benefit relationships are rarely analysed, or even discussed, and exact knowledge concerning these problems is increasing very slowly. Research on all the different aspects of oral health services is therefore essential for constructing a rational basis for the services. This research must be considerably expanded , and the organizers of the oral health services should have a much greater influence on its planning and coordination. Field laboratories and pilot areas are also indispensable in rationalizing the oral health services. The output of the system and the way in which it is work- ing would be known in detail and also where changes in organization could be applied on a limited scale and evaluated carefully prior to their wider applica- tion to the whole system. This approach is still very rare in Europe . However, some countries such as the USSR and some other socialist countries in eastern Europe, together with certain Nordic countries and the United Kingdom, are following these lines. Efforts to maintain good dental health present the oral health services with tasks quite different from the treatment of diseased teeth. The population has to be motivated in favour of prevention and patients have to master the appli- cation of preventive methods . Prevention of dental diseases cannot be put into a WHO Regional Office for Europe. Survey on child dental health in Europe. Report on a study. Copenhagen, 1974 (EURO 5501). 103 practice without control of attitudes and ex tensive exposure of the population to oral health education. In this task the oral health services must look to educational institutions, especially the schools, for assistance. When preventive measures are introduced it is necessary to first enlarge the oral health services, at least in the early stages of this effort, because the work- load of oral health education and preventive treatment will increase but the vol- ume of curative care will not fall immediately. Later, when individuals exposed to preventive measures since birth form a significant proportion of the population, both trends will reach equilibrium and prevention will start to limit the volume of the curative care required. The total cost of the oral health services will then decrease , but total saving may be small because the decrease in curative care will be balanced by an increase in preventive care and oral health education, which need many personnel. In the final stage , introduction of prevention will completely change the character of the oral health services but the dental manpower needs of these services, especially in the well-developed countries , will not change very much, eve n though the style of work changes entirely. Fears about the future of the dental profession are therefore groundless. The Teamwork Concept in the Oral Health Services It seems likely that in the future the oral health services will be delivered predominantly in health centres, but this does not necessarily mean that the character of the future oral health services will correspond to the present-day public oral health service. Oral health centres can be organized on the basis of private practice if the service system makes a good use of group practice and , of course, oral health centres can be run by the dental health insurance com- panies. In Austria, France, and the Netherlands such dental health insurance centres are already functioning. The public oral health service need not be dis- cussed in this connexion because delivery of this service usually takes place in the oral heal th centres. This type of service delivery has several advantages. First , the oral health centres can be integrated, not just administra tively but also physically, with general health centres and dental patients can profit from this whenever medical assistance is needed during treatment , and consultations with medical specialists can be arranged easily and quickly if signs observed in the mouth indicate the possibility of an infectious disease , blood disease, a tumour , etc. Another ad- vantage is the possibility of delivering an integrated oral health service through general dental practitioners and dental specialists working in the same centre . In this respect also patients' expectations are rising. A third advantage in delivering oral care in an oral health centre is the pos- sibility of organizing a teamwork approach. In the past, the separation of oral care from the medical services and the hospital was a serious obstacle to team- work. This situation should now be changed . The relationship between the den- tist and different categories of dental auxiliary personnel must be re-examined, functional profiles established independently of traditional opinions but on the 104 basis of maximum benefit for the patient and the establishment of an efficient working pattern , and the whole and complex question must be thoroughly in- vestigated and the results verified by organizing experimental teams to study their functioning and determine their cost/benefit relationships . This is a task for oral health service field laboratories and pilot area studies. Certain aspects of this problem are discussed later in this report. Other advantages of establishing oral health centres would be the possibility of coordinating working times with the local transportation schedules. Also in an oral health centre it is easy to separate emergency cases and treat them to- gether with new patients arriving for the first time in one operatory, making it possible for the other dentists to follow their set schedules and to deal with patients arriving by appointment at certain times . Finally, one further advantage of oral health centres is the possibility of checking the work of all d1:ntal personnel and organizing regular control of quality . Even without organized control, however, when several dentists work together their self-monitoring improves and both working discipline and patient handling may also benefit. Strategy in Developing the Oral Health Services The basic criterion for the success of the whole oral health service is im- proved oral health in the population as a whole. This principle has to be ob- served when evaluating proposals for strengthening preventive programmes as well as in establishing an optimal mix of the different components of curative care. The fonner problem is dealt with later in this report in analysing the ef- fectiveness and effjciency of prevention of oral diseases ; the latter is discussed now . Strategy for the curative oral health services Two ways of dental treatment How should the development of the curative service be directed to ensure that the oral health of the population as a whole improves? In principle , diseased teeth can be treated in two ways . In the first, each carious cavity is filled to prevent complications of the caries (inflammation of the dental pulp or of the periodontal membrane) and periodontal disease is treated to prevent tissue destruction. In this way the natural teeth are preserved , their life span is prolonged , and their loss by ex traction postponed. The oral health of a population can at any time be expressed through the mean number of natural teeth remaining in situ in patients belonging to a certain age group . The task of curative care is therefore to preserve the natural teeth and to re- move the visible symptoms of oral disease. The second form of treatment is a radical one . Diseased teeth are simply extracted and replaced by a denture. In countries where dental treatment is 105 expensive patients may simplify their requirements even further and request the extraction also of healthy teeth and their replacement by a full denture because they wish to avoid complications and financial expense in later life. However, even when the tooth extraction has its own value from the point of view of secondary prevention, and even if an artificial denture is satisfactory both func- tionally and cosmetically, the principle of "terminal dentistry" can hardly be accepted for an oral health service programme. Once this service is able to pre- serve natural teeth and to treat them there is no choice; dental treatment must be based on the principle of restoration and terminal dentistry reserved for special cases - for example, when a restorative dental service is unavailable on ac- count of the geographical location of the patient or because of the general health status of the patient (physically or seriously mentally handicapped persons). In a restorative or conservative dental service, the oral health status of a population is evaluated according to the mean number of natural teeth preserved up to a certain age and also according to the mean percentage of teeth treated or replaced. These criteria can be differentiated even further to take into ac- count how timely the treatment has been with respect to secondary prevention. Treatment of simple caries is a better contribution to oral health than treat- ment of caries where there is already inflammation of the dental pulp. Using this assessment the level of oral health can be expressed by means of indices such as the mean number of extracted teeth per individual of a certain age or the number of teeth with pulp treatment per 100 teeth with simple fillings. Lost teeth, of course, have to be replaced. This is not true of each tooth without exception, but it is true for those teeth with an important functional or cosmetic value. Correct choice of priorities The oral health service is well organized if, at every evaluation of its total effect, it is seen that the above-mentioned indices of oral health or of the cor- rect choice of priorities in dental treatment, respectively, are steadily improv- ing. Those selecting priorities for dental treatment are often exposed to pres- sures arising from their wish to organize the oral health services in a more rational way than the available financial and human resources permit. In these situations oral health service subsystems such as regular and comprehensive child oral health services are sometimes developed before at least part of the adult population is covered by a restorative dental service. The consequence of this is that children are treated comprehensively to a certain age but in their later life they receive emergency treatment only. Thus many cases of caries and periodontal disease remain without treatment until tooth extraction is finally indicated. It follows that in such marginal cases the regular and comprehensive dental treatment of children may have been in vain. It might have been better to post- pone development of this subsystem and to improve first the restorative dental service for the population as a whole, offering the children a possibility of con- tinuing their comprehensive dental treatment. Uneven development of curative care also occurs when the oral health serv- ice is not directed and follows natural trends such as a preference for prosthetic 106 treatment rather than treatment of simple dental caries and periodontal disease. Another trend favours the treatment of adult patients in preference to children. Treatment of adults may be considered more rewarding both professionally and financially but it may not represent the best choice of priority because ulti- mately it is followed by the extraction of more teeth or by the treatment of disease complications. When selecting priorities for treatment of a strategy for the curative services we must therefore ask at each step the following question. Does the organization of the oral health service lead to improvement of health in the population as a whole, or does oral health just appear to be improving in the way that is characteristic of terminal dentistry , or are certain population groups given priority even if the indices of oral health in the population as a whole are declining? Quality of oral care The quality concept and oral health service development Quality of treatment is one of the priorities to be decided during the development of the oral health services. Professional dental associations are frequently afraid that the introduction of new forms of oral health service , especially dental health insurance and, to a certain degree, a public oral health service , will limit the quality of care delivered and that a "cheap" type of dental service will prevail. This anxiety is provoked by steeply rising demands for care and a corresponding quantitative rise in output, which often leaves individual dentists with little time to consider elaborate types of treatment. Also, the trend characteristic of dental health insurance - namely, support for simple , purposeful , and economical forms of treatment - leads to similar problems. The criterion of maximum benefit for the whole population must apply since the first duty of the new system is to serve as many patients as possible using simple treatment methods, simple treatment being better than none at all. Later, when the opportunities for high quality treatment improve the system should offer more intricate constructions that have a better prognostic value . The strategy related to quality development must therefore correspond to the functioning of the service system and to its developmental stage. In the early stages when the service system is attempting to satisfy all the demands for care a simple approach to the treatment of individual patients must be accepted in order to offer better care to the whole target group . The service system should not be criticized on this account unless it is clear that it has neglected essential aspects of treatment. Work of good quality contributes to the wellbeing of the patient, the durability of the treatment, and the professional satisfaction of the dentist. However, to achieve good quality work a number of conditions have to be met: well-trained personnel , good technical equipment , and regular evaluation of quality . The last requirement implies proper criteria for evaluation and effective evaluation methods. 