Exploring Variation of Coverage and Access to Dental Care for Adults in 11 European Countries: A Vignette Approach

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The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach. Methods: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. Results: Completed vignettes were received from 11 countries, including Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different kinds of physical barriers to access dental care. Major access barriers to public dental care represent the limited availability of contracted dentists especially in rural areas and the unequal distribution and lack of specialised dentists. Conclusions: According to the results, statutory coverage of dental care varies across European countries while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries which in turn leads to high out-of-pocket spending. The individual socioeconomic status is thus a main determinant for access to dental care, but also other factors such as geography, age and comorbidities can inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care. Dentistry Head & Neck Surgery Dental care coverage access cost-sharing benefits financial protection Introduction Oral diseases, such as dental caries (tooth decay), periodontal disease (gum disease) and tooth loss (edentulism) are persistently among the most prevalent conditions globally, despite being largely preventable [ 1 ]. They can have significant consequences, including unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. As such, they pose a substantial health and economic burden, for individuals, families and society as a whole [ 2 , 3 ]. Routine access to primary oral health care allows early detection and management of oral diseases, and can mitigate their negative impacts [ 4 ]. The importance of oral health has received increased attention over the past few years. The 74th World Health Assembly resolution 2021 and The Lancet Issue on Oral Health 2019 highlighted the need to shift from the traditional curative approach towards prevention, and to integrate oral health within the primary health care system and universal health coverage programmes [ 2 – 5 ]. Despite the significant impact of oral health on general health and well-being, many countries restrict dental benefits covered by the statutory health system to specific treatments or age groups [ 6 , 7 ]. Several dental care services require either cost-sharing or have to be paid fully out-of-pocket in many countries. There is large variation in the level of cost-sharing and types of treatments excluded from the benefit basket across national and regional jurisdictions. However, there is increasing evidence to support that limited coverage reduces financial protection and people’s capacity to obtain dental care if they cannot pay for treatment or disposables. This leads to inequalities in access to dental health services within and across countries and eventual inequities in oral health status [ 5 , 7 – 9 ]. A 2019 survey on areas of care where access might be a problem in European countries identified oral health as one area with major gaps in coverage and access [ 10 ]. To achieve better coverage and integration of dental care, the benefit basket and how related services are financed and delivered will inevitably need to be adapted in most countries. For such efforts to be successful, it is equally important to identify and understand barriers to accessing dental care services beyond coverage, such as the physical availability and accessibility of the necessary care providers or potential differential experiences along the social determinants of health. However, the variation in coverage and other access barriers to dental care services across countries remains under investigated. Against this backdrop, the aim of this paper is to compare differences in dental care coverage and access for adults in 11 European countries using a vignette approach. The three most frequent oral diseases (dental caries, periodontal disease and tooth loss [ 3 ] were chosen as the basis for the vignettes. Together, they amounted to approximately 0.7% of total disability-adjusted life years (DALYs) and 2% of years lived with disability (YLDs) globally in 2017 [ 11 ]. On the basis of a patient pathway for each of these three conditions, we first examine which dental care services are covered under statutory package and/or under which conditions and to what extent (i.e. height of user charges in form of cost-sharing or private payment) across countries in our sample. We then compare further barriers to realised access, such as the physical availability of dental care services. This research was carried out as part of work for the Expert Group on Health System Performance Assessment (HSPA) of the European Commission, aiming to explore the usefulness of the patient vignette approach as a complementary tool for identifying gaps and challenges in access to health care in the context of HSPA [ 12 ]. Methods Approach and conceptual framework A vignette is a short description of a person or situation designed to simulate key features of a real-world scenario [ 13 – 16 ]. A vignette case generally specifies a hypothetical patient’s age, gender, medical complaint, and health history. As a research tool, vignettes are usually presented to relevant professionals to solicit their hypothetical response or behaviour. In medical literature, vignettes are mostly used to study variations in decision-making processes, including clinical judgments made by health professionals [ 17 , 18 ]. Recently, vignettes have also been used to compare price levels in hospitals [ 19 – 21 ] and to investigate the availability and nature of certain types of care such as outpatient mental care [ 22 ] and community dementia care [ 23 ]. In this study we do not focus on differences in treatment or cost, but rather gaps in access during an episode of care that can be compared across countries. Therefore, the vignettes also include a delineation of the recommended care pathway and a list of services that could then be used to benchmark and compare access across countries. To compare coverage and access to dental services included in each vignette, we use the framework of the Gaps in Coverage and Access survey [ 10 , 24 ] which explores the three traditional dimensions of coverage (population coverage, service coverage (which benefits are covered) and cost coverage (what proportion of costs is covered)) as well as a fourth dimension, labelled service access. Population coverage was not listed separately for this work, as gaps in statutory health coverage would be picked up under the service coverage dimension. In terms of service access, gaps could be due to i) lack of physical availability of services, due to long distances to the provider, lack of sufficient statutory/contracted providers, poor quality of services, limited opening hours, waiting times and waiting lists; ii) lack of person’s ability to obtain necessary care, due to a person’s incapacity to formulate care request, obtain the care or to apply for coverage (and fulfil the necessary requirements) due to their condition or situation (e.g. people with cognitive impairment, mentally ill, homeless), and ability to navigate the system (for example when referred from one provider to another one); and iii) attitude of the provider, for example due to discrimination (on age, gender, race, religious beliefs, sexual orientation, etc) leading to care denial or inability to accommodate care to the patient’s preferences [ 10 ]. Furthermore, a list of determinants that could improve or worsen access, including patient characteristics (e.g. age, sex, and socioeconomic status, insurance status, legal status, place of residence) as well as other factors (night vs. day treatment protocols), were added to the conceptual framework and respondents were also asked to provide any other determinants they thought could affect access for the vignette. Design of dental care vignettes and survey The vignettes were designed in collaboration with the Department of Oral Diagnostics, Digital Health and Health Services Research at the Charité Medical University in Berlin (Germany). Each vignette and the related care pathway represent a common realistic dental problem and potential treatment options based as much as possible on common practice and international guidelines or recommendations. To shape each vignette recommendations found in systematic reviews or developed by national, European or international organisations in the field of dentistry were used. Three dental care vignettes were designed that illustrate typical care pathways for adult patients with the most common oral health conditions (caries, periodontal disease, edentulism). Vignette 1 explores coverage and potential access barriers in the treatment of dental caries that can be addressed by non-restorative or restorative treatment using different materials (e.g. non-restorative: regular application of fluoride, gels, varnishes or sealants, or a combination thereof, resin infiltration; restorative: fillings using dental amalgams or composite resins, crowns) [ 25 – 28 ]. Vignette 2 focuses on periodontal conditions are caused by plaque induced inflammation of the gingivae characterised by red swollen tissues and bleeding (gingivitis) with periodontitis resulting with further loss of supporting bone and attachment. Recommended treatment includes patient instruction on daily plaque removal as well as the removal of supra-gingival plaque, calculus, stain (dental cleaning) and sub-gingival deposits (root planning) and control of local plaque retentive factors [ 29 , 30 ]. The removal of dental calculus which is part of the scaling and root planning treatment is otherwise also a very effective (primary and secondary) preventive intervention for periodontal disease. Vignette 3 considers coverage and access challenges for edentulous patients. Edentulous patients have a choice among different rehabilitation options: while complete dentures are widely used, implant-borne replacements are increasing and there is evidence supporting that they may aid in minimizing bone resorption. Prosthetic dental work is costly, but different modalities may be more or less affordable to patients [ 31 , 32 ]. Table 1 presents the dental care vignettes broken down in services and describe typical patients of different ages experiencing the three conditions. Each vignette describes the patient, their symptoms and potential care decisions for their clinical situation. The sequence of services corresponds to the usual care pathway which might not necessarily be the same for all countries and settings. It was expected that the chosen services might not reflect standard practice in some participating countries, and respondents were invited to describe these differences. Table 1 Dental care vignettes – patient description and services in patient pathway Vignettes Services Vignette 1: Urgent care with root canal and prosthodontic treatment A 35-year-old patient has not been able to sleep for two nights due to a strong, beating pain in the right-lower jaw. The patient requests an urgent dental appointment. The dentist determines that the patient needs a root-canal treatment to preserve the first lower molar, and treat the pain. The patient decides for the root canal treatment and against the alternative of tooth extraction. Following the root canal treatment, reconstruction with composite (filling) material is used until a fixed prosthodontic treatment (crown/onlay) can be placed. Emergency consultation with dentist Radiography ((bitewing) X-rays) Root canal treatment OR Tooth extraction (interim) reconstruction with white filling material Fixed prosthodontic treatment (crown/onlay) Vignette 2: Periodontal treatment A 66-year-old patient with co-morbidities (obesity, diabetes) has frequent discomfort in the upper jaw. After a consultation, chronic periodontitis with generalized level 2 mobility is diagnosed, requiring scaling and root planning, involving periodontal probing and elimination of dental calculus and frequent follow-up visits to stop disease progression and stabilize bone-loss. Scheduled visit with the dentist Scaling and root planning (performed by a dentist) Periodontal probing, and elimination of dental calculus (performed by dental assistant or hygienist) Regular follow-up visits Vignette 3: Implant-borne restoration and prosthetic rehabilitation An edentulous 75-year-old patient received full upper and lower dentures 5 years ago. She feels she has lost significant capacity to chew as the lower prosthesis is poorly retained and