Public oral health care in Finland

3.6.2016

DDS PhD Battsetseg Tseveenjav

1989 DDS University of Havanna

1989-1999 dentist and university lecturer in Mongolia

1999-2000 Master of Science in Oral Public Health, University of Helsinki

2000-2004 PhD Thesis, University of Helsinki

2004-2005 EU qualification course, University of Turku

2005- currently health center dentist and clinical teacher, City of Helsinki

Oral health care

In most EU member states dental services are largely produced by private dentists

The Nordic model is characterised by a fairly large public sector

In Finland:

Public sector has a market share of about 50% of total oral care production

Children up to 18 years (free-of-charge)

Adults

Private sector is complementary to the public sector

Mainly adults (Costs to patients are subsidised through NHI)

(Ref: Eeva Widström, 2006/Oral health care/Health in Finland)

Public oral health care (PS)

The state has a central role in the guidance and supervision of oral care

system (Ministry of Social Affairs and Health)

Financed from central and local government tax revenue and patient fees

PS is organised/ run by local municipalities

PS was initially restricted to children (under 18-year-olds) due to lack of

resources

In 1980s, PS started gradually to offer services to young adults and special

need groups

In 2000, PS expanded services to persons born in 1956 or later (58% of the

population)

In 2001-2002, the age limits restricting access to PS were removed and at

the same time subsidised private care is expanded to cover all age groups.

NHI Reimbursements are available for the cost of dental and oral treatment provided by a

dentist in private practice, treatment provided by dental hygienist on a dentist's referral, the cost of laboratory and radiology tests prescribed by a dentist, and the cost of travel required to obtain dental treatment.

No reimbursement is available for the following items:

dental care obtained from public-sector providers

prosthetic procedures such as the manufacture or repair of removable dentures

dental crowns, bridges or implants (exception: front-veterans and mine clearance workers)

the services of a dental technician (exception: front-veterans and mine clearance workers)

orthodontic procedures (can be reimbursed under special circumstances)

periods in which you are being treated in a public hospital or institution.

www.kela.fi

4600 active dentists in Finland

(1/1100 inhabitants)

49,9% as public health center dentist

40,4% as private practitioners

9,7% in universities, hospitals, etc.

14-15% are specialized

Full-time

Part-time (popular)

(Ref: Finnish Dental Association)

www.hammaslaakariliitto.fi

Oral health challenges

To integrate oral health care with general health care in all levels:

1. Professional level (dentists and other health professionals)

2. Public understanding

Many recent evidences show: associations of oral infections with general diseases

1. Particularly periodontal diseases vs. diabetes, cardiovascular diseases, and

adverse pregnancy outcomes, etc.

2. Oral status reflects signs and sympthoms of general health and diseases as well

as effects of medications

Resources are limited

Common risk factor approach is recommended

The World Health Organization (WHO) describes a risk factor as any attribute,

characteristic or exposure of an individual that increases the likelihood of

developing a disease or injury.

Common Risk Factors for Chronic Non-communicable and Oral Disease:

Use of tobacco, harmful alcohol use, unhealthy diet, and poor oral hygiene are

risk factors for general diseases as well for oral diseases.

www.who.org

Common risk factor appoach By controlling one risk factor prevent many risk conditions

To improve access to care

1. Emergency care (1-3 days)

2. Non-emergency care

(based on individual risk; access within 3+3 months)

To increase equity in the use of oral health services in order to

narrow health differences

Treatment need is based on individual risk of oral diseases

(Check-up intervals based on individual’s general and oral health

risk, caries and periodontal disease: for example: recommendation

is for high risk individual every 1-2 yrs vs. healthy/low risk

individual every 3-5 yrs)

Oral health challenges

In Helsinki live 620 715 people (year 2015)

Helsinki metropolitan area has 1,2 milloin inhabitants

34 Health center dental clinics (for Helsinki inhabitants)

University Dental Clinic (students do clinical training)

Emergency care unit (Ruskeasuo and Haartman)

Specialist care unit (Ruskeasuolla PKS-SEHYK: dental surgeons,

endodontists, periodontologists, orthodontists, prosthodontists. The

services are for inhabitants of Helsinki metropolitan area)

Purchased Services (Helsinki buys some services from private dentist)

Calling center (for appointment booking, etc.)

Department of Social Services and Health Care

of Helsinki City organizes social and health services

for residents living in Helsinki

Department of Social Services and Health Care

of Helsinki City organizes social and health services

for residents living in Helsinki

A total of 308 dental units in health centers

657 vacancies

214 dentists

28 Dental specialists

330 dental nurses

73 dental hygiensts

16 vastaanottoavustajaa

Assistant dentist: general dentist

who has practical experience

and continuing education in

special field

Assistant orthodontist

Assistant surgeon

Assistant periodontologist

Assitant prosthodontist

Assistant…

Oral health team in PS

general dentists

dental hygienists

chair-side dental nurses

Health center dentist:

37 hours/week

1,5h administrative work (writing referrals

and statements, reading patient papers,,

consultaations with collegues, phone calls,

etc.)

6h patient work

General dentist

Check-ups: adults: 1-2 x 30-40min

Check-ups: children 1-2 x 30min

Fillings 2-4 x 30min

Tooth extractions 2-4 x 30min

Canal treatments 1-2 x 45min

Prosthetics 1-2 x 30min

TMJ 1x30min

Check-ups (Helsinki City)

Up to age of 15 yrs get invitations.