107 Criteria for quality The expression "quality of dental treatment" is often used in connexion with the accomplishment of technical curative procedures. However , in describ- ing the quality of the oral health service system some additional criteria have to be observed. These are discussed below together with their significance for the oral health services. As already explained, in the first stage of development of the new oral health service system use of simple treatment methods for individual patients may be justified , even if they have a less than optimal effect on the natural dentition - simple removable acrylic dentu res , for example. In this way it is possible to provide oral health service coverage for a large proportion of the population, and this in itself raises the level of oral health and the quality of the whole service . The remaining technical criteria of quality can be satisfied later when the oral health service has all the equipment and other conditions necessary for high quality work . The second quality criterion is related to the prognostic value of curative constructions. For example , it is generally accepted that a cast-metal inlay is of higher quality than an amalgam filling, that a cast-metal crown is of a higher quality than the older type of crown fabricated by soldering, and that a cast- metal denture is better than a simple acrylic denture because it protects the re- maining teeth and the gum margin more effectively. This criterion is sometimes used to evaluate the whole oral health service or dental treatment systems , a service that provided predominantly inlays, cast- metal crowns, and cast-metal partial dentures being automatically considered of high quality. For an evaluation of a service system, however, broader criteria should be used and the adequacy of the service should be taken into account. A high quality oral health service system delivering good , protective, curative care to only 10% of the patients leaving the remaining 90% of patients without treatment would be unacceptable . The third quality criterion is related to the treatment plan . Treatment quality depends not only on the construction of a denture or a filling , or on their technical finish, but also on the correct planning for incorporation of the construction into the natural dentition . Mistakes in this direction can be elimi- nated if treatment in all cases is planned comprehensively and the dentist avoids applying individual procedures at random. Measuring treatment quality Lastly , the quality of the oral health service system as a whole has to be eval- uated according to criteria that bring several view-points to a focus - the satis- faction of patients, the proportion of patients treated, and the completeness and timeliness of the treatment. The quality of the service system is clearly rising if it can be shown that it covers a larger segment of the population than before ; that the scope of the service delivered to an average patient is greater ; and that the service system shows trends towards restorative care and fewer extractions , towards dental fitness restorations as against irregular and 108 incomplete treatment, and towards timely treatment (an increase in the num- ber of simple fillings as against the cases of pulp or root treatment). The quality of the oral health service system cannot be defined without taking into account the development of the service and the equipment and re- sources available, as well as the task undertaken by the service . For tactical or strategical reasons the manager may be content in the first developmental stage_ to satisfy the great demand for service in a quantitative way, thereby enabling him to offer treatment to more patients in spite of limited financial , material , and human resources. This approach meets in the first place the political expec- tations of the population with regard to the service system. Later , when the re- sources of the service increase the treatment strategy can , and should, change , and more elegant and expensive constructions with a higher prognostic value should be provided . Treatment quality in the oral health services must be monitored and evalu- ated systematically and the working quality of the service system should increase steadily . It has to be kept in mind, however , that the dentist learns the rules for quality treatment during his undergraduate dental education from teachers who may have learnt the same rules from their own teachers a generation earlier. Thus, the criteria of quality transferred from one generation to another are often based on simple , uncontrolled experience and not on experimental evidence . Since future oral health service managements will undoubtedly insist that quality cri- teria be respected , even when this makes the treatment more time-consuming and more expensive, the features of curative procedures on which quality depends should be known . All such questions need experimental evaluation to ascertain that the principles to be applied in quality control are valid. From the patient's point of view the most important aspect of quality other than the cosmetic effect may be the durability of the treatment. Treatment of reasonable quality, whether a simple filling or a more complex procedure, should have a long life . This is imp or tan t in relation to the volume of treatment because when the durability of treatment is good few patients return, which means that the working capacity of the service is used for treating more new patients and that the proportion of the population covered by the service increases . Conversely, when durability is poor , a large number of patients return for treatment. This aspect of oral care must be incorporated in national oral health service systems because working economy is improved and the proportion of satisfied patients increased without allocating more resources to the service. Unfortun- ately, the durability of dental treatment is largely unknown . The average life of a good filling , inlay , or crown should be determined as soon as possible . The quality of treatment in relation to the return of patients for further treatment should also be emphasized in undergraduate dental curricula. Dental students must be shown by means of oral health service models how treatment of low quality increases the volume of work for the service. Quality control Difficulties experienced in quality control are connected to a certain ex- tent with the unwillingness of the oral health service manager to control per- sonally the quality of work produced by his dental colleagues . However , the 109 quality of work should be monitored in all oral health services. Quality stan- dards are required for comparing different teams working in the oral health service system as well as for evaluating the whole national oral health service systems . Such standards would make a significant contribution to international comparative studies of oral health services. 2. CONSTRUCTING AND EQUIPPING THE ORAL HEALTH SERVICE FACILITIES The physical planning and equipping of the oral health service facil- ities must be adapted to service development as the scope of the service will increase , the dental manpower augment , and the oral health service facil- ities will need considerably more space. First, the curative departments must be enlarged and equipped for an expansion in periodontal treatment, and new departments for oral health education and prevention will be needed. Also, facilities for practical training in oral hygiene procedures, etc., must be provided . These need to be equipped with washbasins and mirrors of the pattern used , for example, in Scandinavian school dental services. If oral health education is to be successful , this department should be large enough to accommodate every patient touched by the curative services because every patient needs instruction in readjusting his attitudes towards prevention. Equipment supplied for the curative department should be adapted ergo- nomically to the work performed . This enhances productivity and conforms to the requirements of occupational health. This is discussed more extensively below (see p. 111). An ergonomically sound style of working, including "four- handed dentistry", is more and more frequently being a(iopted in the developed countries. It should be developed in an organized way, which includes studying its effect on , and consequences for, the organization of the curative service , the satisfaction felt by both patients and personnel , and the cost/benefit balance of curative treatment. In the developing countries the physical planning and equipping of oral care facilities will probably follow a different course. Since in these coun- tries great emphasis is placed on the cost and output of the service, and since the financial resources available to the oral health service are usually very limited, it should be stressed that dental treatment of good quality can be performed with simpler equipment than that on the market in the developed countries. Most dental equipment is produced to satisfy the requirem,ents of com- petitive private dental practice . According to these criteria, the equipment has not only to be functional and comfortable but is designed also to impress pa- tients by its design and finish. Simple equipment for safe and comfortable work is mostly constructed for use in oral health services of the armed forces . Developing countries should look for this type of equipment, and it would be 110 particularly useful if it were available in a transportable form for use by oral health teams visiting localities where there are no oral health centres. Such equipment should be simply constructed and easily repaired, and a good supply of spare parts should be available. "Dental buses" equipped with a laboratory for a dental technician and an X-ray machine are extremely useful though their cost is usually too high to permit their use in developing countries. 3. A NEW WORKING STYLE FOR THE ORAL HEAL TH SERVICES As already pointed out, we are experiencing at this time a violent up- surge in demand for oral health services. National oral health service systems must cater for, on the one hand, an increase in population size and, on the other hand, rising expectations stemming from higher living standards. If oral health service development cannot meet the requirements of the pop- ulation and part of the demand for service. remains unsatisfied, the popula- tion will receive a mix of emergency treatment and restorative and preven- tive oral care. This is worse than before, in so far as the proportion of emer- gency treatment increases and that of restorative and preventive care de- creases. To avoid this situation, the oral health service manager must meet the rising demand for services, even in situations where resources in the na- tional budget do not increase fast enough. In that event there is only one way open to the manager - namely, to use whatever internal reserves are available in the service system. Some reserves are generally available in every service system, and the problem facing the manager is to find a means of raising the output of the service without increasing the costs or the numbers of oral health personnel. Chairside Economy In the USA, the organization of oral health care to establish a harmonious balance between human capabilities, the technical characteristics of the equip- ment used , and productivity (i.e., ergonomics) are sometimes dealt with under the heading "chairside economy". The core of the problem is how to achieve a higher output through improved and more purposeful organization of work in the curative services without exposing the oral health personnel to occupational hazards. The main features are described below of the working process being studied in a number of American dental schools and tested in practice in sev- eral field trials. 111 Dental Surgery Equipment and its Use This concept has several aspects, one of which is connected with dental surgery equipment. The equipment must be designed and constructed with a view to protecting the health and promoting the effectiveness of the personnel using it, so that the maximum amount of work is delivered with minimal strain. In the dental surgery the equipment must be so arranged as to enable the best use to be made of the available space . The criteria for this have to be derived from an analysis of the working process , taking into consideration every move- ment performed by all members of the oral health care team to establish the closest coordination between the equipment and the personnel. In this way working comfort increases and working time is used most productively. All unnecessary procedures and movements must be eliminated, distances between different parts of equipment shortened, and each part of the equipment placed in such a position that it can be reached with ease. The whole function then develops smoothly, the different procedures follow one another logically with- out interruptions, and productivity rises considerably. The Role of the Patient The patient has to be included in this analysis; his position and accessi- bility in the dental chair must be adapted to the working process . In most instances the patient is placed in a modern dental chair in a reclined position, enabling him to relax during treatment. The dental personnel sit near the patient's head on easily moveable stools, and all the main instruments are within reach. The chairside assistant works mostly in the way typical of "four- handed dentistry" and assists the dentist in a similar way to the general surgery assistant. Division of Working Functions Another general feature of this working system is its divergence from the former division of working functions. The working functions and their division are based on the principle that the deciding factor is the output of the whole team for the whole working time. Output should be the maximum possible and the distribution of working functions within the working team , the number of the team members , and their education and training must be redefined to cor- respond to the basic functional task of the team . The old division of work, according to which the dentist deals with practically all curative procedures and the chairside assistant only assists him, preparing and holding instruments, mixing dental materials and so on, is being abandoned. 