gets displaced when speaking or eating. She seeks counseling from her dentist, who recommends two implants on the lower anterior jaw and an overdenture to improve retention. She agrees with this course of treatment and against more sophisticated fixed alternatives. Consultation and surgical planning Surgical implantation Prosthetic rehabilitation: New prosthesis or adjustment of old prosthesis using the implants OR (Partially) fixed dentures To collect the data, a survey was constructed which presented each vignette in a separate table outlining all individual services per vignette (Table 1 ). In addition, for each service, experts were asked to indicate the statutory service coverage (which benefits are covered) and cost coverage (what proportion of costs is covered). Moreover, for the access dimension they were asked to indicate physical availability of services, person’s ability to obtain care, providers’ attitude and any additional determinants they thought could affect access for each service of the vignettes. Sample, data collection and synthesis The survey with vignettes (supplementary material 4) was sent to experts in 11 countries, including Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, Netherlands, Poland, Portugal, Slovakia and Sweden. The country selection was made to ensure variation of health systems (i.e., social health insurance vs. tax-financed, multi- vs single payer, centralised vs decentralized) as well as geographical distribution. Depending on the country, vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists. The information provided by individual country experts in the survey were extracted and summarized in one table per vignette (supplementary material 1-3): per country, for each service of the patient pathway and along three dimensions: coverage, cost-sharing, and physical availability/determinants of access. We further synthesized responses (Tables 2 - 4 , below) using a traffic light system (green – yellow – red, see explanation of colour codes below Tables 2 - 4 ) to visually compare results across countries. These comparative tables build the foundation for a cross-country analysis of the coverage of each service provided in the three different patient pathways. Results on physical availability and determinants of access are broken down in more detail in Table 5 and analysed separately as access barriers were similar across the three vignettes. Table 5. Physical availability and determinants of access Country Access dimension Vignette 1: Root canal and prosthodontic treatment Vignette 2: Periodontal treatment Vignette 3: Prosthetic treatment Bulgaria Physical availability Lower density of dentist and dental assistants and contracted dentists in rural areas; Referral to providers/laboratories due to lack of necessary equipment in most dental practices; 24-hours emergency dental care available only in large cities Few specialized and experienced dentists in the field of dental implantology Determinants of access Socioeconomic status and place of residence Estonia Physical availability Only contracted dentists covered; Longer distances in remote areas; Not every dentist provides radiology services France Physical availability Regional variation in access & waiting times; Consultations difficult during night/ weekend/public holidays Determinants of access More difficult access for people with low socio-economic status, no VHI or specific vulnerabilities (such as people living with mental disorders) Germany Physical availability Lower density in rural areas, potential lack of equipment in older clinics Lower availability of specialists in some areas, regional variation of dental assistants and hygienists Specialist in implantology scarce in rural areas Ireland Physical availability Variation of dentists by region and area deprivation: specialist practices generally confined to more urban areas, while only two dental specialties are recognised in Ireland (oral surgery and orthodontics); Declining numbers of contracted dentists participating in the DTSS scheme which largely provides care for lower socioeconomic groups. Determinants of access Socioeconomic status; area of residence; access difficulties for older adults in rural areas (especially those with mobility issues) and vulnerable groups particularly children and adults in residential care, refugees, asylum seekers, homeless people, and other socially excluded groups resulting in long waiting lists for general anaesthetic and other referral services Lithuania Physical availability Regional variation in access; Restricted availability due to limited opening hours Lack of contracted specialists, limited opening hours, considerable waiting time Lack of specialists in rural areas implying limited access for elderly, disabled, severely ill residents Netherlands Physical availability Potentially longer waiting times for patients not registered with dentists with varying waiting times across regions; VHI often covers up to a maximum amount (mostly between EUR 250 and 1 000, depending on the premium paid) Poland Physical availability Emergency dental care points mainly in large cities Regional variation of dentist-to population ratio, varying waiting times across regions Portugal Physical availability Regional variation of dentists Slovakia Physical availability Limited opening hours in rural areas. Distance to dentists in Roma settlements Lack of dentists specialized in chronic periodontitis, Accessibility issues in rural areas and for the elderly Availability of implant services in rural areas as it is still not standard procedure for some dentists Determinants of access Socioeconomic status, HIV/hepatitis and education Sweden Physical availability Waiting times and variable opening hours in rural settings, Accessibility issues for patients with physical impairments, very low dentist-to-population ratio in remote areas Results Completed vignettes were received from 11 countries, including Bulgaria, Estonia, France, Germany, Ireland, Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden between October and December 2020. If answers were unclear, country experts were contacted to provide clarifications. Answers varied in granularity of provided information; occasionally the answers indicated that the differentiation between columns in the vignette template was unclear or interpreted differently than originally intended. Some responses showed the complexity of the coverage system for dental care, indicating need for further explanation before being tailored in the vignettes, in particular on Ireland and Sweden. Dental services in Ireland are delivered through three publicly funded schemes: (i) the Public Dental Service (PDS) provides emergency and some routine oral healthcare for children under the age of 16 and certain vulnerable groups, (ii) the Dental Treatment Services Scheme (DTSS) entitles certain adults to some dental services free of charge, and (iii) under the Dental Treatment Benefit Scheme (DTBS) discounted dental treatment is provided to those who have paid three years of social insurance contributions [ 33 – 35 ]. In addition, private dental care is available that patients must pay fully out-of-pocket and claim back fees through tax relief up to a maximum of 20% of the treatment cost for certain non-routine procedures [ 36 ]. In Sweden dental care is free up to the age of 23, all others receive a general dental care allowance of EUR 30 to EUR 60 year to encourage dental check-ups and preventive care. People with certain illness or conditions (e.g. difficult-to-treat diabetes) receive a special dental care subsidy of EUR 60 every six months. In addition, most dental care in Sweden is subject to a high-cost protection scheme which aims to protect patients from very high dental care costs. Treatment costs above certain thresholds during a twelve-month period are covered at 50% (for costs between EUR 295 and 1 470) or 85% (costs above EUR 1 470) of the reference prices. The Netherlands stands out in regard to coverage of dental care by complementary voluntary health insurance (VHI). Most dental care services are not publicly covered but reimbursed fully or in part by voluntary health insurances which are taken up by 84% of the population. In France, private insurance also plays an important role in the reimbursement of non-routine dental care services not publicly covered. The following sections summarize results on coverage per vignette, followed by results on service access across vignettes. 1. Coverage Vignette 1: Urgent care with root canal and prosthodontic treatment The first vignette explores treatment for acute pain due to caries. Related dental care services are in general covered in most responding countries, except for the Netherlands and Portugal (Table 2 ). Emergency services and radiography are covered in most countries, often with standard cost-sharing such as in France and Sweden (sometimes covered by complementary VHI) or with restrictions in regard to the number of emergency visits and radiographs covered, such as in Ireland, where patients are eligible for one emergency consultation per year only. In Bulgaria, Ireland and Slovakia emergency consultations are covered only if patients have not received another consultation during the year. In the Netherlands and Portugal emergency dental care visits as well as the other services of the vignette are not covered at all as dental services are generally not part of the statutory benefit package. However, in the Netherlands the majority of the population purchases VHI to cover part of dental care. In regard to the alternatives of root canal treatment or tooth extraction, there is more variation in terms of coverage with respect to the treatment alternatives of tooth extraction or root canal treatment. While tooth extractions are covered nearly in full in almost all responding countries, root canal treatments are less comprehensively covered. Limited services and cost coverage for tooth extractions can be found in Estonia where it is only covered in case of emergency and in France, Lithuania and Sweden where cost-sharing is required. In Ireland, only DTSS beneficiaries are entitled to tooth extraction. Root canal treatment can be excluded from coverage, such as in Bulgaria and Ireland, or be limited to certain parts of the mouth (usually covered for visible teeth, i.e. molar to molar), as in Poland. In many countries, molar root canal treatment requires substantial cost-sharing, and it can be fully excluded from public coverage for the majority of the population, as in Ireland. Restoration with composite material and prosthodontic treatment are less comprehensively covered overall. In Germany, there is a fixed subsidy of 60% for standard treatment of crowns or onlays, which can be increased if patients are demonstrably consistent about preventive visits. The remaining costs, as well as any difference of costs due to patients choosing superior materials than those covered by insurance have to be paid out-of-pocket (OOP). In all other countries, only a fraction of the costs for fixed prosthodontic treatment is covered by the statutory health insurance. In several countries, complementary VHI seems to play an important role for the reimbursement of dental treatments which are not or only partially covered, including prosthodontic treatment. Vignette 2: Chronic periodontal condition The second vignette describes a multimorbid patient with chronic periodontitis that requires a scaling and root planning and regular follow-up visits. Regular check-up visits with the dentist seem to be less comprehensively covered across countries than the acute visit in Vignette 1. In some countries, the number of dental check-ups are limited to one visit per year (Bulgaria, Ireland, Slovakia, Poland) or are subject to cost-sharing such as in Estonia and France (Table 2 ). Scaling and root planning are also only partially covered in many countries or limited to a share of teeth (e.g. in Poland). The number of planned follow-up visits to stop disease progression and stabilize bone-loss are again restricted in some counties (Ireland, Poland and Slovakia). Interestingly, there is large variation in regard to coverage of periodontal probing and elimination of dental calculus which is part of periodontal treatment to prevent disease progression. The latter treatment is usually performed by a dental assistant or dental hygienist. In Germany, with comparatively comprehensive coverage for dental care overall, dental cleanings are not covered by the statutory health insurance, while in Slovakia, which has more limited coverage, the social health insurance would cover periodontal