EUROPEAN ORTHODONTIC SPECIALISTS IN 2002
Wolfgang J. Schmiedel*, Frans P.G.M. van der Linden**, Ronald J. Bijlstra***
* Past President of EFOSA, ** President of EFOSA, and *** Previous Secretary and Vice President of EFOSA
Summary
The results of a recent survey examining the situation of the speciality of orthodontics in Europe are presented. Among the many items included are the recognition and availability of orthodontic specialists, their training, and working conditions, the fees charged, and the present insurance and refunding systems.
Introduction
Orthodontics has become a highly sophisticated health care service that can provide excellent treatment of malocclusion and facial deformity, based on the premise that this treatment is given by well educated, skilled and experienced specialists. Therefore, adequately qualified manpower is the key to providing the best possible service to the population.
The freedom of exchange of professionals, services and trades implemented by the European Union (EU) in 1978 presented countries with high educational and performance standards with less qualified practitioners and professionals coming in from other countries. That was particularly true for the field of orthodontics. The existing discrepancy in the level of education and variation in the quality of care provided called for the formulation of clear and well-defined guidelines to arrive at a programme for the education of specialists in orthodontics.
Based on the above considerations the second author applied for an Erasmus grant of the EU to develop a commonly accepted programme for the education of specialists in orthodontics. Fifteen university professors were invited from 15 different European countries to take part in this project. Consensus was reached in all essential matters. The statements, conclusions and the content of the programme were supported unanimously by all participants. The programme specifies the main objectives for speciality education in orthodontics, the conditions required, and the course contents for general biological and medical subjects, for orthodontic subjects, techniques and treatment procedures, and the time to be devoted to these subjects and to preclinical/clinical work and research. The programme became known as the Erasmus Programme for the speciality education in Orthodontics (Van der Linden et al. 1992).
The EU provides directives only for the minimal length and overall contents of educational programmes. As these directives do not deal with details and specific requirements, the Erasmus Programme has not been formalised by the EU. Nevertheless, it has been implemented in most European countries and incorporated in the law of several countries.
The impact of the Erasmus Programme has been much larger than initially expected. Before 1992 no guidelines for the education of orthodontic specialists had been formulated in detail and requirements were not specified. When guidelines became available many organisations and universities, not only in Europe but also in other continents, accepted the Erasmus Programme and tried to implement it. As such the Erasmus Programme provided a worldwide stimulus to improve the education of orthodontic specialists and also the care delivered by those educated accordingly.
With the closer co-operation developing within Europe and the increase in regulations formulated by the EU, information on the professional situation within individual countries is essential to be able to anticipate and influence the future development and the conditions that will be proposed by the authorities in Brussels.
This applies not only to the practice of dentistry and orthodontics and the manpower involved, but also to the training of their practitioners, the recognition, the regulation, and the functioning of specialities, and the coverage of fees by insurances and other systems.
A previous survey on the state of orthodontics within the individual countries in Europe has been carried out (P. Moss 1993). However, as many changes have since taken place, it was felt that new information was needed.
This paper will deal with the aspects listed above regarding orthodontics and is based mainly on a questionnaire survey undertaken by the European Federation of Orthodontic Specialists Associations (EFOSA), which was established in 1976 and restructured in 1998, when the Constitution and Bye-laws were changed and extended.
In Article 4 of the Constitution the goals of EFOSA are specified as follows:
The aim of the Federation is to unite associations or groups of orthodontic specialists or practitioners, who have a comparable education and working conditions as orthodontic specialists with a view to
- obtaining official recognition of orthodontic specialists in all countries in Europe,
- providing and promoting orthodontic treatment by orthodontic specialists of the highest quality in all countries of Europe according to the concept of quality improvement,
- defending, in the widest sense, the professional, political and economic interests of orthodontic specialists, especially through the establishment of relations with national and international authorities and bodies with a view to their eventual representation at the Economic and Social Committee instituted by Articles 193 to 198 of the Treaty of Rome, as well as through contacts and agreements with the representatives of other professions,
- formulating and updating the conditions of professional practice of orthodontic specialists in each of the member countries of Europe while seeking the unification of the national legislations governing the practice of the profession by taking part in the formulation of the directives in the manner provided by Article 57 of the Treaty of Rome,
- assisting the authorities of the European Union through their experience as practitioners, and to intercede with such authorities, especially when dealing with the question of the right of free choice of residence and the freedom of right to practice as a specialist,
- interceding, if need be, in a member country of Europe to the extent that such intercession may be helpful in allowing the members of the associations or groups to practice their profession under the best conditions. The intercession may be made, however, only upon the specific request of the member association or group of the country in question,
- improving the contents and quality of education for orthodontic specialists by means of formulating proposals geared toward defining and co-ordinating the teaching of orthodontics at the university and post-university level,
- standardising European examinations at the end of specialist training programs in orthodontics,
- advising and supporting national associations or groups that aim to obtain recognition for the speciality of orthodontics in their country, establish an official specialist register and form a national society of orthodontic specialists,
- seeking financial support through grants and other means to realise the aims listed above.