112 In the new system now being developed functions are delegated by the dentist to the auxiliary members of the team, whose duties are being broadened (the so-<:alled expanded function system).a The main rule for this delegation of functions, which is observed in the American system, is that the dentist attends to all procedures that are of an irreversible nature. All such procedures have to be well performed because bad work is difficult to repair (e.g., preparation of a carious cavity or preparation of a tooth for an artificial crown). These pro- cedures are not delegated because poor workmanship could seriously inconven- ience the patient. Reversible procedures such as filling a prepared cavity, polishing the filling, application of a gingival pack, or taking an impression of the jaw can be delegated to adequately trained auxiliary personnel. The utiliza- tion of dental auxiliaries is considered in detail in chapter 5. In a system controlled by the working economy, the dentist performs ir- reversible procedures and deals with the reversible ones only when this is nec- essary for the harmonious functioning of the whole team. If, for instance, all the other members of the team are busy, the dentist might complete the placing of a filling. The patients should attend at specified times, the chairside assistant prepares the patient , and the dentist performs the preparation or other procedure considered necessary, leaving a third member of the team to place a filling or otherwise complete the treatment. A prerequisite is to have several dental chairs available and a good working plan for each half day's or full day's work so that there are no avoidable delays. It is clear that this style of working requires more than the purposeful equipping of the dental surgery or the delegation of certain functions to auxiliary person- nel. While the system has a higher output than existing European systems, it is also more demanding because each team member has a specific role and must adapt to the working speed, the procedure selection, and the concentration of the whole team. The dental surgeries are on the whole larger and have more equipment. As far as possible mechanized methods are employed. Many sets of standardized dental instruments are provided and these are all sterilized together, neces- sitating adequate sterilizing facilities. The patients must become adjusted to this style of working. They must attend punctually for treatment because if one patient fails to arrive the planned working sequence is disturbed, impairing the working of the whole team. Remaining Problems Some aspects of this working style have not yet been fully studied, and the described system includes several elements of risk that have to be taken into account or avoided. On the whole , however, it represents considerable progress in the organization of oral health care. Each step towards this fully functional a See Allied, H. The training and use of dental auxiliary personnel in Europe. Copen- hagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 7). I 13 arrangement provides good service for patients. It seems likely that this, or a similar, system will prevail in the oral health services of the future, even when a rather profound change is required in the mode of working style and the team- work concept. Research in this area of delivery of oral health services is very desirable. 4. TYPES OF ORAL HEALTH PERSONNEL AND THEIR EDUCATION Dentists The oral health services are large and relatively expensive; they have this character because the oral diseases are very prevalent and treatment is much in demand. On the one hand, this makes the oral health service an important branch of the general health service; on the other hand, it should make oral health service managers think about the economics of the delivery of this serv- ice and search for ways to conserve resources. Among the problems they will encounter are those of selecting suitable professional profiles for the different categories of dental manpower and the most appropriate educational curricula. This complex question is dealt with in detail later in this report (see p. 120). Here, comment will be limited to outlining the basic problem in order to indicate the conceptual questions that must be dealt with in future oral health service models. The term "dentist" is used in Europe for various types of professional having different backgrounds. In Austria, Italy, Luxembourg, and Spain den- tists are professionals who hold a degree in medicine and have received a spe- cialized postgraduate training in dentistry. These dentists are sometimes called "stomatologists". They exist also in Belgium and France, where they represent a small minority of the dental profession. In eastern Europe a stomatologist specializes in dentistry as an under- graduate. His education includes a combination of medical and dental subjects, the medical part emphasizing the biological background. Disciplines such as biology, chemistry , anatomy, physiology, are usually allocated approximately equal teaching time in the medical and dental curricula. Training in clinical medicine is limited but clinical conditions of the mouth are covered in full . In some of the eastern European countries, such as Czechoslovakia, the stoma- tologist receives a medical degree, but by a health ministry regulation he is bound to work in the field of dentistry only. In the remaining European coun- tries the dentist is partner to the physician and receives a specialized education like the pharmacist or sanitary engineer. In the countries where there is a relatively long dental education involving medical studies the production of dentists is usually slow. As a result, some 114 European countries during the early parts of this century allowed dental tech- nicians who passed a special examination to perform dental treatment along with fully qualified dentists. These experiments hindered the development of the dental profession and, as a study of Part II of this report shows, all have now been discontinued. It is generally recognized that dentistry demands university-level education, but practical experience with different types of dentist demonstrates that a good oral health service can be based on any of the types of dentist mentioned. It would seem, therefore, that the type of training to be preferred is that which is well adapted to the dentist's daily work and which is the least expensive. Existing differences in dental education stem from the origins of the oral health services. Present patterns were established under the influence of the profes- sional dental organizations and inspired by a wish for a professional status simi- lar or equal to that of a physician. While this striving for recognition is under- standable, it may not represent the optimal approach to solving the problem of providing oral health care for all the population. This question was discussed at a conference on undergraduate dental educ- cation in Europe organized by the European Regional Office of the World Health Organization in 1968 .a The report of this conference states that dental education must be developed according to the expected function of the dentist. This function must be ascertained by analysing the dentist's work profile, taking into account the procedures he uses and the frequency with which he performs them. Undergraduate dental education should teach primarily those procedures that occur often during the dentist's work. These form the basic part of his clinical dental education. In addition , the dental student needs enough know- ledge of biological subjects to understand the character of the disease he is treating and the nature and implications of the treatment he applies . He should know when and why complications could arise and how to prevent and treat them. These principles should define the dental education curriculum. The den- tist's professional title and his comparability with other categories of health manpower are of secondary significance. Treatment procedures that are performed infrequently can either be taught in postgraduate courses or reserved for specialists. Overloading the undergradu- ate dental curriculum with teaching of rarely performed procedures or uncon- nected biological subjects invokes the law of diminishing returns. Part of the effort invested in undergraduate education is wasted, and some of the technical skills acquired are lost due to infrequent use . In a national approach to dental education the first thing we need to know is exactly what the dentist does and how often he does it. Profile analysis of the dentist's dailt work has not yet properly begun in Europe. There are very few publications 'dealing with this subject and studies have not been made systematically . This is probably because the economic aspects of education for dental personnel are not taken sufficiently into account. Another reason evidently concerns the professional status of the oral health professions. Nevertheless, dental professional associations should give a WHO Regional Office for Europe. Undergraduate dental education in Europe. Report on a Conference. Copenhagen , 1969 (EURO 0543). 115 their support to moves to base dental education curricula on a functional ana- lysis of the dentist's work rather than on local tradition and considerations of professional status. This problem remains to be faced in connexion with the use of dental auxiliaries, and its study and analysis are very urgent matters. Possible future changes in the dentist's work must also be taken into account. The present professional profile of the dentist is not binding on the future. For example, in many European countries it is felt that dental education in the past had a rather too limited biological background, being based mainly on technical procedures and the properties of dental materials. This aspect of dental educa- tion should be expanded and more emphasis placed on the general methodology of clinical medicine. This conforms to the feelings of many patients who would like to be assured of safety in respect of the various possible complications that accompany some dental procedures, and most dentists would welcome a broad- ening of their training along these lines. In short, the concept of the future oral health service must first be decided in order to clear the way to solving the problem of an optimal professional profile for the dentist. On average, the dentist works for about 40 years after graduating. The undergraduate dental education he receives therefore determines the dentist's knowledge, skills, and attitudes for a long period ahead. Thus, we should now start thinking about what the dentist will be doing in 50 years' time in order to lay a foundation for future concepts of dental education. Dental Auxiliaries One outstanding problem is the team concept of oral health work. The question of cooperation between dentists and dental auxiliary personnel, especially so-called operating auxiliaries, and the delegation of part of the den- tist's work to these auxiliaries is emotionally charged. Certain circumstances in the past history of the oral health services and certain professional aspirations make many dentists distrustful of, or clearly hostile to, any delegation of the dentist's duties to auxiliary personnel. A rational solution to this problem requires an experimental approach. The limits to delegation of the dentist's proper functions to an auxiliary, suit- able education for dental auxiliary personnel , and the degree of supervision and direct guidance to be exercised by the dentist can only be resolved by creating the various categories of auxiliary, monitoring their in-service performance , recording all the information needed for a final evaluation, and evaluating the results of the experiment, i.e., the output of the auxiliary and quality of the work delivered. Experiments of this kind have already started in the United Kingdom and the USA, for example, and careful evaluations using a "double blind" method have confirmed that the auxiliary can perform delegated work safely and to a standard comparable with that achieved by the dentist.a a A more comprehensive treatment of this topic is to be found in the following re- port. Allred, H. The training and use of den ta! auxiliary personnel in Europe. Copenhagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 7). 116 This is a complex problem, and the many aspects of using auxiliary person- nel should be studied experimentally. The sooner this analysis begins, the better for the future of the oral health services. Because this problem is often discussed in an emotional way, and because some national dental associations are opposed to the employment of auxiliaries, it should be tackled with care and the opinions of the dental associations should be respected . No solutions should be imposed without making an attempt to obtain the cooperation of the dental profession or encouraging the profession to attempt a solution itself. While there is urgent need to design and plan practical experiments in the use of dental auxiliary personnel, national dental associations should be invited to participate on account of the legal questions involved. In considering what legal protection is needed to prevent the auxiliary from trespassing on the pro- fessional field , the views of the dental associations should always be taken into account. 