probing, and elimination of dental calculus for this patient. In general, basic dental hygiene in Slovakia is partly covered by SHI insurance twice a year in case patients attend regularly preventive check-ups. In Ireland, one scale and polish per year is covered up to EUR 42 for those who contributed to social insurance in the last three years (Dental Treatment Benefit Scheme (DTBS)), corresponding to almost half of the population. In Estonia and Lithuania some cost-sharing applies while in the remaining countries patients have to pay fully out-of-pocket for this kind of services likewise to Germany. Vignette 3: Coverage of implant-borne restoration and prosthetic rehabilitation across countries The third vignette describes prosthetic treatment for an older, edentulous patient who received full upper and lower dentures five years ago. Overall, the required interventions of prosthetic restoration are less comprehensively covered than services in vignettes 1 and 2. Coverage gaps exist in particular regarding the requirement for cost-sharing from the patient (Table 4 ). While some countries employ financial protection measures to support lower-income individuals with the procurement of dentures (e.g. Germany, Ireland, Netherlands), the OOP (out-of-pocket) cost to be borne by the patients can remain substantial. In many countries, coverage of prosthetic rehabilitation or dentures is time-bound, with coverage intervals ranging between three to five years. In Lithuania and Estonia, for example, costs for new prosthetic rehabilitation are covered up to a ceiling of EU 561 (Lithuania for pensioners, disabled and cancer patients) and EUR 260 (Estonia) every three years and if provided by contracted dentists (the exact amount covered can vary by level of bone retention). France expanded the coverage of dental prostheses (including bridges, crowns and movable prosthetics) as of 2021. In Germany, surgical implantation is only covered for patients with exceptional medical indications (e.g. jaw deformities). For prosthetic rehabilitation or fixed dentures, the fixed subsidy for dentures applies that covers 60-75 % of costs. Overall, implants are not covered by statutory insurance and are subject to full out-of-pocket in most countries. An exception in coverage for prosthetic treatment are the Netherlands where general dental care is usually excluded from the broad benefit package for adults. The Dutch statutory basic tariff, however, covers the cost of full dentures at a reimbursement rate of 75% for new prothesis and at 90% for repair of full dentures with an annual deductible of EUR 385 (lower jaw implants are covered under certain conditions) and with an excess to be paid by the insured person of EUR 250 per jaw. The annual mandatory deductible applies not only to dental care costs but also other health care costs (except GP care, maternity care, district nursing) and has to be paid by adults before the insurer begins to reimburse for services. 2. Service access: physical availability and other determinants The results reported in the three vignettes also show that patients may experience very different kinds of physical barriers to access dental care (Table 5 ). The most important barriers reported in all three vignettes across countries relate to the availability of dental care providers, be that due to a general shortage of professionals contracting with public payers or regional variation. In Estonia, for example, the number of contracted dentists per capita is very low and represents the major limitation for access to dental care. In Ireland, the number of dentists contracted to operate in the public dental scheme is rapidly declining. Almost all countries reported shortage of dentists in particular in rural and remote areas as well as deprived areas with important implications on waiting times, opening hours (shorter in rural areas) and travel distances. With dentists primarily being located in urban areas, physical access to dental care for patients in rural areas is often more difficult. Especially for interventions that require several visits, waiting time constitutes a major access barrier. In Poland, for example, the average waiting time in 2020 was 16 days, but varied from 6 days to 41 days across regions. Moreover, appropriate technical equipment (e.g. x-ray units) is not equally available across dental practices which makes referrals to other providers or laboratories necessary, such as in Bulgaria. Accessibility issues for people with reduced mobility in smaller and older dental clinics were reported as another access barrier such as in France, Lithuania and Sweden; for example, dental care facilities are not accessible for wheelchair users due to lack of ramps or narrow doors. While the majority of physical access barriers were similar across the three vignettes, emergency care (Vignette 1) and more specialised treatment pathways (Vignette 2 and 3) highlight access barriers specific to specialized services and providers. Emergency dental services and out-of-office hour dental care in general are often only available in large cities in some countries (Vignette 1). The unequal distribution and/or lack of specialised dentists as well as dental hygienists constitute major barriers in many countries. In Ireland, dentists with a special interest in endodontics are generally confined to more urban areas. In Slovakia, the lack of specialists on periodontal conditions results in low quality of care for these patients (Vignette 2). Lithuania experiences a lack of dental assistants in facilities contracted by the statutory health system. As a result, patients have to pay out-of-pocket as services of dental assistants are only covered if they are employed in a contracted facility. Moreover, the lack of specialists in rural areas has become a main barrier for access (Vignette 2). For Slovakia, respondents highlight that stomatology centres are confined to larger cities which create access barriers for patients requiring implant-based treatments and also in Bulgaria, very few dentists are experienced in the area of dental implantology as it is a relatively new specialty (Vignette 3). The socioeconomic status of patients was reported as the main determinant of access to dental care in nearly all countries. In particular when patients have to pay upfront for services which are reimbursed retrospectively by the health insurance, or cover very high OOP costs, socioeconomic status is crucial. In Lithuania, for example, the high cost of dentures (Vignette 3) implies that the intervention remains unaffordable for low-income groups. Several countries recognized that in theory, those with cognitive impairment or mental health conditions might be less well placed to formulate a care request or understand the different benefits and treatment processes of alternatives, for instance root canal vs. extraction. In some countries, providers might deny care due to financial reasons (related to insurance status or income level). For all vignettes, most respondents highlighted that patient age can inhibit access and affect outcomes, for instance by complicating long distance travel. Access barriers due to difficulties with formulating the care request may be similarly exacerbated in this patient group, particularly for the third vignette, patients may find it difficult to understand the benefits of different options and/or navigate complicated administrative processes that would have helped with claiming support to cover OOP costs. Other determinants may also impact access: for instance, evidence from Sweden identified female gender, higher educational levels, and native status as drivers for seeking care for chronic conditions – men, less educated people and foreigners are less likely to seek care. Foreigners and the less educated are also less likely to make use of cost-sharing alleviations. The question on the role of provider attitudes was the one most frequently left without adequate responses due to lack of relevant evidence. However, several countries reported indicative reasoning for motivating factors. Most frequently, care denial was driven by insufficient coverage (either because public coverage tariffs are too low or because patients are deemed unable to cover OOP costs) or insufficient skill on the side of the practitioner, for example for working with children, cognitively impaired patients or individuals living with a mental disorder. One country also mentioned dentists refusing care to patients with chronic infectious diseases, such as hepatitis C or HIV due to for example required efforts to practice standard precautions. Discussion This vignette study has demonstrated the limited public coverage of many common dental services. The three vignettes exemplified the considerable variation of service and cost coverage for dental are across the 11 countries. Basic dental care, such as emergency consultations, tooth extraction and x-rays are covered in most countries without co-payments. In general, tooth extraction might be considered as the most affordable choice and therefore be more broadly covered by statutory insurance. However, this largely depends on the location of the tooth. In most cases, tooth loss creates not only deteriorating jawbone, gum disease, poor eating habits or difficulty speaking, but also reduces overall quality of life [ 37 ] and requires more expensive treatments to replace removed teeth. For the majority of services in the vignettes, cost-sharing applies as a rule and is structured very differently across countries. Cost-sharing may come in the form of co-insurance (such as in France), fixed subsidies (Estonia, Germany and Sweden) or are deductible (the Netherlands, where also co-payments applies in case of total prothesis). The most significant cost-sharing applies to fixed prosthodontic treatment where only a fraction of the costs is covered by the statutory system and therefore these options remain unaffordable for many people. In many countries, the number of dental services covered is limited per annum (e.g. dental examination) or over a defined period of several years (for dental protheses). The specific teeth covered for some treatments can also be restricted. In most countries, statutory coverage is limited to standard materials; above-standard materials, which ensure high-quality dental care and thus better health outcomes have to be paid out-of-pocket by the patient. This showcases the general limited coverage of dental care in terms of service coverage compared to other health services. Overall, dental care seems to be subject to more cost-sharing and restrictions compared to other health care areas. This results in limited financial protection for the costs of oral health care in many countries (see also [ 10 ]) and financial hardship for households impacting on the use of dental care. When comparing unmet needs for different types of care (medical care or prescribed medicines), dental care is the most frequent type of care that people forego due to financial reasons. On average 14% of adults report unmet needs for dental care due to costs in EU and OECD countries [ 38 ]. Financial protection measures are often addressed to specific population groups such as low-income people or other vulnerable groups (pregnant women, children, patients with serious illness or mental or physical disabilities) [ 7 ]. Some financial protection mechanisms also exist for older people, for example in Estonia and Lithuania pensioners receive higher reimbursement for prosthodontic treatments than younger adults. In Sweden, people above the age of 65 years as well as individuals 24–29 years old are eligible for a general dental care grant which is higher than for all other adults [ 7 ]. However, even with mitigating measures in place such as the high-cost protection scheme in Sweden, OOP burden is not necessarily fully alleviated. For services only provided in the private sector without public coverage, prices are often unregulated (e.g. Poland), and resulting OOP costs are substantial. In many countries, voluntary health insurance is common for dental care (e.g. Germany, France, the Netherlands and Portugal), for full coverage of services or coverage of cost-sharing obligations. In the Netherlands VHI reimbursement is capped, depending on the insurance policy, making people to pay additionally out of pocket for more expensive treatments. In particular, older patients are confronted with high out-of-pockets costs as many of the teeth are increasingly being retained into older age but are often heavily restored and/or have some degree of advanced periodontal disease [ 3 , 25 ]. There is a large