Age of children/Recalls Check-ups are carried out by

1-, 3- and 5-year-olds Dental nurses

1st and 5th school year pupils Dental hygienists

3rd and 8th school year pupils Dentists

17-year-olds (all) Get letter recommending to do booking for

dental hygienist

High riski patients Dentist/dental hygienist

(For example every year can be recalled)

Adults are not recalled.

Work distribution:

dentist and dental hygienist

Dentist:

Oral check-ups

Treatment plan

Diagnosis

Preventive procedures

Fillings

Root canal treaments

Extractions

Prosthetic treament

When need, referral to

specialized care

Dental hygienist:

Health check-ups

Health counselling (motivating patients for self-

care, preventive home measures: brushing,

interdental cleaning, diet, smoking, alcohol use,

etc.,)

Preventive procedures (among others, sealants)

Scaling

Administrative work is increasing all the time …

Several patient information systems do not communicate between…

Compiling different statistics…

Public oral care emphasis: prevention

Detection of risk factors of oral diseases

Plaque/biofilm control

Early detection of initial lesions

Remineralization of caries lesions

Treatment of oral diseases

Treatment of gingival and periodontal inflammations

Patient role: Caries and inflammaroty periodontal diseases are biofilm caused diseases. Patients should understand that most common oral

diseases are behavioural and therefore, patient’s role is very important in treatment success.

Prevention vs. treatment

Prevention: a lot of work is done and doing but… still needed

1. Research

2. Risk-based prevention and treatment need

3. A lot of materials for patient education (Helsinki City, Hammaslääkäriliitto,

local societies, etc.)

Materials in many languages

Positive discrimination project: Eastern Helsinki area: preventive

activities in schools, kindergardens and for parents

Still treatment orientated services dominate

Health 2000 and 2011 Surveys (National Institute of Health and Welfare)

The main objective of the Health 2000 and 2011 Surveys was to

produce an up-to-date overview of the health and functional capacity

in the working-age and elderly populations as well as of changes in

them. In the survey the prevalence and factors contributing to the

most common health problems were studied as well as the need for

treatment, rehabilitation and assistance associated with these

problems.

You can find a lot of information

on general and oral health of Finnish population (www.thl.fi)

Oral Health of Finnish population in short (year 2000)

Toothbrushing (n=5595) All Men Women

Twice daily 61% 45% 76%

Once a daily 31% 41% 22%

Less often 8% 14% 2%

Edentulous (n=6719) All 30-64-yr-olds 65+

All 15% 6% 44%

Men 11% 5% 38%

Women 17% 6% 48%

Mean number of teeth

(n=5611)

All 30-64-yr-olds 65+

All 22.8 24.1 15.4

Men 23 24.1 15.7

Women 22.6 24.1 15.2

Oral Health of Finnish population in short: DMFT

(n=5611 in 1980 and n=5389 in 2000)

Mean number of

filled teeth (FT)

All 30-34 35-44 45-54 55-64 65+

Mini-Finland Study 8.2 11.8 9.8 7.8 5.6 3.1

Health 2000 12.4 10.6 14.9 13.3 11.1 8.9

Mean number of

decayed teeth (DT)

All 30-34 35-44 45-54 55-64 65+

Mini-Finland Study 2.5 2.5 2.6 2.6 2.2 2.5

Health 2000 0.8 0.6 0.7 0.9 0.8 1.1

Oral health has improved over the past 20-30 years.

1. The most prominent improvements were the decrease in the prevalences of

edentulousness and caries.

2. There have also been significant increases in the use of dental care services.

3. Twice daily brushing increased, but still among men is lower than among women.

4. The most prominent improvements were seen in the youngest age groups and in

persons with the most education.

5. Caries is strongly polarized since 1990s, smaller proportion of people owing the

most lesions.

(8% of 5-15-year-olds owing 76% of total caries lesions, Vehkalahti et al., 1998)

Oral Health of Finnish population in short

How can individuals promote their own oral health?

You can yourself look after your oral and dental health by:

1. having a healthy diet,

2. brushing your teeth twice a day with fluoride toothpaste,

3. cleaning interdental spaces and

4. visiting a dental clinic regularly.

Challenges:

The parents should look after that their children’s teeth are taken

care of and that children brush their teeth twice a day.

What about elderly????

Gerodontology

People live longer

Elderly have in their mouth more and more natural teeth

Treatment need increases: need of fillings, canal treatments, treatments of

periodontal diseases as well as mucosal lesions

More emphasis on quality of life

Full denture is not the most common treatment need for elderly

More and more fixed prosthesis manifacturing and reparation need increases

Dentists also more and more educate themselves

in elderly care

Who helps them in brushing their teeth

and dentures, when they need help???

Professional organizations

Finnish Dental Association

Finnish Dental Society (continuing education)

Health Center Dentists’ Society

Women Dentists’ Society

References

http://www.hammaslaakariliitto.fi/fi/suunterveys/mista-

hoitoa

http://www.hammaslaakariliitto.fi/fi/suunterveys/yleisti

etoa-suunterveydesta

http://www.kela.fi/hammashoito

http://www.stm.fi/suun-terveydenhuolto

http://www.hammaslaakariliitto.fi/fi/tyoelama