5. UTILIZATION OF DENTAL AUXILIARY PERSONNEL The Character of Oral Care and its Implications Curative oral care is a special mixture of procedures of a predominantly medical or predominantly technical character. The part of treatment that is clearly medical in character consists of surgical interventions in the dental and maxillofacial fiel'ds, diagnosis and treatment of diseases of the oral mucous membrane , oncological problems of the mouth and adjacent tissues, develop- ment of the maxillofacial region (orthodontics) , a good part of the treatment of periodontal disease , and all problems connected with etio-pathogenesis of oral diseases and the related research. The part that is predominantly technical consists of procedures for restorative and prosthetic dental treatment (mainly treatment of dental caries and replacement of lost teeth) . At the present stage of oral health service development the more technical procedures occupy around 75% of a general dental practitioner's working time. This professional profile bears closely on the relationship between dentist and physician, on the conditions laid down in different countries for admission of candidates to dental practice , and on dental education. All oral treatment procedures , whether technical or medical in character, have to take account of the biological characteristics of the oral tissues. The biological background of dental education is now emphasized in all countries , but in earlier stages of development of dental education curricula more atten- tion was paid to the properties of dental materials and the use of dental in- struments than to the biological aspects of oral health . This approach grad- ually changed, and in some European countries (mostly the Latin countries and 117 Austria) a complete medical education was required before admission to den- tistry. This gave the dentist a broad biological background and a social status equal to that of the physician, but it exposed him to the risk of being less than adequately trained in the technical procedures that are so important for his daily work.a Another disadvantage of this system is , as already pointed out, the length of the education . In some countries - Italy , for example - general medical studies continue for 5 years and specialized postgraduate dental studies for a further 3 years. In order to ease the shortage of graduate dentists some European countries in the past accepted dental personnel with a subuniversity education; these were mostly dental technicians who received vocational training. Dental associations viewed such arrangements with deep misgivings. In fact, the new " dentists" received only limited professional training but were admitted to practise the whole , or nearly the whole, range of dental procedures. Gradually this solution came to be recognized as inadequate, and at the present time such training has been discontinued in almost all European countries. Th.e modern categories of dental auxiliary personnel that are now gaining wide recognition differ greatly from the type of"dentist" described above . They receive a thorough education and appropriate training and function only in a limited, clearly defined area of oral care. Since the question of using dental aux- iliaries has been studied widely and the experimental basis for the evaluation of dental auxiliary personnel broadened, many dentists now recognize that , under certain conditions, the dental auxiliary can execute work comparable in quality and safety with that performed by a dentist.b It is also clear that the volume of demand for oral care is too great for dentists alone to cope with. The attitude of the dental profession towards dental hygienists has become more positive and in the foreseeable future this category of auxiliary will prob- ably be accepted in all European countries. The category of dental auxiliary personnel called "dental therapists" and represented by the New Zealand school dental nurse presents a more difficult problem. The treatment of dental caries, including ex.traction of teeth, is delegated to this category of auxiliary in some children's public oral health services. In Europe this category of per- sonnel is being used in the United Kingdom and , on an experimental basis , in the Netherlands. Other countries have not yet considered introducing dental therapists. Many national dental associations are afraid that introduction of this category of dental auxiliary would radically alter the profile of the dental profession. Fears for the professional survival of the dentist are probably unfounded but the delegation of curative duties to auxiliary personnel could substantially change the present professional profile . Some of the problems and difficulties still to be resolved are considered in this section . a Most of the participants of a conference on undergraduate dental education, con- vened by the WHO Regional Office for Europe in 1968, expressed reservations about this type of dental education: see WHO Regional Office for Europe. Undergraduate dental education in Europe. Report on a conference. Copenhagen, 1969 (EURO 0343) . b See also Allred, H. Th e training and use of dental auxiliary personnel in Europe. Copenhagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 7) . 118 Utilization of Dental Auxiliary Personnel Extension of dental therapists' work to adults If the school dental nurse can treat caries in schoolchildren success- fully and with safety , why should not auxiliaries of this type be used to pro- vide oral care for adults also? This question has been asked ever since school dental nurses were introduced in New Zealand. In an oral health service sys- tem where the treatment of adults is also delivered on a public oral health service basis, and where dentists are overloaded with curative duties, this type of auxiliary might be employed to treat dental caries in patients of any age . Such an extension of the duties of these auxiliaries would facilitate the satisfaction of the rising demand for oral health services and make it easier for dental associations to oppose the admission of dentists with sub- university education . Extension of dental therapists' duties to prosthetic care If dental auxiliaries were permitted to treat dental caries in adults, why should they not also provide prosthetic services for these patients? In some Scandinavian countries , notably Denmark , there is a special category of dental technician (or prosthetic therapist) called "denturist". These personnel have proved, through a special examination, their ability to treat patients and are allowed to prescribe , make, or fit removable dentures without supervision by a dentist. Once this category of auxiliary is in existence patients may ask why the scope of its duties should not be broadened to include, after adequate training of personnel , also crown and bridge work. There seems to be no fundamental difference between this kind of work and the preparation of carious cavities for a filling. In both cases the dental pulp has to be protected (against heat generated in drilling or grinding the dental hard tissues , for example) and the auxiliary must be trained to avoid such health risks. If this condition were fulfilled, there is probably no objective reason why the dental auxiliary should not perform this type of work. In countries where private dental practice prevails, dental health associations are unlikely to accept this arrangement, not least because this is the part of dental treat- ment that is financially the most rewarding. However , in oral health service systems of a public service character working economy is very important because the whole service system is financed from public funds. Dentists mostly receive a fixed salary, which does not depend directly on the type of work they perform, and in this situation they could more easily be per- suaded to relinquish certain types of work to dental auxiliaries . They would benefit from a reduction in the load of curative care, giving them more time for prevention and for observing criteria of quality in their work. Dentists in some countries already feel that frequent repetitive procedures should be delegated to other types of personnel. 119 How Should Professionals React to the Employment of Auxiliary Personnel? Restructuring of dental manpower may take place along the lines described at some time in the future when the dentists' attitudes are determined primarily by the character of the service system and when oral health service systems are managed on a rational basis. The dental profession should not simply resist the introduction and use of operating auxiliaries without proposing alternatives. It was this attitude that stimulated the use of Dentisten with subuniversity education in some European countries in the 1920s. However, the dental pro- fession should insist that the training and use of dental auxiliaries be carefully analysed and coordinated, and properly organized. What Future Developments are Foreseen in Dental Education? In the future, primary prevention should decrease the frequency of dental caries and periodontal disease. The dentist will perform comparatively more den- tal and oral surgery, deal more extensively with diseases of the mucous mem- branes, and more frequently provide periodontal treatment and orthodontic regulation. Under these conditions the dentist's professional profile must change, and dental education also. Since in dental work there are the two components of different character, and since the balance between these two com- ponents depends on the implementation of preventive measures, then logically the balance should move in the future towards the medical end of the care spectrum and the profile of dental education must shift in that direction. Some experts have been suggesting for some time that this change is to be expected and that future dentists will delegate to auxiliaries repetitive procedures such as treatment of carious lesions or removal of dental calculus, and that after this delegation of tasks the dentist's working profile will approach that of the physician. Under these conditions a change in dental education may be justified to give the dentist a full medical background or an education anal- ogous to that given to other medical specialists. This education could well pay considerably more attention to the social sciences and to other subjects related to the public health service concept and theory than existing medical curricula allow for. Staffing the Future Oral Health Services Several problems emerge in connexion with the future staffing of oral health services. Three questions are particularly important. First, how should the fields of work of dentists and auxiliary personnel be delineated? Second, should operating oral health personnel have the status of auxiliary workers and 120 should they be guided and supervised directly by a dentist, or should they have the status of independent health professionals? Third, how should these op- erating oral health workers be utilized to avoid wastage and achieve the best results? Defining the work of the dentist and the auxiliary The problems of defining the auxiliary's field of work and the basic differences between the duties of the dentist and the auxiliary have been attacked in two different ways; first, through the American system of ex- panded functions for auxiliary personnel and, second, through use of New Zealand-type school dental nurses. In the first system, as explained previously (see p. 113), the dentist performs irreversible procedures while reversible procedures are delegated to auxiliaries. In the New Zealand system the school dental nurse performs both reversible and irreversible procedures but is not allowed to work outside the public oral health service or to treat patients other than children. The question of division of work between the dentists and auxiliaries should be decided experirnen tally. If we accept that dentist' atti- tudes and interests may not be the same in every oral health service system and that in public oral health service systems they may be radically different , if not opposite to, those prevailing in private dental practice , then a reappraisal of this problem is called for. We should verify by means of well planned and well evaluated experi- ments which parts of the work can be delegated to auxiliaries and under what conditions (of training, guidance, supervision, etc.). The criteria for delegation of duties to auxiliaries must be the quality of the work (in comparison with that of the same work performed by a dentist) and the safety of the patient. The auxiliary's work output should be measured in relation to the length and cost of his or her training because the main reason for delegating work is to achieve greater economy. Thus, a final delineation of the fields of work of dentist and of auxiliary should await the results of experimental studies. Experiments might be planned and designed on the basis of the following working hypothesis. Delegation is the easier if the success and quality of the procedures depend more on technical skills and less on the level of the biological or medical know- ledge . (Knowledge and skills cannot, of course, be clearly separated from each other; there are no procedures in clinical dentistry for which knowledge of the biology of the oral tissues would be irrelevant.) Thus we should delegate those procedures that do not demand an extensive biological education. (The ques- tion of what constitutes an adequate biological education also has to be studied experimentally. The answer will certainly depend on the quality of the educa- tion and the degree to which the biological component in the clinical proce- dure is understood.) For a start we might accept a rule that delegation will begin with treat- ment of dental caries and/or prosthetic dental treatment, with one reservation: all surgical procedures, including tooth extraction, should be performed by the dentist. Because of the risk of serious complications, anaesthetization, both general and local, should only be performed by the dentist or by a dental 121 auxiliary working under his direct supervision. Treatment of dental caries and prosthetic treatment both require respect for, and protection of, the dental pulp and periodontium. In some cases removal of the dental pulp is indicated and the tooth has to be treated to prevent chronic inflammation of the periodontal membrane around the apex of the root. In the American concept mentioned above this procedure is considered irreversible and is reserved for the dentist. For purely practical reasons it might be advantageous to try to delegate this part of the treatment as well if the feasibility of doing so could be verified experi- mentally. It can be argued that this treatment does not belong to the field of dental surgery proper. The biological or medical knowledge necessary for good performance of this treatment is important but rather simple , and it is ex- pressed through application of strict safety measures such as working under aseptic conditions or using drugs and materials with suitable properties for filling the pulp chamber. These rules can be relatively easily planned and observed in practice. On the other hand, a great deal of technical skill is re- quired for good performance of the procedures within the small dimensions of the root canals. Experimental verification of the feasibility of delegating various curative tasks to auxiliary personnel should also extend to patients' attitudes. If the possibility of delegating treatment of dental caries and prosthetic treatment is under consideration it is probably not necessary to discuss all individual pro- cedures in detail. Provided that problems are solved experimentally practically any procedure can be scrutinized and evaluated. In making this rational approach to curative care the dental professional organizations should not be excluded from the designing of experiments or from the development of a concept for structural change in the oral health manpower edifice. An oral health service cannot function properly if the dental profession is fundamentally dissatisfied with any important aspect of its work. Attitudes change slowly and are probably never based on rational reasoning alone. By keeping this in mind and trying to solve the difficult problem of delegation in collaboration with the dental profession, the dental professional organizations are given sufficient time to make the necessary adaptation. The status of oral health personnel The second question deals with the status of auxiliary personnel to whom some duties of the dentist are delegated . Should they remain subject to super- vision by a dentist or should they be granted the status of an independent den- tal health profession? A good oral health service concept is patient-centred, and the patient's wellbeing is paramount. This principle may be applied in considering the ques- tion of status. An oral health worker should have dental auxiliary status if it is in the patient's interests that his work is supervised and controlled by a dentist. This may be necessary to assure the quality of curative work and to protect the patient from possible complications, or, if complications occur, to ensure that proper treatment is given. The behaviour patterns of these oral health workers and their relationship with patients might also require supervision. 