variation of incentives created by services coverage across countries, which can be contradictory. While dental extraction seems to be better covered than tooth retaining procedures (root canal treatment) in many countries, there are different schemes to incentivize preventive care such as in Germany or Slovakia. In Slovakia, patients only receive a dental allowance (EUR 100 to 150 per year) to cost-sharing requirement if they had dental examination in the previous year. In Sweden, the general dental care grant intends to encourage adults to regularly visit their dentist for check-ups and preventative care. However, the current potential of preventive therapies in dentistry to improve oral health and contain costs is still underutilised throughout Europe. Countries will need to step back from the current treatment focused approach and create new ways of oral disease prevention and oral health promotion by strengthening integration of oral health into primary health care [ 4 , 5 , 39 , 40 ]. In all countries, statutory coverage of dental care does not necessarily imply that people have unrestricted access to dental care services. Many similar barriers limit access to dental care across countries which relate to the physical availability of care (due to long distance, poor quality, reduced opening hours, waiting times) as well as the person’s ability to obtain necessary care or the attitude of the provider. In particular, the limited availability of contracted dentists creates a major access barrier to public dental care in many countries. This is particularly detrimental for patients residing in rural areas or less wealthy regions, that may not profit from the same density of professionals, specialized clinics or state of the art equipment as those residing in urban centres. Another interesting element is the lack of consideration of physical accessibility for people with disabilities in older, more remote facilities (e.g. wheelchair access). Most respondents highlighted the potential difficulties of patients with cognitive impairment or other types of dependency to seek care, understand the benefits and disadvantages of different care options, adhere to treatment plans or navigate the complicated reimbursement system that may have helped them deal with financial barriers. Barriers to high-quality care in some countries are also attributable to the lagging establishment of “best practice”. For the third vignette, newer prosthetic treatments involving surgical implants are not widely available in all countries. In Slovakia, for example, implants are still not a standard procedure for some dentists and thus the physical availability of the service is worse in some parts of the country. Lack of a respective dental guideline may be the major reason for these non-harmonised treatment pathways. At the European level, there is currently no detailed, common guidance concerning management and treatment of patients with oral health problems which complicates the comparison of coverage and access to oral health services. This vignette study on coverage and access to dental care has several strengths and limitations. This study demonstrated the potential of the approach to pick up access barriers usually not demonstrated by performance assessment indicators. It also confirmed previous knowledge about the limited coverage of dental services; this restrictive coverage automatically pre-disposes patients from lower socioeconomic strata to experiencing further barriers along the path to realised access, widening health inequalities. At the same time, the study has several limitations. A clear limitation of vignettes is that they may not accurately reflect the real world, both with regard to the textual descriptions of used case examples and the elicited hypothetical behaviour [ 18 , 41 ]. The comprehensiveness and representativity of information relied on the knowledge and experience of respondents. Participating experts may not always have comprehensive knowledge on each dental procedure covered in the vignettes, the relevant regulations of coverage, or the effective access to these services. There was substantial variation in the detail level of responses. Furthermore, it became clear that responses could have been skewed by the initial focus of the vignette template on coverage, as categories further to right of the table related to realised access were not always tackled in detail. This was probably also compounded by the background of respondents (see methods section). For this exercise on dental care, it is conceivable that the three chosen vignettes were too many in terms of services included to be answered at once, as a certain level of respondent fatigue was obvious for the third vignette on edentulism (less granularity, more skipped fields in the template). Conclusion The results of the vignettes reveal that statutory coverage of dental care varies across 11 European countries, but access barriers are largely similar. Statutory coverage of many dental services is limited, and substantial cost-sharing applies in most countries which in turn leads to high out-of-pocket spending. The socioeconomic status thus is a main determinant for access to dental care, but also other factors such as geography, age and comorbidities can inhibit access and affect outcomes. Moreover, different incentives structures have implications on how countries are treated in regard to state-of-the-art dental care. Further, our findings showed that coverage in most oral health systems is targeted at treatment and less at preventative oral health care. Policies are needed that exploit the potential of preventive oral care and favour its integration into existing strategies for the prevention and control of NCDs which have major common risk factors and social determinants in common. Enhanced integration of oral health care with medical care is also needed to better meet the needs of the growing population of older adults with multiple health conditions. The study showed that the vignette approach revealed important gaps in access that would have stayed under the radar when only looking at available services in the benefit basket and thus remains interesting to pursue further. Finally, our approach revealed the lack of common guidelines in the field of dentistry at national and European level. It is important developing common guidelines and promoting best practice rules for dental care in EU to which dentists adhere. A major prerequisite for this is an evidence base for dental guidelines that is established and internationally agreed. Abbreviations DTSS Dental Treatment Services Scheme DTBS Dental Treatment Benefit Scheme EU European Union NCD Non-communicable disease OOP Out-of-pocket PDS Public Dental Service SHI Social health insurance YLD Years lived with disability Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements Not applicable References GBD 2017 Oral Disorders Collaborators. 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Int J Clin Health Psychol. 2015;15(2):160–170. doi: 10.1016/j.ijchp.2014.12.001 Tables Due to technical limitations, tables 2, 3, & 4 are only available as a download in the Supplemental Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Supplementarytables.docx Cite Share Download PDF Status: Published Journal Publication published 08 Mar, 2022 Read the published version in BMC Oral Health → Version 1 posted Editor invited by journal 12 Oct, 2021 Submission checks completed at journal 12 Oct, 2021 First submitted to journal 11 Oct, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Policies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ewout","middleName":"van","lastName":"Ginneken","suffix":""},{"id":56288986,"identity":"ab28bedd-69c7-4850-a709-d62bc4f40d3e","order_by":23,"name":"Dimitra Panteli","email":"","orcid":"","institution":"European Observatory on Health Systems and Policies","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dimitra","middleName":"","lastName":"Panteli","suffix":""}],"badges":[],"createdAt":"2021-10-11 19:14:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-964070/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-964070/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-022-02095-4","type":"published","date":"2022-03-09T01:48:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":19008255,"identity":"36b7c398-97f0-4b0f-aaa9-e0e21537b8c5","added_by":"auto","created_at":"2022-03-09 01:48:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":589152,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-964070/v1/bf020c02-ded5-462f-939f-cf74f13ac6d2.pdf"},{"id":14490655,"identity":"dc40a763-b7e6-441b-aa70-577b72847317","added_by":"auto","created_at":"2021-10-13 14:52:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22629,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-964070/v1/f4496470b7e5ce41ad4d3ac0.docx"},{"id":14490656,"identity":"f31dc465-c93a-4856-b1f7-20ca43f1437f","added_by":"auto","created_at":"2021-10-13 14:52:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":62485,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytables.docx","url":"https://assets-eu.researchsquare.com/files/rs-964070/v1/e73a93652bdb2d79ba5e9422.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring Variation of Coverage and Access to Dental Care for Adults in 11 European Countries: A Vignette Approach\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral diseases, such as dental caries (tooth decay), periodontal disease (gum disease) and tooth loss (edentulism) are persistently among the most prevalent conditions globally, despite being largely preventable [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They can have significant consequences, including unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. As such, they pose a substantial health and economic burden, for individuals, families and society as a whole [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Routine access to primary oral health care allows early detection and management of oral diseases, and can mitigate their negative impacts [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The importance of oral health has received increased attention over the past few years. The 74th World Health Assembly resolution 2021 and The Lancet Issue on Oral Health 2019 highlighted the need to shift from the traditional curative approach towards prevention, and to integrate oral health within the primary health care system and universal health coverage programmes [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the significant impact of oral health on general health and well-being, many countries restrict dental benefits covered by the statutory health system to specific treatments or age groups [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Several dental care services require either cost-sharing or have to be paid fully out-of-pocket in many countries. There is large variation in the level of cost-sharing and types of treatments excluded from the benefit basket across national and regional jurisdictions. However, there is increasing evidence to support that limited coverage reduces financial protection and people\u0026rsquo;s capacity to obtain dental care if they cannot pay for treatment or disposables. This leads to inequalities in access to dental health services within and across countries and eventual inequities in oral health status [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A 2019 survey on areas of care where access might be a problem in European countries identified oral health as one area with major gaps in coverage and access [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo achieve better coverage and integration of dental care, the benefit basket and how related services are financed and delivered will inevitably need to be adapted in most countries. For such efforts to be successful, it is equally important to identify and understand barriers to accessing dental care services beyond coverage, such as the physical availability and accessibility of the necessary care providers or potential differential experiences along the social determinants of health. However, the variation in coverage and other access barriers to dental care services across countries remains under investigated.