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