122 These requirements could be met through direct supervision by a dentist and continuance of dental auxiliary status for operating dental workers. How- ever, other mechanisms could have the same effect. The careful selection of candidates for this type of work, followed by adequate training and thorough evaluation of the work produced for safety and quality, as well as output , might be as important as personal supervision by a dentist. If this could be achieved direct supervision would rarely be necessary. The dentist will, of course, need reassurance that the auxiliary will not usurp his specific duties, and the oral health service system must make sure that this does not happen by adopting protective legislation , making regular surveys , and eliminating all causes that lead to unauthorized practice (especially shortages of dental manpower). If this condition is observed , unauthorized practice would be unlikely to occur and independent status could be granted to more groups of oral health workers than dental associations are willing to admit at the present time. The functions of the different categories of personnel The third question , or group of questions, relates to the conditions needed to ensure the best utilization of new categories of dental auxiliary or, more generally , of all categories of oral health manpower. Dentists often point out that there is little professional stability among New Zealand school dental nurses and that there is great wastage in this category due to changes of profes- sion or marriage. Reports dealing with the experience of the New Zealand den- tal health service with school dental nurses admit that in the early stages of their use , which extended over several years , there was much wastage of person- nel. However, after the dental nurses became accepted by most New Zealand dentists as a useful and natural addition to the oral health manpower, and when it appeared that this kind of work offers good job opportunities for young women, there developed a stability comparable with that of the dental profession. Some time elapsed before dentists realized that they could work with this new category of dental auxiliary and that fears of their interference with the dentists' work were unjustified . On the other hand , the dental nurses recognize that they are paid a fair salary, enjoy good working conditions, and that the oral health service system is really interested in their work and creates job op- portunities for all dental nurses who complete their training. Without creating the right conditions a new profession cannot expect to attract enough suitably qualified young people . Discussions with auxiliaries of a similar type in the United Kingdom (i.e ., British New Cross dental auxiliaries)° showed that some of them would like to have , in addition to the conditions described above, the possibility of advancing in their profession. At present , the only opportunities for promotion a See Allred, H. The training and use of den tal auxiliary personnel in Europe. Copen- hagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 7). 123 are to the position of tutor in schools for auxiliaries. Such expectations are, of course, natural in any profession. This suggests the possibility of arranging the individual professions within the field of oral health in ascending order, the profession having the most limited responsibility and smallest remuneration being placed on the lowest rung of a "career ladder", and that having the greatest responsibility and highest remuneration (i.e., dentists) at the top of the ladder. The condition for operating such a career ladder successfully is that person- nel in the lower categories could advance up the ladder through receiving addi- tional training, and might reasonably expect in due course to become a dentist. All oral health personnel dealing directly with patients and providing treatment might be placed on such a ladder in the following order of categories: chairside assistant, dental preventive worker, dental hygienist, school dental nurse (or dental therapist , this term now being preferred in many countries),0 and dentist. These proposals for the use of oral health manpower refer to the developed countries. A developing country taking the first steps to organize an oral health service system may choose a different approach . In these countries there are usually not more than a few dentists and dental technicians available and what- ever oral health service exists in the country relies heavily on traditional dental healers. If a country starts to build an oral health service from scratch it should develop first a health manpower reserve able to satisfy the need for emergency oral care . The emergency service will offer extractions, treatment of abscesses, and, for serious cases, hospitalization of patients in a general hospital . If new dentists cannot be trained quickly enough the country might choose to pro- duce dental therapists who, after adequate training, could deliver emergency procedures and later, when oral health conditions improve, receive additional training to qualify as dentists. In the European Region there is probably little demand for this special category of dental auxiliary because all the countries have a nucleus of oral health manpower to start with. Educating dentists in the use of auxiliary personnel Management of dental auxiliary personnel forms a regular element in the curricula of American dental schools, at least in those schools where the question of employing expanded function auxiliaries is dealt with. Both the theory and the practice of the new style of oral health teamwork is taught in departments of curative care organized on this pattern. This type of teach- ing has not yet been introduced in the European dental schools, but it would appear to be highly desirable if changes in the delivery of the oral health service are to be put into practice in the reasonably near future . a See Notes on terminology (p. 12). 124 6. INTRODUCING PREVENTION IN THE COMMUNITY The Problem Dentists are generally not equipped by their professional education to cope with some important aspects of introducing preventive measures in the com- munity. The basic dilemma is that dental education trains the dentist to combat the biological causes of oral disease but he works in a field dominated by people's attitudes. The attitudes influencing oral health and oral health care , and preven- tion and treatment of oral diseases, have little to do with the pathogenic pro- cess but are connected with the socioeconomic and educational status of the family and with the technical manifestations of affluence in the community . The complex nature of human behaviour is not yet well understood, and knowledge of the development of people's attitudes towards oral health and oral health care is very incomplete . Since people's attitudes have a very great effect on the services provided , more research in this field is essential. Specific attitudes develop slowly in a population and rarely influence all people at the same time but, being usually linked to levels of education and eco- nomic status, they develop faster in that part of the population where these con- ditions are optimally fulfilled and only later in the rest of the population . Conse- quently , at any given time, a mixture of attitudes prevails in a population. The most commonly held attitudes motivate the behaviour of the majority of people. The prevailing attitude towards the oral health services in most countries, even in the best developed ones, is that of interest in dental treatment and the replacement of lost teeth. While most members of the community hold this at- titude, a minority neglect their teeth and request emergency treatment only. Another minority has already begun to appreciate the value of dental health and favours active preventive measures . Water Fluoridation Most dentists have become used to the fact that the prevailing attitude of the public towards prevention is a benign indifference , and have begun to develop educational methods to penetrate this barrier. However , when several years ago ideas about water fluoridation started to spread, the attitude of the public often proved a serious obstacle and public health dentists in some European countries experienced distrust, suspicion , and even active resistance to this measure. Dentists were confused by this reaction and limited their preven- tive activities , concentrating on methods that can be applied through the public oral health service . In order to understand this situation it is necessary to consider a number of factors related to prevention of dental caries in general and to the use of fluorides in particular. 125 Fears of environmental deterioration Undesirable changes in our living environment - pollution of the atmos- phere, rivers, lakes, and the sea - are observed on all sides, diminishing the possibilities for recreational use of nature and impairing comfort at home and at work. People are upset and afraid about the future, all the more so since no one seems to know how the community can avoid these dangers, which daily seem to grow more acute. Another similar problem is associated with the greater and more frequent use of food additives and diets that are becoming more and more synthetic. People are also aware that certain substances introduced to combat insect vectors of disease, crop pests , weeds , etc., have shown them- selves to be harmful to man ; this has increased their uneasiness and raised barriers of suspicion against new substances claimed to have a beneficial effect and towards arguments proposed by scientists in favour of the widespread use of these substances. Past mistakes in controlling certain drugs have also con- tributed to public anxiety. This is the background against which many people view proposals for fluoridation. If dentists are confident that this procedure is harmless, and if the experience of communities using it confirms this, well and good, but, the anxious argue , do we know all about this method or are there dangers not yet discovered that need longer to manifest themselves than the time during which fluoridation has been practised? Is there any harmful potential for the next generation? Have all the methods necessary for reliable testing of possible dan- gers connected with fluoridation been developed? People 's rights to express these opinions cannot be denied. It has to be realized that for many people it is extremely difficult to distinguish clear- ly between, on the one hand, changes in the environment (fluoridation of drinking-water, for example) that benefit health and, on the other hand, dangerous pollution. Opposition to fluoridation may be a manifestation of general anxieties about the misuse of various materials rather than a specific fear of fluoride. Role of the state administration Antifluoridationists form a numerically small, but highly committed, active group, and many dentists have experienced how difficult it is to coun- ter their arguments. In the face of such opposition success or failure in in- troducing water fluoridation and other preventive measures in the commun- ity depends firstly on the health administration and secondly on the political decision-makers . Some 15 or 20 years ago it was relatively easy to introduce water fluoridation because contrary views were held by rare individuals only. Since then environmental questions have become much more widely and warmly debated . Countering opposition to fluoridation What should public health dentists do if they meet opposition to com- munity water fluoridation proposals from antifluoridationist groups? Mainly , 126 they should follow the prevailing attitudes of the public towards oral health and be ready to cooperate with community adminstrations in reacting to pub- lic opinion. If the situation seems to favour the introduction of preventive measures such as fluoridation, and the public is not emotionally involved, they should not hesitate to discuss their aims with decision-makers in the state ad- ministration but should avoid public discussion of the issues. If the antifluori- dationist groups become involved in the discussion, state the known facts in favour of fluoridation pointing out that no harmful effects have been observed in areas where fluoride occurs naturally in the water, that no harmful effects have been reported from communities where water fluoridation started several years ago, that the preventive dose of fluoride is far lower than the dose at which any harmful effects may arise, and that far higher dosages are used in treating cases of osteoporosis that sometimes accompany old age. Fluoride committees In Czechoslovakia and the Netherlands, for example, small groups of ex- perts in various fields (heal th administration, dentistry, epidemiology, toxi- cology, endocrinology, water engineering, etc.) form fluoride committees that work closely with the state administrations and discuss all technical problems relating to fluoridation, formulate proposals for administrative decisions, and monitor the effect of measures