\u003c/p\u003e \u003cp\u003eAgainst this backdrop, the aim of this paper is to compare differences in dental care coverage and access for adults in 11 European countries using a vignette approach. The three most frequent oral diseases (dental caries, periodontal disease and tooth loss [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] were chosen as the basis for the vignettes. Together, they amounted to approximately 0.7% of total disability-adjusted life years (DALYs) and 2% of years lived with disability (YLDs) globally in 2017 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. On the basis of a patient pathway for each of these three conditions, we first examine which dental care services are covered under statutory package and/or under which conditions and to what extent (i.e. height of user charges in form of cost-sharing or private payment) across countries in our sample. We then compare further barriers to realised access, such as the physical availability of dental care services.\u003c/p\u003e \u003cp\u003eThis research was carried out as part of work for the Expert Group on Health System Performance Assessment (HSPA) of the European Commission, aiming to explore the usefulness of the patient vignette approach as a complementary tool for identifying gaps and challenges in access to health care in the context of HSPA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eApproach and conceptual framework\u003c/h2\u003e\n\u003cp\u003eA vignette is a short description of a person or situation designed to simulate key features of a real-world scenario [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. A vignette case generally specifies a hypothetical patient\u0026rsquo;s age, gender, medical complaint, and health history. As a research tool, vignettes are usually presented to relevant professionals to solicit their hypothetical response or behaviour. In medical literature, vignettes are mostly used to study variations in decision-making processes, including clinical judgments made by health professionals [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Recently, vignettes have also been used to compare price levels in hospitals [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] and to investigate the availability and nature of certain types of care such as outpatient mental care [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] and community dementia care [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. In this study we do not focus on differences in treatment or cost, but rather gaps in access during an episode of care that can be compared across countries. Therefore, the vignettes also include a delineation of the recommended care pathway and a list of services that could then be used to benchmark and compare access across countries.\u003c/p\u003e\n\u003cp\u003eTo compare coverage and access to dental services included in each vignette, we use the framework of the Gaps in Coverage and Access survey [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] which explores the three traditional dimensions of coverage (population coverage, service coverage (which benefits are covered) and cost coverage (what proportion of costs is covered)) as well as a fourth dimension, labelled service access. Population coverage was not listed separately for this work, as gaps in statutory health coverage would be picked up under the service coverage dimension. In terms of service access, gaps could be due to i) lack of physical availability of services, due to long distances to the provider, lack of sufficient statutory/contracted providers, poor quality of services, limited opening hours, waiting times and waiting lists; ii) lack of person\u0026rsquo;s ability to obtain necessary care, due to a person\u0026rsquo;s incapacity to formulate care request, obtain the care or to apply for coverage (and fulfil the necessary requirements) due to their condition or situation (e.g. people with cognitive impairment, mentally ill, homeless), and ability to navigate the system (for example when referred from one provider to another one); and iii) attitude of the provider, for example due to discrimination (on age, gender, race, religious beliefs, sexual orientation, etc) leading to care denial or inability to accommodate care to the patient\u0026rsquo;s preferences [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, a list of determinants that could improve or worsen access, including patient characteristics (e.g. age, sex, and socioeconomic status, insurance status, legal status, place of residence) as well as other factors (night vs. day treatment protocols), were added to the conceptual framework and respondents were also asked to provide any other determinants they thought could affect access for the vignette.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eDesign of dental care vignettes and survey\u003c/h2\u003e\n\u003cp\u003eThe vignettes were designed in collaboration with the Department of Oral Diagnostics, Digital Health and Health Services Research at the Charit\u0026eacute; Medical University in Berlin (Germany). Each vignette and the related care pathway represent a common realistic dental problem and potential treatment options based as much as possible on common practice and international guidelines or recommendations. To shape each vignette recommendations found in systematic reviews or developed by national, European or international organisations in the field of dentistry were used.\u003c/p\u003e\n\u003cp\u003eThree dental care vignettes were designed that illustrate typical care pathways for adult patients with the most common oral health conditions (caries, periodontal disease, edentulism).\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eVignette 1\u003c/span\u003e explores coverage and potential access barriers in the treatment of dental caries that can be addressed by non-restorative or restorative treatment using different materials (e.g. non-restorative: regular application of fluoride, gels, varnishes or sealants, or a combination thereof, resin infiltration; restorative: fillings using dental amalgams or composite resins, crowns) [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eVignette 2\u003c/span\u003e focuses on periodontal conditions are caused by plaque induced inflammation of the gingivae characterised by red swollen tissues and bleeding (gingivitis) with periodontitis resulting with further loss of supporting bone and attachment. Recommended treatment includes patient instruction on daily plaque removal as well as the removal of supra-gingival plaque, calculus, stain (dental cleaning) and sub-gingival deposits (root planning) and control of local plaque retentive factors [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. The removal of dental calculus which is part of the scaling and root planning treatment is otherwise also a very effective (primary and secondary) preventive intervention for periodontal disease.\u003c/p\u003e\n\u003cp\u003e\u003cspan class=\"BoldItalic\"\u003eVignette 3\u003c/span\u003e considers coverage and access challenges for edentulous patients. Edentulous patients have a choice among different rehabilitation options: while complete dentures are widely used, implant-borne replacements are increasing and there is evidence supporting that they may aid in minimizing bone resorption. Prosthetic dental work is costly, but different modalities may be more or less affordable to patients [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the dental care vignettes broken down in services and describe typical patients of different ages experiencing the three conditions. Each vignette describes the patient, their symptoms and potential care decisions for their clinical situation. The sequence of services corresponds to the usual care pathway which might not necessarily be the same for all countries and settings. It was expected that the chosen services might not reflect standard practice in some participating countries, and respondents were invited to describe these differences.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDental care vignettes \u0026ndash; patient description and services in patient pathway\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVignettes\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eServices\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVignette 1: Urgent care with root canal and prosthodontic treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 35-year-old patient has not been able to sleep for two nights due to a strong, beating pain in the right-lower jaw. The patient requests an urgent dental appointment. The dentist determines that the patient needs a root-canal treatment to preserve the first lower molar, and treat the pain. The patient decides for the root canal treatment and against the alternative of tooth extraction. Following the root canal treatment, reconstruction with composite (filling) material is used until a fixed prosthodontic treatment (crown/onlay) can be placed.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmergency consultation with dentist\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRadiography ((bitewing) X-rays)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRoot canal treatment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTooth extraction\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(interim) reconstruction with white filling material\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFixed prosthodontic treatment (crown/onlay)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVignette 2: Periodontal treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 66-year-old patient with co-morbidities (obesity, diabetes) has frequent discomfort in the upper jaw. After a consultation, chronic periodontitis with generalized level 2 mobility is diagnosed, requiring scaling and root planning, involving periodontal probing and elimination of dental calculus and frequent follow-up visits to stop disease progression and stabilize bone-loss.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScheduled visit with the dentist\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScaling and root planning (performed by a dentist)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeriodontal probing, and elimination of dental calculus (performed by dental assistant or hygienist)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRegular follow-up visits\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVignette 3: Implant-borne restoration and prosthetic rehabilitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn edentulous 75-year-old patient received full upper and lower dentures 5 years ago. She feels she has lost significant capacity to chew as the lower prosthesis is poorly retained and gets displaced when speaking or eating. She seeks counseling from her dentist, who recommends two implants on the lower anterior jaw and an overdenture to improve retention. She agrees with this course of treatment and against more sophisticated fixed alternatives.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConsultation and surgical planning\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSurgical implantation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProsthetic rehabilitation: New prosthesis or adjustment of old prosthesis using the implants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(Partially) fixed dentures\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTo collect the data, a survey was constructed which presented each vignette in a separate table outlining all individual services per vignette (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, for each service, experts were asked to indicate the statutory service coverage (which benefits are covered) and cost coverage (what proportion of costs is covered). Moreover, for the access dimension they were asked to indicate physical availability of services, person\u0026rsquo;s ability to obtain care, providers\u0026rsquo; attitude and any additional determinants they thought could affect access for each service of the vignettes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eSample, data collection and synthesis\u003c/h2\u003e\n\u003cp\u003eThe survey with vignettes (supplementary material 4) was sent to experts in 11 countries, including Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, Netherlands, Poland, Portugal, Slovakia and Sweden. The country selection was made to ensure variation of health systems (i.e., social health insurance vs. tax-financed, multi- vs single payer, centralised vs decentralized) as well as geographical distribution. Depending on the country, vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.