Oral health, the great forgotten of the public system

BarcelonaThe state of our mouth has a direct impact on our health. Diseases that affect teeth and gums share risk factors with other pathologies, such as obesity, diabetes, cardiovascular diseases and some types of cancer. Despite being closely related, dentistry and medicine have advanced along different paths in Catalonia, and most patients who receive oral care do so outside primary care centres (CAP), that is, in private practices. For decades, different Governments of the Generalitat have tried, without success, to effectively incorporate dental services into the portfolio of public benefits.

Since 2020, CAPs have offered oral health care to children up to 14 years of age, who are already vulnerable groups due to social and health conditions. These are basic services such as tooth extractions, cleanings, treatment of infections and wounds. Minors are also given fillings to treat cavities and sealants, and patients with cervical-facial cancer are given implants and prostheses. However, union sources consulted by the ARA say that not all of these services are offered because there are not enough resources to cover them. In this context, the Minister of Health, Olga Pané, has promised as a priority for this legislature to unblock the law on oral health once and for all and to progressively expand these services.

"They have been trying to unblock it for 25 years," says the president of the Official College of Dentists and Stomatologists of Catalonia (COEC), Germán Pareja, who argues that a decisive political commitment and the allocation of more resources is necessary if the law is to be implemented. Currently, there are 6,300 registered dentists in Catalonia, but only 400 work in the public health system. In addition, most of these dentists who work in public centres only work half-time and the rest of the time they work in private clinics. According to Pareja, there are no more professionals working in CAPs because there are no more places available, but the will of the sector is there. As for the private sector, in Catalonia there are more than 3,600 dental clinics authorised by the Department of Health.

Whether due to a lack of knowledge of the services offered by the public health system or because they cannot access them, the majority of Catalans who want to take care of their oral health turn to the private sector as a priority. According to a study by Key Stone, in the last four months Catalans have spent an average of more than a thousand euros on the dentist, a much higher expense than in the rest of the State, where the average for dental treatments is almost 700 euros. The COEC warns that oral diseases affect "disproportionately" people with fewer resources, who cannot afford a private dentist, which creates inequalities that, in the opinion of the association, are "unfair and modifiable".

An "election tool"?

When Pané announced that they would reinstate the Law, he predicted that before the end of 2024, public dental services would begin to be expanded for people with disabilities and also for those who are socially and economically vulnerable. The intention then was to carry out a progressive rollout throughout 2025. However, the law has not yet started and currently Salut is "planning and analyzing the costs of incorporating the population in a situation of social vulnerability or risk of exclusion." Sources from the department have explained to ARA that, to deploy the Law, new budgets are needed, although the Government They have already openly assumed that they will not be able to approve the 2025 accounts after ERC's refusal to negotiate them. The COEC regrets that the department has not contacted the college at any time to discuss the implementation of the rule.

Xavier Marco, dentist, secretary of the Association of Dentists of Catalonia (ADC) and delegate of the Doctors of Catalonia union in the Terrassa Health Consortium, considers Pané's announcement to be an "electoral tool" and believes that there is no real will to deploy oral health care. Be careful that with the resources that are currently available they do not manage to carry out all the services that are included in the regulations in force since 2020, not only due to lack of money, but also of professionals and spaces. "In the center where I work, for example, we are not killing nerves because we do not have time. We only have two chairs and a long waiting list. A visit lasts about 20 minutes and to kill a nerve I need an hour," he complains.

The COEC also warns that there are territorial inequalities that must be reversed. For example, caries treatments for children up to 14 years of age are included in public health, but for now "they are not offered throughout the country." Another of the basic services that is not guaranteed in a large part of the country is the treatment of osdental trauma, that is, when a tooth is fractured. According to the College, these patients can receive care, diagnosis and assessment by primary care dentistry teams, but "in most cases there is neither the infrastructure nor the necessary material for their treatment." It also regrets that there is no referral circuit in public centers where patients can be treated.

Colau's dentist

Ada Colau and the Comuns also made oral health one of their main issues and proposed to promote a municipal dental service in Barcelona open to everyone and with rates up to 40% cheaper. The plenary session of the City Council approved the project in 2019, but it was never launched because it quickly got stuck in court. It was the COEC who denounced the launch of this service, arguing that the council does not have the authority to offer dental services, since they correspond exclusively "to the Generalitat as a health administration."

At the end of last year, the municipal dental service was finally buried before it opened a medical consultation to provide cheaper care to the citizens of the Catalan capital who cannot afford this type of service. The Supreme Court gave the final blow to the program with Jaume Collboni as mayor, who responded to the ruling by ensuring that he fully respects the judicial decisions and passed the ball to the Government. The City Council therefore urged the Generalitat to implement the law, which has yet to begin to operate.

More prevention

Until the law is passed, experts insist that there are other ways to take care of citizens' oral health from the public system. In 2022, for example, Salut began to incorporate hygienists into the CAPs and so far more than 288 professionals have been incorporated, almost 80% of those planned. In addition, the department maintains that many efforts are being made in prevention, with consultations and group activities. Pareja maintains that this is a very effective measure to reduce the incidence of diseases in the teeth and gums and, on the other hand, does not have as high a cost as the effective implementation of the law. In addition, he recalls that these diseases can be related to other pathologies outside the mouth, so the incidence of these, such as diabetes, would also be reduced.

Dentist Núria Vallcorba, who has been president of the Catalan Society of Dentistry and Stomatology, the Spanish Society of Periodontology and Osteointegration and the SEPA Foundation for Periodontology and Dental Implants, also focuses on prevention. Early detection, she stresses, can also make treatment cheaper for both the patient and the health system. "We need to educate people about proper brushing, the use of toothpaste with fluoride and interdental hygiene. This will greatly reduce these diseases," argues the expert.

Recognizing specialties

Another of the improvements that dentists are demanding is the recognition of specialties in dentistry. The president of the Spanish Society of Periodontology and Osteointegration, José Nart, explains that the sector has been trying to obtain this recognition for 20 years, as have most European countries, but has not been successful. "The five-year degree does not give you all the skills to treat a certain type of pathology, which can be more severe, or to carry out a certain type of treatment, which can be more complex," he says. Thus, the proposal of the scientific societies is that specialties such as periodontics, oral and maxillofacial surgery, endodontics or pediatric dentistry, among others, be recognized.

Nart argues that this recognition benefits patients, since it "ensures the highest quality of care" at all times. In order for the ministry to study the proposal, however, the scientific societies need the support of at least seven autonomous communities, and so far they have only managed to get the signatures of Murcia and Aragon. Even so, it is expected that in 2025 the remaining signatures will be added and they will begin to move towards a model with specialists, which, however, will not be effective this year.