already adopted. Role of national dental associations Another practical measure that could help public health dentists gain ac- ceptance for water fluoridation is to seek the support of the national dental association. A national dental association usually does not hesitate to support moves towards prevention, even those favouring water fluoridation, but rarely ex- plores the whole range of alternatives. Public health dentists could seek broader cooperation with national dental associations. For example, associations could survey members' attitudes towards water fluoridation. It is generally assumed that dentists will approve of preventive measures, but we cannot be sure of this. We should not forget that their undergraduate dental education, especially in the case of older dentists, probably did not deal in detail with prevention of dental disease, and especially the more modern measures such as water fluori- dation or alternative methods of using fluoride. Undergraduate dental educa- tion, generally speaking, overemphasizes dental treatment methods. If such a survey showed that dentist' attitudes towards prevention were in- consistent, two remedies could be applied. First, topics related to prevention and the use of fluorides could be included in the ongoing education for dentists , and, second , an attempt could be made to increase the teaching time devoted to prevention in the undergraduate curriculum. It might also be useful for the public health dentist to cooperate with the national dental association in preparing comprehensive plans for nation-wide preventive measures. Plans prepared by the national dental association could be expected to be more far-reaching than the health ministry would be able 127 to accept because of legislative and financial constraints. Nevertheless, all such proposals made by a national dental association should be welcomed as a positive sign of its interest in public health matters, and the association might be consulted over the selection of experts to sit on a fluoridation com- mittee, etc . Alternatives to Water Fluoridation If water fluoridation is already practised and fluoridated water supplies reach the whole population the public health dentist will not be concerned with alternative methods. But if fluoridation has not been accepted , or is delayed for a number of years , or if treated water supplies are not available in all parts of the country, alternative preventive methods will be needed urgently . In some western European countries where water fluoridation was refused public health dentists have ignored the alternatives . Probably, no alternative method is as dependable and convenient as water fluoridation, and some public health dentists are afraid that communities might make adoption of an alterna- tive method an excuse for postponing fluoridation of drinking-water indefi- nitely. This view is not necessarily correct. Alternative methods offering the consumer a free choice, such as use of fluoridated salt or fluoride tablets , can introduce fluoride into the community and demonstrate that fears of toxicity are groundless. After a time, the community might come to accept water fluoridation , which is both more effective and simpler. Well-tried methods that have been used effectively in some countries should be chosen as alternatives to water fluoridation. Experiments with fluori- dation of foods such as sugar and bread are theoretically interesting, but from the practical point of view they are not useful because it is necessary to devise methods for adding fluoride to the food and for measuring the level of fluoride present. In addition , consumption of the fluoridated food has to be monitored and both the preventive value of the measure and its cost/effectiveness deter- mined. Fluoride tablets Fluoride tablets are the safest and best known alternative to water fluori- dation. The safety of this method has been verified in many countries. The pre- ventive value of fluoride tablets is about half that of fluoridated water and their cost/effectiveness depends entirely on the way of administering them. Administration through the family is not very satisfactory because the mother sooner or later grows tired of making daily distributions of tablets and effec- tiveness falls off. On the other hand , distribution organized by the public oral health service is too costly. The best way seems to be to transfer the responsi- bility to kindergartens and schools, and the public health dentist should at all times seek the cooperation of these institutions in preventive activities. 128 Fluoridated kitchen salt This is the most interesting and promising alternative. Successful experi- ments in the use of enriched salt {250 - 300 mg of sodium fluoride per kg) have been made in Colombia and Switzerland. Similar experiments in Hungary are still in progress but preliminary reports show equal promise. Effectiveness is about the same as that of fluoridated water. The enriched salt is distributed through commercial channels and the cost is paid by the population {according to calculations made in Switzerland the cost of the salt is not much increased). The only difficulty to be overcome is organizing the commerical distribution of enriched salt to produce a level of fluoride corresponding to that in drinking- water. Although full information about salt consumption is not available the Colombian and Swiss experience indicates that intake of salt is regular enough to provide a sufficient amount of fluoride in the body. However, the reliability of the method may depend on the technical equipment in the salt industry. As a precaution against overdosing, accurate salt consumption data are required and a thorough knowledge should be obtained of fluoride concentrations in local water supplies. When these requirements are fulfilled the public oral health officer may safely recommend the use of fluoridated salt. If there are gaps in this knowledge it may be preferable to use fluoride tablets. Effectiveness and Efficiency of Prevention Under this heading are discussed problems that every senior oral health officer has to tackle sooner or later. Is it invariably true that "prevention is better than cure"? If not , what are the constraints that limit its validity, and what are the implications for delivery of oral care? Mix of prevention and cure Consider two examples relating to prevention of dental caries. {I) A dentist applies a preventive measure that prevents, say, 50% of carious lesions. He provides no treatment for carious teeth . In the 50% of teeth that become carious the lesions will spread and destroy the tooth- crown , and finally these teeth will be lost by extraction . Theoretically , this dentist's efforts have the final result that patients retain 50% of their teeth intact but lose the other 50%. (2) Another dentist applies no prevention but , at least theoretically, treats every carious lesion in time and with good results. The end result of his work is that very few teeth remain intact but all teeth are preserved , pro- vided they are not lost as a result of some other dental disease. This analysis seems to argue in favour of the dentist who only treats de- cayed teeth and does not attempt prevention . It is possible to object , however , 129 that few dentists are in a position to treat successfully every carious lesion, and that a successful outcome might still have been improved by a combination of prevention and cure . It has, in fact, been demonstrated that the best result in oral health care is achieved through a mix of prevention and cure. This will remain true as long as preventive methods are only partly effective and prevent less than 100% of carious lesions: the lesion that could not be prevented can always be treated but there is no preventive remedy for lack of treatment. In any case, patients will not allow the dentist to devote all his working time and efforts to preven- tion while neglecting to treat carious teeth. Thus , if we accept as a working hypothesis the principle that the best results are achieved through a mix of prevention and curative dental care , three questions have to be posed . What sort of mix is desirable? How much curative care should be included in that mix? How much prevention can we afford? Answers to these questions are needed because most dentists seem to be overwhelmed by the number of carious lesions they have to treat and frequently have no time left for prevention, or far less time than that required to produce the best results. However, we can answer the questions only if the working pro- ductivity or the efficiency of both the curative services and the proposed pre- ventive methods are known. Assessing the efficiency of prevention The working productivity or efficiency of services and methods can only be estimated approximately. Let us assume that, for an improvement in oral health , a carious lesion successfully treated is roughly equivalent to a lesion prevented . Then, the effectiveness of any preventive method can be assessed by comparing it with the effectiveness of treatment. In other words, in a given working time as many lesions must be prevented as could have been treated succcessfully. Consider another example. A children's dentist finds 2000 carious lesions every year in his group of patients . He spends all his working time in treating these lesions and has no time left for prevention. If he then decides to engage in prevention for 25% of his working time , he should be able to prevent 500 carious lesions. If the preventive method he uses is only 50% effective, he will be able to prevent 250 lesions but the 250 lesions that occur will remain untreated because the dentist has no time left for either prevention or treatment. If, therefore , he adopted this working pattern for any length of time untreated lesions would accumulate in his target group. Owing to an improper mix of pre- vention and cure the oral health of the children would become steadily worse. The working economy or productivity of preventive methods (their input/output, input/effect, or cost/benefit relationships) has been analysed by Davies.a This study shows clearly that the highest efficiency is achieved by preventive methods that are not performed by the oral health services directly. Water fluoridation is the best method because it has the greatest preventive a Davies, G.N. Cost and benefit of fluoride in the prevention of dental caries. Geneva, World Health Organization, 1974 (WHO Offset Publication No . 9). 130 effect and is implemented by the water production services; the health admin- istration is usually not even responsible for meeting the cost of fluoridation. Salt fluoridation could be equally useful. The efficiency of other preventive methods is questionable if they are applied through the oral health services. The reason for this is that the salaries paid to oral health personnel greatly affect cost/benefit relationships of this practice. This is true particularly of the classical methods for topical applica- tion of fluorides. However, the input/effect relationships of all methods applied through the public oral health service should be very carefully examined and every effort made to reduce the cost or working time inputs.0 These methods can, of course, be delegated to dental auxiliary personnel. If, for example, a dental hygienist is able to apply these methods as well and as quickly as a dentist, and if two dental hygienists can be hired for a cost equiva- lent to the salary of a public health dentist, the efficiency of the appplication is doubled. However, in a system where the community bears the cost of training the health personnel the duration of both the education and the working career of these personnel should also be taken into consideration. Dental studies con- tinue mostly for 5 -6 years and the dentist works for some 40 years after graduation. His career is, therefore, about eight times longer than his education. The economics of training auxiliary personnel can be assessed as follows. If we assume that the cost of training a dental hygienist is equal per annum to that of educating a dentist, then a hygienist with 1 year's training should work for 8 years to attain the same cost/effectiveness as a dentist. In fact, the annual cost of training a hygienist is probably around 50% lower than this. Therefore, her training is economically justified after only 4 years' employment. Some countries (Denmark and Norway, for example) use auxiliaries with a brief training (a course lasting a few weeks) for one simple task such as supervision of mouth rinsing or tooth brushing with fluoride solutions by groups of school- children, and their training becomes economical after several months' work. Methods for self-application of fluoride, where the task of the personnel is limited to supervision of groups of children, usually have a more favourable cost/effect relationship than those administered by dentists or dental auxiliary personnel. However, the reader's attention is again drawn to the report by Davies (see p. 130). A small modification in the way a fluoride solution is applied can lower its efficiency to a critical level, and an exact evaluation is always useful. Some Norwegian and Swedish modifications of these methods have reasonably high cost/benefit relationships but they remain much inferior in their working economy to water fluoridation or supervised administration of fluoride tablets. a Some public oral health service officers believe that discussion of the economic and financial aspects of prevention represents an attempt to save money through restricting the range of preventive activities or limiting the financial resources already allocated to preven- tion. This is incorrect. The financial aspects of prevention (and of curative care) are taken into account in order to achieve maximum levels of community oral health with the finan- cial resources available. Budget savings can be reinvested in oral health. There is no merit in neglecting economy in any professional work - after all, it is the taxpayers' money and it should be used as effectively as possible. 