\u003c/p\u003e\n\u003cp\u003eThe information provided by individual country experts in the survey were extracted and summarized in one table per vignette (supplementary material 1-3): per country, for each service of the patient pathway and along three dimensions: coverage, cost-sharing, and physical availability/determinants of access. We further synthesized responses (Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e-\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, below) using a traffic light system (green \u0026ndash; yellow \u0026ndash; red, see explanation of colour codes below Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e-\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) to visually compare results across countries. These comparative tables build the foundation for a cross-country analysis of the coverage of each service provided in the three different patient pathways. Results on physical availability and determinants of access are broken down in more detail in Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e and analysed separately as access barriers were similar across the three vignettes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Physical availability and determinants of access\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabc\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAccess dimension\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVignette 1: Root canal and prosthodontic treatment\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVignette 2: Periodontal treatment\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVignette 3: Prosthetic treatment\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBulgaria\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eLower density of dentist and dental assistants and contracted dentists in rural areas; Referral to providers/laboratories due to lack of necessary equipment in most dental practices; 24-hours emergency dental care available only in large cities\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFew specialized and experienced dentists in the field of dental implantology\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDeterminants of access\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eSocioeconomic status and place of residence\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEstonia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eOnly contracted dentists covered; Longer distances in remote areas; Not every dentist provides radiology services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eRegional variation in access \u0026amp; waiting times; Consultations difficult during night/ weekend/public holidays\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDeterminants of access\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eMore difficult access for people with low socio-economic status, no VHI or specific vulnerabilities (such as people living with mental disorders)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGermany\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLower density in rural areas, potential lack of equipment in older clinics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLower availability of specialists in some areas, regional variation of dental assistants and hygienists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpecialist in implantology scarce in rural areas\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIreland\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eVariation of dentists by region and area deprivation: specialist practices generally confined to more urban areas, while only two dental specialties are recognised in Ireland (oral surgery and orthodontics); Declining numbers of contracted dentists participating in the DTSS scheme which largely provides care for lower socioeconomic groups.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDeterminants of access\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eSocioeconomic status; area of residence; access difficulties for older adults in rural areas (especially those with mobility issues) and vulnerable groups particularly children and adults in residential care, refugees, asylum seekers, homeless people, and other socially excluded groups resulting in long waiting lists for general anaesthetic and other referral services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLithuania\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eRegional variation in access; Restricted availability due to limited opening hours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of contracted specialists, limited opening hours, considerable waiting time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of specialists in rural areas implying limited access for elderly, disabled, severely ill residents\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNetherlands\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003ePotentially longer waiting times for patients not registered with dentists with varying waiting times across regions; VHI often covers up to a maximum amount (mostly between EUR 250 and 1 000, depending on the premium paid)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePoland\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEmergency dental care points mainly in large cities\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRegional variation of dentist-to population ratio, varying waiting times across regions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePortugal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eRegional variation of dentists\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSlovakia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLimited opening hours in rural areas. Distance to dentists in Roma settlements\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of dentists specialized in chronic periodontitis, Accessibility issues in rural areas and for the elderly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAvailability of implant services in rural areas as it is still not standard procedure for some dentists\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDeterminants of access\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eSocioeconomic status, HIV/hepatitis and education\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSweden\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical availability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eWaiting times and variable opening hours in rural settings, Accessibility issues for patients with physical impairments, very low dentist-to-population ratio in remote areas\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eCompleted vignettes were received from 11 countries, including Bulgaria, Estonia, France, Germany, Ireland, Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden between October and December 2020. If answers were unclear, country experts were contacted to provide clarifications. Answers varied in granularity of provided information; occasionally the answers indicated that the differentiation between columns in the vignette template was unclear or interpreted differently than originally intended.\u003c/p\u003e\n\u003cp\u003eSome responses showed the complexity of the coverage system for dental care, indicating need for further explanation before being tailored in the vignettes, in particular on Ireland and Sweden. Dental services in Ireland are delivered through three publicly funded schemes: (i) the Public Dental Service (PDS) provides emergency and some routine oral healthcare for children under the age of 16 and certain vulnerable groups, (ii) the Dental Treatment Services Scheme (DTSS) entitles certain adults to some dental services free of charge, and (iii) under the Dental Treatment Benefit Scheme (DTBS) discounted dental treatment is provided to those who have paid three years of social insurance contributions [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. In addition, private dental care is available that patients must pay fully out-of-pocket and claim back fees through tax relief up to a maximum of 20% of the treatment cost for certain non-routine procedures [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn Sweden dental care is free up to the age of 23, all others receive a general dental care allowance of EUR 30 to EUR 60 year to encourage dental check-ups and preventive care. People with certain illness or conditions (e.g. difficult-to-treat diabetes) receive a special dental care subsidy of EUR 60 every six months. In addition, most dental care in Sweden is subject to a high-cost protection scheme which aims to protect patients from very high dental care costs. Treatment costs above certain thresholds during a twelve-month period are covered at 50% (for costs between EUR 295 and 1 470) or 85% (costs above EUR 1 470) of the reference prices. The Netherlands stands out in regard to coverage of dental care by complementary voluntary health insurance (VHI). Most dental care services are not publicly covered but reimbursed fully or in part by voluntary health insurances which are taken up by 84% of the population. In France, private insurance also plays an important role in the reimbursement of non-routine dental care services not publicly covered.\u003c/p\u003e\n\u003cp\u003eThe following sections summarize results on coverage per vignette, followed by results on service access across vignettes.\u003c/p\u003e\n\u003ch2\u003e1. Coverage\u003c/h2\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eVignette 1: Urgent care with root canal and prosthodontic treatment\u003c/h2\u003e\n\u003cp\u003eThe first vignette explores treatment for acute pain due to caries. Related dental care services are in general covered in most responding countries, except for the Netherlands and Portugal (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Emergency services and radiography are covered in most countries, often with standard cost-sharing such as in France and Sweden (sometimes covered by complementary VHI) or with restrictions in regard to the number of emergency visits and radiographs covered, such as in Ireland, where patients are eligible for one emergency consultation per year only. In Bulgaria, Ireland and Slovakia emergency consultations are covered only if patients have not received another consultation during the year. In the Netherlands and Portugal emergency dental care visits as well as the other services of the vignette are not covered at all as dental services are generally not part of the statutory benefit package. However, in the Netherlands the majority of the population purchases VHI to cover part of dental care.\u003c/p\u003e\n\u003cp\u003eIn regard to the alternatives of root canal treatment or tooth extraction, there is more variation in terms of coverage with respect to the treatment alternatives of tooth extraction or root canal treatment. While tooth extractions are covered nearly in full in almost all responding countries, root canal treatments are less comprehensively covered. Limited services and cost coverage for tooth extractions can be found in Estonia where it is only covered in case of emergency and in France, Lithuania and Sweden where cost-sharing is required. In Ireland, only DTSS beneficiaries are entitled to tooth extraction. Root canal treatment can be excluded from coverage, such as in Bulgaria and Ireland, or be limited to certain parts of the mouth (usually covered for visible teeth, i.e. molar to molar), as in Poland. In many countries, molar root canal treatment requires substantial cost-sharing, and it can be fully excluded from public coverage for the majority of the population, as in Ireland.\u003c/p\u003e\n\u003cp\u003eRestoration with composite material and prosthodontic treatment are less comprehensively covered overall. In Germany, there is a fixed subsidy of 60% for standard treatment of crowns or onlays, which can be increased if patients are demonstrably consistent about preventive visits. The remaining costs, as well as any difference of costs due to patients choosing superior materials than those covered by insurance have to be paid out-of-pocket (OOP). In all other countries, only a fraction of the costs for fixed prosthodontic treatment is covered by the statutory health insurance. In several countries, complementary VHI seems to play an important role for the reimbursement of dental treatments which are not or only partially covered, including prosthodontic treatment.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eVignette 2: Chronic periodontal condition\u003c/h2\u003e\n\u003cp\u003eThe second vignette describes a multimorbid patient with chronic periodontitis that requires a scaling and root planning and regular follow-up visits. Regular check-up visits with the dentist seem to be less comprehensively covered across countries than the acute visit in Vignette 1. In some countries, the number of dental check-ups are limited to one visit per year (Bulgaria, Ireland, Slovakia, Poland) or are subject to cost-sharing such as in Estonia and France (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Scaling and root planning are also only partially covered in many countries or limited to a share of teeth (e.g. in Poland). The number of planned follow-up visits to stop disease progression and stabilize bone-loss are again restricted in some counties (Ireland, Poland and Slovakia).\u003c/p\u003e\n\u003cp\u003eInterestingly, there is large variation in regard to coverage of periodontal probing and elimination of dental calculus which is part of periodontal treatment to prevent disease progression. The latter treatment is usually performed by a dental assistant or dental hygienist. In Germany, with comparatively comprehensive coverage for dental care overall, dental cleanings are not covered by the statutory health insurance, while in Slovakia, which has more limited coverage, the social health insurance would cover periodontal probing, and elimination of dental calculus for this patient. In general, basic dental hygiene in Slovakia is partly covered by SHI insurance twice a year in case patients attend regularly preventive check-ups. In Ireland, one scale and polish per year is covered up to EUR 42 for those who contributed to social insurance in the last three years (Dental Treatment Benefit Scheme (DTBS)), corresponding to almost half of the population. In Estonia and Lithuania some cost-sharing applies while in the remaining countries patients have to pay fully out-of-pocket for this kind of services likewise to Germany.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eVignette 3: Coverage of implant-borne restoration and prosthetic rehabilitation across countries\u003c/h2\u003e\n\u003cp\u003eThe third vignette describes prosthetic treatment for an older, edentulous patient who received full upper and lower dentures five years ago. Overall, the required interventions of prosthetic restoration are less comprehensively covered than services in vignettes 1 and 2. Coverage gaps exist in particular regarding the requirement for cost-sharing from the patient (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). While some countries employ financial protection measures to support lower-income individuals with the procurement of dentures (e.g. Germany, Ireland, Netherlands), the OOP (out-of-pocket) cost to be borne by the patients can remain substantial. In many countries, coverage of prosthetic rehabilitation or dentures is time-bound, with coverage intervals ranging between three to five years. In Lithuania and Estonia, for example, costs for new prosthetic rehabilitation are covered up to a ceiling of EU 561 (Lithuania for pensioners, disabled and cancer patients) and EUR 260 (Estonia) every three years and if provided by contracted dentists (the exact amount covered can vary by level of bone retention). France expanded the coverage of dental prostheses (including bridges, crowns and movable prosthetics) as of 2021. In Germany, surgical implantation is only covered for patients with exceptional medical indications (e.g. jaw deformities). For prosthetic rehabilitation or fixed dentures, the fixed subsidy for dentures applies that covers 60-75 % of costs. Overall, implants are not covered by statutory insurance and are subject to full out-of-pocket in most countries.\u003c/p\u003e\n\u003cp\u003eAn exception in coverage for prosthetic treatment are the Netherlands where general dental care is usually excluded from the broad benefit package for adults. The Dutch statutory basic tariff, however, covers the cost of full dentures at a reimbursement rate of 75% for new prothesis and at 90% for repair of full dentures with an annual deductible of EUR 385 (lower jaw implants are covered under certain conditions) and with an excess to be paid by the insured person of EUR 250 per jaw. The annual mandatory deductible applies not only to dental care costs but also other health care costs (except GP care, maternity care, district nursing) and has to be paid by adults before the insurer begins to reimburse for services.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003e2. Service access: physical availability and other determinants\u003c/h2\u003e\n\u003cp\u003eThe results reported in the three vignettes also show that patients may experience very different kinds of physical barriers to access dental care (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). The most important barriers reported in all three vignettes across countries relate to the availability of dental care providers, be that due to a general shortage of professionals contracting with public payers or regional variation. In Estonia, for example, the number of contracted dentists per capita is very low and represents the major limitation for access to dental care. In Ireland, the number of dentists contracted to operate in the public dental scheme is rapidly declining. Almost all countries reported shortage of dentists in particular in rural and remote areas as well as deprived areas with important implications on waiting times, opening hours (shorter in rural areas) and travel distances. With dentists primarily being located in urban areas, physical access to dental care for patients in rural areas is often more difficult. Especially for interventions that require several visits, waiting time constitutes a major access barrier. In Poland, for example, the average waiting time in 2020 was 16 days, but varied from 6 days to 41 days across regions.\u003c/p\u003e\n\u003cp\u003eMoreover, appropriate technical equipment (e.g. x-ray units) is not equally available across dental practices which makes referrals to other providers or laboratories necessary, such as in Bulgaria. Accessibility issues for people with reduced mobility in smaller and older dental clinics were reported as another access barrier such as in France, Lithuania and Sweden; for example, dental care facilities are not accessible for wheelchair users due to lack of ramps or narrow doors.\u003c/p\u003e\n\u003cp\u003eWhile the majority of physical access barriers were similar across the three vignettes, emergency care (Vignette 1) and more specialised treatment pathways (Vignette 2 and 3) highlight access barriers specific to specialized services and providers. Emergency dental services and out-of-office hour dental care in general are often only available in large cities in some countries (Vignette 1). The unequal distribution and/or lack of specialised dentists as well as dental hygienists constitute major barriers in many countries. In Ireland, dentists with a special interest in endodontics are generally confined to more urban areas. In Slovakia, the lack of specialists on periodontal conditions results in low quality of care for these patients (Vignette 2). Lithuania experiences a lack of dental assistants in facilities contracted by the statutory health system. As a result, patients have to pay out-of-pocket as services of dental assistants are only covered if they are employed in a contracted facility. Moreover, the lack of specialists in rural areas has become a main barrier for access (Vignette 2). For Slovakia, respondents highlight that stomatology centres are confined to larger cities which create access barriers for patients requiring implant-based treatments and also in Bulgaria, very few dentists are experienced in the area of dental implantology as it is a relatively new specialty (Vignette 3).\u003c/p\u003e\n\u003cp\u003eThe socioeconomic status of patients was reported as the main determinant of access to dental care in nearly all countries. In particular when patients have to pay upfront for services which are reimbursed retrospectively by the health insurance, or cover very high OOP costs, socioeconomic status is crucial. In Lithuania, for example, the high cost of dentures (Vignette 3) implies that the intervention remains unaffordable for low-income groups. Several countries recognized that in theory, those with cognitive impairment or mental health conditions might be less well placed to formulate a care request or understand the different benefits and treatment processes of alternatives, for instance root canal vs. extraction. In some countries, providers might deny care due to financial reasons (related to insurance status or income level).\u003c/p\u003e\n\u003cp\u003eFor all vignettes, most respondents highlighted that patient age can inhibit access and affect outcomes, for instance by complicating long distance travel. Access barriers due to difficulties with formulating the care request may be similarly exacerbated in this patient group, particularly for the third vignette, patients may find it difficult to understand the benefits of different options and/or navigate complicated administrative processes that would have helped with claiming support to cover OOP costs.\u003c/p\u003e\n\u003cp\u003eOther determinants may also impact access: for instance, evidence from Sweden identified female gender, higher educational levels, and native status as drivers for seeking care for chronic conditions \u0026ndash; men, less educated people and foreigners are less likely to seek care. Foreigners and the less educated are also less likely to make use of cost-sharing alleviations.\u003c/p\u003e\n\u003cp\u003eThe question on the role of provider attitudes was the one most frequently left without adequate responses due to lack of relevant evidence. However, several countries reported indicative reasoning for motivating factors. Most frequently, care denial was driven by insufficient coverage (either because public coverage tariffs are too low or because patients are deemed unable to cover OOP costs) or insufficient skill on the side of the practitioner, for example for working with children, cognitively impaired patients or individuals living with a mental disorder. One country also mentioned dentists refusing care to patients with chronic infectious diseases, such as hepatitis C or HIV due to for example required efforts to practice standard precautions.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis vignette study has demonstrated the limited public coverage of many common dental services. The three vignettes exemplified the considerable variation of service and cost coverage for dental are across the 11 countries. Basic dental care, such as emergency consultations, tooth extraction and x-rays are covered in most countries without co-payments. In general, tooth extraction might be considered as the most affordable choice and therefore be more broadly covered by statutory insurance. However, this largely depends on the location of the tooth. In most cases, tooth loss creates not only deteriorating jawbone, gum disease, poor eating habits or difficulty speaking, but also reduces overall quality of life [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and requires more expensive treatments to replace removed teeth.