131 Probably no country has enough money or oral health personnel to base its preventive programme on professionally administered preventive methods. Self-application of fluoride (or its application by mothers to children) is very promising because prevention is taken outside the public oral health domain. Research on these methods should therefore be extended. Delegating prevention outside the public oral health service Consider another step in the delegation of preventive work. Fluoride tab- lets can be distributed , for example, in kindergartens and schools . In Austria , there is a nation-wide programme for distribution of fluoride tablets in this way . Not all teachers are willing to cooperate but , generally speaking, the Austrian experience is satisfactory. The results are achieved with out supporting legislation through cooperation based on good information and an understanding of teachers ' difficulties , and with the help of reinforcement workers who travel throughout the country visiting schools to explain , again and again, the impor- tance of prevention for the children's health. Switzerland also (Canton of Zurich) has successfully transferred to a number of schools responsibility for distribution of fluoride tablets and for supervised mouth rinsing and tooth brushing with fluoride solutions , as well as instruction and training in oral hygiene. Some senior oral health officers continue to doubt the usefulness of such programmes . They have found cooperation with the schools not altogether promising. They need the cooperation of the schools and teachers in their efforts to provide for the regular and systematic treatment of children 's teeth , and they have met with resistance. They have been told that school programmes are already over-full and cannot bear any disturbance , and that the schools can- not perform any tasks for other sectors of the community. On these grounds, some oral health officers refuse to consider further development of prevention or treatment for children. It has to be realized that prevention operates within a set of constraints. First , the preventive methods available are not 100% effective , but even if we tried to apply them to all children we should still have to undertake a mix of prevention and cure because a huge section of the older population is already in need of oral care , and we cannot neglect this. Second , for the oral health services prevention is not only a question of dental caries or the use of fluoride. Even using fluoride fully and in the best way , it will always be necessary to teach people the principles of rational nutri- tion and good oral hygiene practices . It may be asked whether it is necessary , or even desirable, to deliver this education and practical training through an oral health service and whether it would not be more appropriate to make use of other institutions having access to sections of the population. The objection that schools are not ready to accept these duties is not entirely correct. Schools have already undertaken additional duties unknown in any school 50 years ago , such as teaching the traffic rules and the rules of social behaviour and providing sexual education or guidance about the misuse of drugs . In the future integrated health education encompassing oral health education and training could be included in the school curriculum. 132 This would represent another step towards the coordination of community functions (see also p. 134). Increased coordination and integration will greatly benefit the health serv- ices in many ways , but patience is needed as progress may be slow, depending on the initiative and activity of health workers and on the goodwill of school authorities , teachers, and others in responsible positions in the community. Oral health service officers in many parts of the world are already working towards these goals. The concept of prevention, especially prevention applied through the public oral health service, is changing, just as the whole field of dentistry is changing. This change is marked by a growing trend to engage the whole community in prevention and to make use of all available ways and means to make prevention part of the life of every citizen and to stress in the work of the public health dentist diagnosis, planning, training of teachers, and evaluation of the preventive programmes. This preventive concept should help the community to raise the level of oral health. 7. MANAGEMENT OF THE ORAL HEALTH SERVICES Management Policy - Directing the Oral Health Service System System direction Both work and development are directed in an efficient oral health service system. This means that the development and functioning of the system are not determined by spontaneously occurring trends. An undirected system is seldom functionally harmonious and its development is usually unequal be- cause, owing to the lack of direction, the stronger components or trends in the system influence the development of the system as a whole, tending to create conditions for unbalanced growth. Direction of a service system cannot be limited to administrative control but must also regulate the working conditions so that the system's success and fulfilment of its functions are in the interests of those creating and working in the system. The work must be satisfying professionally as well as rewarding fi- nancially, allowing dentists to make full use of their knowledge and skills. The functional value and social usefulness of the system should also be upheld . Functions of the direction "System direction" is a broader notion than "service administration". The administrator of the service bases his activities on the service concept, preparing regulations for the organization of the system and seeing to their observance. However, direction includes also the coordination, planning, evaluation, and study of the system. All these functions are interconnected. 133 The directing unit of the system would, as a rule, be located in the health ministry, but it need not necessarily deal directly with all the functions men- tioned above. Some of these can be delegated to other departments or trans- ferred to institutions outside the ministry such as research institutes , planning commissions, centres for collection of statistical data, etc . A necessary condi- tion of successful direction is a well-functioning information system to produce all the data necessary for planning the service and for making essential changes in the organization. The information system makes use of all main sources of demographic and statistical data available in the country and ensures the regu- lar collection of information relating to the work of the system, research on oral health, attitudes of patients, public opinion about the oral health services , and so on. The planning function of the direction is to suggest how the financial resources available should be used. This can only be done successfully if the planner knows the current output of the service and how adequately it is satis- fying the total treatment needs and the corresponding wishes of the popula- tion. This requires sound information at the outset, a clear statement about tl1e goals of the service, and a knowledege of the alternative means of reaching the stated goals; further, the planner should have the ability to transform the accepted plan into operational directives. Evaluation is usually a mirror image of tlle planning process ; its goal is to ascertain how far the function of the service has been fulfilled, the degree of satisfaction of the population , and the quality and efficiency of the service . The evaluation should be sincere and feedback to tlle organization or the service easy, if possible automatic. It should also not be too expensive. The task of coordination is to ensure that the service system operates evenly over tlle whole country and tllat it off.m comparable satisfaction to all population groups. It has to establish tl1e correct balance between the preven- tive and curative services , between oral healtll care for priority groups and for tlle whole population, and between the specialized and the general services. Anotller task of coordination is to ensure integration of the oral healtll service system and community life. This topic is discussed further in the following section. Research in service management may be centred on new curative and preventive procedures , or on management and organization methods , or on information collection. This function requires that the fullest use be made of the scientific potential available in the country . This is not an easy task since the main interest of the scientific worker is centred on clinical studies , laboratory scientific work, and basic research. The interest of scientific workers in the concept and organization of the service should therefore be stimu- lated by all possible means. In well-functioning oral healtll service systems, scientists take part in the study of management problems. In other systems it is necessary to show that tllis field of work offers equal possibilities and applies the same kind of reasqning, the same ways of asking questions, and the same search for answers as laboratory or clinical research. 134 Studying the Oral Health Service System Oral health service systems are usually run on traditional lines; the rules of management are mostly based on the simple experience of the managers or on the recommendations of individual experts. This could have been good practice in the past but we are now more aware of the complexity of serv- ice system management, the interconnexions of individual elements, and the importance of aspects such as the attitudes of patients and personnel about which very little was known several decades ago . As a consequence, a manager who favours a rational approach to oral health service problems must continually study the service system as a whole. This he can do himself, but the large field to be studied, the variety of problems to be expected, and the different methods of study to be used usually call for the help of pro- fessional research workers. The oral health service manager should preferably be helped by a group of experts who are affiliated to a dental school or to a dental research insti- tute and have a scientific background and experience in analysing problems related to the oral health services. This group should discuss all current prob- lems and consider whether enough relevant information is available. Where gaps exist these should be filled by collecting new data. The oral health service manager recognizes the problems that arise in his work and probably knows what information he needs; the professional research worker may have a better approach to the precise formulation of research questions, a clearer insight into the complexity of problems, and a knowledge about the methodological planning of studies. Mutual confidence is therefore an essential condition for fruitful discussion of this sort. After preliminary discussions various concrete questions emerge and, when necessary resources become available, studies can begin. Certain gaps in the oral health service manager's knowledge call for bet- ter information but not necessarily for research. The manager must make use of data already available in the country - in population census data, numbers of oral health personnel, etc. These data must be updated regularly and their reliability checked. There are, however, many problems where new research is needed to facilitate decision-making or to confirm the value of traditional solutions. The number of problems insufficiently known is very large; the scope of information collection and the research activities in the oral health services should be correspondingly large and should con- tinue steadily. Information system The oral health information system should create a useful basis fordecision- making by the oral health service manager or his superior in the health ad- ministration. These decisions are related to aspects of the oral health serv- ice concept or delivery. In the WHO Regional Office for Europe's oral health programme areas of relevant information are grouped in the following way. 135 (1) Information for management.a Comprising all information related to the task of the service, its resources, and its outcome or product. (2) Alternative solutions to organizational problems. Information related to alternative methods for oral health service delivery (e.g., methods of treat- ment and prevention of oral diseases, alternative methods of satisfying patients' requirements, and alternative ways to equip the service). (3) Management methodology. The main part of this comprises planning and evaluation of the oral health services and collection of related information. In this connexion it may be useful to mention the report of a WHO working group convened by the Regional Office for Europe in 1971 on planning and evaluating oral health services.b As a follow-up to the above-mentioned working group, the WHO Regional Office for Europe carried out a study of information used for the evaluation of the oral health services in five European countries (Czechoslovakia, Federal Republic of Germany, Norway, Romania, United Kingdom), and a report on the study appeared in 1974.c This discusses the use of routine on-service data, on the one hand, and independent epidemiological and sociological surveys, on the other. The report also describes practical examples of surveys and their planning, and should therefore be useful to all those intending to collect data on a wider scale. It has to be kept continually in mind that research and information collec- tion are expensive activities. Data that are not useful should not be collected. The function of every piece of information must be defined in advance and data should not be accumulated simply because they are in some vague way "interesting". It is difficult to describe how the manager should build up his information system. Data collection is fairly advanced in some service systems but has scarcely begun in others. Also, priority areas differ according to the character of the service. Generally speaking, the manager should use experience and com- mon sense in selecting the areas and problems to start with. A pragmatic ap- proach may be quite useful at first but later, when important research prob- lems are tackled, a more elaborate approach is needed. The first stage The manager probably needs some information urgently, whereas other data are not required until specific problems are dealt with. Data collection a Research on oral health and the oral health services, as well as the collection of rele- vant information, is , of course, not necessary only for managerial decision-making but also for helping all those concerned to understand the oral health service system and its function. b WHO Regional Office for Europe. Planning and evaluating dental health services. Report on a Working Group. Copenhagen , 1972 (EURO 5505). c WHO Regional Office for Europe. Evaluation of dental health services. Report on a study. Copenhagen, 1974 (EURO 5504). 