\u003c/p\u003e \u003cp\u003eFor the majority of services in the vignettes, cost-sharing applies as a rule and is structured very differently across countries. Cost-sharing may come in the form of co-insurance (such as in France), fixed subsidies (Estonia, Germany and Sweden) or are deductible\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e (the Netherlands, where also co-payments applies in case of total prothesis). The most significant cost-sharing applies to fixed prosthodontic treatment where only a fraction of the costs is covered by the statutory system and therefore these options remain unaffordable for many people. In many countries, the number of dental services covered is limited per annum (e.g. dental examination) or over a defined period of several years (for dental protheses). The specific teeth covered for some treatments can also be restricted. In most countries, statutory coverage is limited to standard materials; above-standard materials, which ensure high-quality dental care and thus better health outcomes have to be paid out-of-pocket by the patient. This showcases the general limited coverage of dental care in terms of service coverage compared to other health services. Overall, dental care seems to be subject to more cost-sharing and restrictions compared to other health care areas. This results in limited financial protection for the costs of oral health care in many countries (see also [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]) and financial hardship for households impacting on the use of dental care. When comparing unmet needs for different types of care (medical care or prescribed medicines), dental care is the most frequent type of care that people forego due to financial reasons. On average 14% of adults report unmet needs for dental care due to costs in EU and OECD countries [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinancial protection measures are often addressed to specific population groups such as low-income people or other vulnerable groups (pregnant women, children, patients with serious illness or mental or physical disabilities) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Some financial protection mechanisms also exist for older people, for example in Estonia and Lithuania pensioners receive higher reimbursement for prosthodontic treatments than younger adults. In Sweden, people above the age of 65 years as well as individuals 24\u0026ndash;29 years old are eligible for a general dental care grant which is higher than for all other adults [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, even with mitigating measures in place such as the high-cost protection scheme in Sweden, OOP burden is not necessarily fully alleviated. For services only provided in the private sector without public coverage, prices are often unregulated (e.g. Poland), and resulting OOP costs are substantial. In many countries, voluntary health insurance is common for dental care (e.g. Germany, France, the Netherlands and Portugal), for full coverage of services or coverage of cost-sharing obligations. In the Netherlands VHI reimbursement is capped, depending on the insurance policy, making people to pay additionally out of pocket for more expensive treatments. In particular, older patients are confronted with high out-of-pockets costs as many of the teeth are increasingly being retained into older age but are often heavily restored and/or have some degree of advanced periodontal disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a large variation of incentives created by services coverage across countries, which can be contradictory. While dental extraction seems to be better covered than tooth retaining procedures (root canal treatment) in many countries, there are different schemes to incentivize preventive care such as in Germany or Slovakia. In Slovakia, patients only receive a dental allowance (EUR 100 to 150 per year) to cost-sharing requirement if they had dental examination in the previous year. In Sweden, the general dental care grant intends to encourage adults to regularly visit their dentist for check-ups and preventative care. However, the current potential of preventive therapies in dentistry to improve oral health and contain costs is still underutilised throughout Europe. Countries will need to step back from the current treatment focused approach and create new ways of oral disease prevention and oral health promotion by strengthening integration of oral health into primary health care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn all countries, statutory coverage of dental care does not necessarily imply that people have unrestricted access to dental care services. Many similar barriers limit access to dental care across countries which relate to the physical availability of care (due to long distance, poor quality, reduced opening hours, waiting times) as well as the person\u0026rsquo;s ability to obtain necessary care or the attitude of the provider. In particular, the limited availability of contracted dentists creates a major access barrier to public dental care in many countries. This is particularly detrimental for patients residing in rural areas or less wealthy regions, that may not profit from the same density of professionals, specialized clinics or state of the art equipment as those residing in urban centres. Another interesting element is the lack of consideration of physical accessibility for people with disabilities in older, more remote facilities (e.g. wheelchair access). Most respondents highlighted the potential difficulties of patients with cognitive impairment or other types of dependency to seek care, understand the benefits and disadvantages of different care options, adhere to treatment plans or navigate the complicated reimbursement system that may have helped them deal with financial barriers.\u003c/p\u003e \u003cp\u003eBarriers to high-quality care in some countries are also attributable to the lagging establishment of \u0026ldquo;best practice\u0026rdquo;. For the third vignette, newer prosthetic treatments involving surgical implants are not widely available in all countries. In Slovakia, for example, implants are still not a standard procedure for some dentists and thus the physical availability of the service is worse in some parts of the country. Lack of a respective dental guideline may be the major reason for these non-harmonised treatment pathways. At the European level, there is currently no detailed, common guidance concerning management and treatment of patients with oral health problems which complicates the comparison of coverage and access to oral health services.\u003c/p\u003e \u003cp\u003eThis vignette study on coverage and access to dental care has several strengths and limitations. This study demonstrated the potential of the approach to pick up access barriers usually not demonstrated by performance assessment indicators. It also confirmed previous knowledge about the limited coverage of dental services; this restrictive coverage automatically pre-disposes patients from lower socioeconomic strata to experiencing further barriers along the path to realised access, widening health inequalities. At the same time, the study has several limitations. A clear limitation of vignettes is that they may not accurately reflect the real world, both with regard to the textual descriptions of used case examples and the elicited hypothetical behaviour [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The comprehensiveness and representativity of information relied on the knowledge and experience of respondents. Participating experts may not always have comprehensive knowledge on each dental procedure covered in the vignettes, the relevant regulations of coverage, or the effective access to these services. There was substantial variation in the detail level of responses. Furthermore, it became clear that responses could have been skewed by the initial focus of the vignette template on coverage, as categories further to right of the table related to realised access were not always tackled in detail. This was probably also compounded by the background of respondents (see \u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003emethods\u003c/span\u003e section). For this exercise on dental care, it is conceivable that the three chosen vignettes were too many in terms of services included to be answered at once, as a certain level of respondent fatigue was obvious for the third vignette on edentulism (less granularity, more skipped fields in the template).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of the vignettes reveal that statutory coverage of dental care varies across 11 European countries, but access barriers are largely similar. Statutory coverage of many dental services is limited, and substantial cost-sharing applies in most countries which in turn leads to high out-of-pocket spending. The socioeconomic status thus is a main determinant for access to dental care, but also other factors such as geography, age and comorbidities can inhibit access and affect outcomes. Moreover, different incentives structures have implications on how countries are treated in regard to state-of-the-art dental care.\u003c/p\u003e \u003cp\u003eFurther, our findings showed that coverage in most oral health systems is targeted at treatment and less at preventative oral health care. Policies are needed that exploit the potential of preventive oral care and favour its integration into existing strategies for the prevention and control of NCDs which have major common risk factors and social determinants in common. Enhanced integration of oral health care with medical care is also needed to better meet the needs of the growing population of older adults with multiple health conditions.\u003c/p\u003e \u003cp\u003eThe study showed that the vignette approach revealed important gaps in access that would have stayed under the radar when only looking at available services in the benefit basket and thus remains interesting to pursue further. Finally, our approach revealed the lack of common guidelines in the field of dentistry at national and European level. It is important developing common guidelines and promoting best practice rules for dental care in EU to which dentists adhere. A major prerequisite for this is an evidence base for dental guidelines that is established and internationally agreed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDTSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDental Treatment Services Scheme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDTBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDental Treatment Benefit Scheme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Union\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-communicable disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOut-of-pocket\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Dental Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial health insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYears lived with disability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2017 Oral Disorders Collaborators. 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Int J Clin Health Psychol. 2015;15(2):160\u0026ndash;170. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijchp.2014.12.001\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eDue to technical limitations, tables 2, 3, \u0026 4 are only available as a download in the Supplemental Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dental care, coverage, access, cost-sharing, benefits, financial protection","lastPublishedDoi":"10.21203/rs.3.rs-964070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-964070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eOral health has received increased attention over the past few years coupled with rising awareness on the impact of limited dental care coverage for oral health and general health and well-being. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eCompleted vignettes were received from 11 countries, including Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different kinds of physical barriers to access dental care. Major access barriers to public dental care represent the limited availability of contracted dentists especially in rural areas and the unequal distribution and lack of specialised dentists.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAccording to the results, statutory coverage of dental care varies across European countries while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries which in turn leads to high out-of-pocket spending. The individual socioeconomic status is thus a main determinant for access to dental care, but also other factors such as geography, age and comorbidities can inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.\u003c/p\u003e","manuscriptTitle":"Exploring Variation of Coverage and Access to Dental Care for Adults in 11 European Countries: A Vignette Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-10-13 14:52:13","doi":"10.21203/rs.3.rs-964070/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvited","content":"","date":"2021-10-12T09:44:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-10-12T09:38:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2021-10-11T18:59:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a8060a1-e4ae-4ca6-a6b0-2511d72c98f1","owner":[],"postedDate":"October 13th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":7829006,"name":"Dentistry"},{"id":7829007,"name":"Head \u0026 Neck Surgery"}],"tags":[],"updatedAt":"2022-03-09T01:48:08+00:00","versionOfRecord":{"articleIdentity":"rs-964070","link":"https://doi.org/10.1186/s12903-022-02095-4","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2022-03-09 01:48:08","publishedOnDateReadable":"March 9th, 2022"},"versionCreatedAt":"2021-10-13 14:52:13","video":"","vorDoi":"10.1186/s12903-022-02095-4","vorDoiUrl":"https://doi.org/10.1186/s12903-022-02095-4","workflowStages":[]},"version":"v1","identity":"rs-964070","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-964070","identity":"rs-964070","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}