136 should start in areas closely related to the expected decisions . Some textbooks of public oral health suggest, for example, that for planning the oral health service system the manager must know the extent of the need for the oral health service, and that this should be ascertained through epidemiological sur- veys. This is only partly true. The task of the oral health services is based on need for service only in the target groups where comprehensive oral care is to be provided. Target groups are usually children or other specifically defined groups. A large slice of the population, however, is treated on the basis of demand for service, which depends largely on patients' attitudes, which can be estimated from certain on-service information - utilization of the oral health service, for example. Epidemiological surveys can determine patients' attitudes only when they are specifically planned for, and adjusted to, that purpose.a Also, the oral health service manager in Europe is rarely free to plan his country's oral health services from the very beginnning as these services have usually operated in the country for a considerable time . It would seem appropriate to study first the working capacity and productivity of the existing services; planned extensions could then be expressed in terms of current service capacity (i.e., output). Lastly, during this first stage of planning the manager may be interested in oral health service delivery and its organization. This is a complex problem, and information previously gathered on service conditions and performance will assist the manager in tackling it. The second stage In the second round of information collecting and research designing, the oral health service manager may expand his knowledge concerning the resources of the oral health service. He may try to draw up a complete inventory of oral health manpower - all personnel currently practising in the country classified according to category (dentists, auxiliaries) and age, sex, education, and hours worked {based on full-time equivalents). Regarding material resources, he may be interested in the technical equipment of the oral health services (types of equipment , year of purchase, functioning, and need for renovation or replace- ment). This information will be particularly important for the public oral health service. When the manager starts to analyse the task of the oral health services he will need demographic data tabulated according to age and sex . Where the serv- ice system has to provide treatment on the basis of "need for service" he will require specific information about target groups . The sizes of these groups should be known as well as the need for service expressed at least in terms of numbers of individuals needing dental treatment and the outcome of the service currently provided (proportion of individuals dentally examined , proportion of those found in need of dental treatment, and the proportions of those in need of treatment , treated comprehensively , and partially treated). a See Gray, P.G. et al. Adult dental health in England and Wales in 1968. London, Her Majesty's Stationery Office , 1970. 137 ~ I In the segment of the population treated on the basis of "demand for service", data for service utilization reflect roughly the total demand for serv- ice. The total utilization of the service could be separated into the proportion of patients utilizing the service regularly and treated up to dental fitness and proportion of those who request emergency service only .0 In the area of service output information can be obtained from routine on- service data, but the reliability of this information should be checked by means of epidemiological surveys. These data should be arranged according to single items of service delivered in, for example, a period of 1 year. Also, the quality of the service can be monitored in terms of the timeliness of treatment (the proportion of teeth treated successfully or extracted; the proportion of teeth requiring pulp treatment in relation to all teeth treated by fillings ; the propor- tion of complete dentures and partial den tures in relation to all prosthetic treatment). In the study of patients ' attitudes an attempt can be made to relate dif- ferences in service utilization to the socioeconomic status of the patient or to different parts of the country . This may help to define underserviced areas. The third stage In the third round of collecting and analysing information, all aspects and details of the oral health services' task can be examined . Epidemiological sur- veys can be organized to provide a basis for comparisons with other oral health service systems or for later evaluations of changes in the oral health status of the population . Attitudes of patients may be ascertained in population groups differing with respect to socioeconomic and educational status, occupation, and other conditions. Demand for service and other attitudes should be studied, on the one hand, directly through interviews and questionnaires, and, on the other hand, indirect- ly by analysing patients' behaviour. In this way it is possible to analyse service use according to different items of service. It is possible to ascertain, for ex- ample , the threshold where demand occurs for prosthetic services by observing which losses of teeth are treated prosthetically and which are neglected . Information of this kind probably cannot readily be transferred from one oral health service system to another because patients' attitudes may vary from one country to another. For example, the oral health service in the United Kingdom produces a much greater proportion of simple removable dentures and a much smaller proportion of crown and bridge work than oral health services in continental European countries. On account of the fee structure set up, this solution is acceptable in the United Kingdom, and consequently the oral health service is able to solve the problem of prosthetic treatment in a rather simple way and achieve good coverage in this area more easily than the oral health services in the continental countries. In this advanced stage of information collection, conditions should be created for detailed evaluation of oral health service output and its quality. The latter problem calls for new criteria and for longitudinal studies. ' a Gray et al. (see footnote on p. 137). 138 Analysing oral health service delivery Problems of analysing the mechanism of oral health service delivery can finally be tackled. These problems have not received enough attention in the past. Oral health service delivery should be studied in a similar way to the other problems described above. In addition, however , when changes in the rules governing service delivery are contemplated , the probable impact of the new rules should be studied experimentally. As mentioned earlier (p. 103), pilot areas or laboratories should be used for the study of oral health service delivery . Successful delivery of the oral health service should be able to offer all the oral care , education , and prevention envisaged in the oral health service con- cept. In practice , service delivery is rarely as broad or successful as this . Failures may be due to a number of weaknesses : ( 1) lack of financial , human , or material resources ; (2) neglecting, in some respects , the attitudes of patients or oral health service personnel ; (3) the rules governing oral health service delivery are not sound or not expressed clearly or their application is not controlled effectively . For a start, the manager should examine his own attitude towards oral health service delivery, treating this as a largely unknown problem. If it appears that in some respects service delivery has not been successful , he should attempt to analyse whether it is adjusted to the attitudes of patients and personnel and whether the rules for delivery are sound and well taken. It is desirable that problems of oral health service delivery should in the future be investigated with the assistance of service managers . Meanwhile, oral health service managers may wish to study the experience gained in other countries in solving service delivery problems . Some of the countries where this kind of research has been conducted are the Scandinavian countries , the United Kingdom, the USSR, and certain countries in eastern Europe . Other countries in the European Region are also starting to investigate this problem area. A rational approach to the future development of all oral health services may be expected. The work of the WHO Regional Office for Europe in this field is described in the following section. 8. THE WHO REGIONAL OFFICE FOR EUROPE ORAL HEALTH PROGRAMME, 1958-79 The European Regional Office activities in the field of oral health started in 1958 and have continued steadily. The various ac tivities dealt with in the oral health programme have a common denominator , all being related in some way to oral health service management. As already pointed out (p. 136), they 139 can be considered under three headings : management methodology , collection of information , and alternative methods for oral heal th service delivery . Management Methodology This deals , on the one hand , with general questions discussed in Regional Office courses on oral public health (organized in 1967 in French , in 1969 in English , and in 1971 in Russian) and , on the other hand , with methods of plan- ning and evaluation in dental health services .a Collection of Information A series of Regional Office projects for the collection of information related to oral health started in 1964 with a pilot survey of child oral health in Europe. b Six countries were involved and information was collected on six aspects of child oral care . In 1970 another survey was made of child oral health in Europe , but the scope of the information requested was somewhat different ; eight aspects of oral care were investigated.c Twenty-five countries cooperated in the second survey , which produced very interesting results and influenced the fur- ther development of the Regional Office programme in dental health. These two surveys were later followed by a course on methods for epidemiological surveys of oral conditions organized in English (1972), Russian (1974), and French (1976). Alternative Methods for Oral Health Service Delivery This is the most extensive part of the Regional Office oral health pro- gramme , dealing with questions of oral health service organization , dental education, training and use of dental auxiliary personnel, prevention, and the diagnosis of oral tumours . All these topics are of importance for some or all Member States of the European Region for the strengthening of their oral heal th services . a See WHO Regional Office for Europe. Planning and evaluating dental health services. Report on a Working Group . Copenhagen , 1972 (EURO 5505) , and WHO Regional Office for Europe. Evaluation of dental health services. Report on a study . Copenhagen, 1974 (EURO 5504) . b Slack, G.L. & Osvald, O.K. Child dental health in Europe. A pilot survey. Copen- hagen, WHO Regional Office fo r Europe , 1964/65 (EURO 151.3). c WHO Regional Office for Europe. Survey on child dental health in Europe. Report on a study. Copenhagen, 1974 (EURO 5501). 140 A study was made in 1958 of oral health services for children in European countries,a and the report describes the basic characteristics of these services in different countries . This study was followed in 1960 by a seminar on oral health services for children,b which discussed various aspects of such services and made recommendations that influenced the Regional Office oral health programme during the next years. Another Regional Office report on child oral health services in Europe was issued in 1974 .c In 1965 a series of WHO interregional courses on child oral health was organized by the Regional Office. These courses, supported by the Government of Denmark and intended primarily for teachers of child dentistry in all the WHO regions, were repeated each year up to , and including, 1971. The topic was then changed to "dental public health", and courses on this were arranged in 1973 and 1975. A third brief series of courses supported by the Government of Denmark and dealing with oral oncology was held in 1974 and 1976. Problems of undergraduate and postgraduate dental education were dis- cussed by conferences in 1968 and 1970, respectively _d, e The study made by Davies of different uses of fluoride in the prevention of dental caries, which was organized by the WHO Regional Office for Europe, was issued by WHO headquarters in 1974 in the Offset Publication Series/ Further, provision is made under the Regional Office programme budget for 1978 - 79 for a fellowships programme of training in methods of prevention for oral health officers in 1978 and for a working group on comprehensive programmes for prevention of dental caries in 1979 . Also in 1979 , a study is planned of dental health insurance systems in selected European countries. Finally, as already mentioned elsewhere in this report, a study was carried out by Allred of the training and use of dental auxiliary personnel in Europe_g a WHO Regional Office for Europe. Report of the study group on dental health serv• ices for children. Copenhagen, 1958 (EURO 151.1). b WHO Regional Office for Europe. Dental health services for children. Report on a seminar. Copenhagen, 1961 (EURO 151.2). c Duckworth, R. Child dental health services in Europe. Report on a study. Copen- hagen, WHO Regional Office for Europe, 1974 (EURO 5501(72)) . d WHO Regional Office for Europe. Undergraduate dental education in Europe. Re- port on a conference. Copenhagen, 1969 (EURO 0343). e WHO Regional Office for Europe. Postgraduate dental education. Report on a con- ference. Copenhagen, 1970 (EURO 0431). f Davies, G.N. Cost and benefit of fluoride in the prevention of dental caries. Geneva, World Health Organization, 1974 (WHO Offset Publication No. 9) . g Allred, H. Training and use of dental auxiliary personnel in Europe. Report on a study. Copenhagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No. 7). 141