Each European country can be presented in EFOSA by its professional organisation but the type of membership varies according to the national situation as is laid down in Article 5 of the Constitution.
- Active membership is confined to professional associations or groups of orthodontic specialists exclusively, from countries within the European Union having regulated the profession in accordance with the E.E.C. directives of 1978 and having an official register of specialists. The above also applies to countries that have an arrangement of free movement and the right of free establishment within the EU countries on the basis of mutual speciality recognition.
- Provisional membership is confined to professional associations or groups of practitioners, who have a comparable education and working conditions as orthodontic specialists, from countries within the European Union still waiting for the official recognition and professional regulation in accordance with the E.E.C. directives of 1978. The duration of the provisional membership is for a limited period of time that will be decided by the Assembly of the Federation depending on the conditions of the country involved.
- Affiliated membership is confined to professional orthodontic associations or groups from European countries that fulfil the requirements of article 5 paragraph 1 or 2, but of countries that do not belong to the European Union or do not have an arrangement of free movement and the right of free establishment within the European Union countries on the basis of mutual speciality recognition.
- Only one professional association or group may function as the representative of a country.
Material and methods
In 2001 a questionnaire with 45 questions was sent to the 19 professional orthodontic specialist organisations in Europe that were members of EFOSA and to three organisations that were not members at that time. In 2002 the information was checked and updated by officers of the national organisations and their delegates. The response was 100 per cent.
Results
The data collected are presented in tabular form. The size of the population, the number of dentists and orthodontic specialists and their ratio to the population are given in Table 1. Most countries have a dentist: population ratio between 1: 1000 and 1: 2500 with a relatively large number of dentists in Greece and Iceland and too few in Turkey. The ratio of orthodontic specialists varies considerably, with a medium value of approximately 1: 35.000. The Netherlands with 1: 61.538, the United Kingdom with 1: 73.333 and Italy with 1: 68.235 are on the low side and Portugal with 1: 1.200.000 and Turkey with 1: 294.783 on the very low side.
The percentage of orthodontic patients treated by specialists is also shown in Table 1. General dental practitioners treat the remaining percentage. The shortage or surplus of orthodontic specialists and the right to have general dental practitioners, dental hygienists and dental assistants undertake treatment on patients in an orthodontic specialist practice are also given in Table 1.
In most countries, with the exception of Norway and Iceland, a substantial number of orthodontic patients are treated by general dental practitioners. Overall, approximately 70 per cent are under the care of orthodontic specialists.
There was a large variation in the response by the national orthodontic specialist organisations to the question "Are there too few or too many orthodontic specialists presently available in your country". It was considered that there was a shortage in Austria, Denmark, Italy, the Netherlands, Norway, Poland, Portugal, Sweden, Turkey and the United Kingdom, and a surplus in Belgium, Cyprus, Germany, Greece and Ireland.
Most countries allow general dental practitioners to undertake orthodontic treatment in specialist offices. However that is not the case for Belgium, Denmark, France, Norway, Spain and Sweden.
Dental hygienists are not available in all countries. They are legally allowed to carry out treatment on patients in orthodontic specialist offices in Denmark, Finland, Germany, Iceland, Israel, Italy, the Netherlands, Norway, Poland, Portugal and Switzerland. This also applies to dental assistants, but not in Ireland, Israel, Italy, Poland, Portugal, Switzerland and the United Kingdom.
The present status of membership of the national organisations in EFOSA, together with the formal and legal aspects regarding the recognition of the orthodontic speciality, the protection of the title "orthodontic specialist", the availability of an official register for orthodontic specialists, and the responsible authority for these matters are shown in Table 2. In all countries, except Austria, Luxembourg and Spain the specialty is recognised officially, the title protected and a speciality register established. However, in Austria, Luxembourg and Spain many well-trained practitioners undertake orthodontic treatment and their practices are limited to orthodontics. In Belgium the specialty was officially recognized in May 2002, but that country does not have a register yet.
Table 2 also lists if orthodontic specialist practices are restricted to orthodontic care or whether other dental treatments can also be provided. The possibility to be a specialist in more than one field is indicated.
The opportunities for postgraduate training, the contents of programmes, universities as educational centres, examinations at the end of the programme, and the level of the training provided are presented in Table 2. All countries have a three-year training programme, except Belgium, France, the Netherlands, Poland and Switzerland where four years are required. One year of experience in general practice is required in Germany, and two years in Sweden and the United Kingdom. All programmes are full-time, except in France. In Austria no programme has yet been defined. Cyprus, Iceland and Luxembourg have no training facilities.
Insufficient opportunities for postgraduate training are reported for Austria, Cyprus, Denmark, Finland, Iceland, the Netherlands, Poland, Portugal, Spain, Sweden, Switzerland, Turkey and the United Kingdom.
Most countries report to offer an education that conforms to the Erasmus Programme, with education possible only at universities. That is not the case for Germany where the general requirement is at least one-year’s university experience and up to two years preceptorship with a privately practising orthodontic specialist, approved for that purpose by the state dental organisation. Large variations exist in the way the final examinations are carried out, if they are performed at all. The examination is mainly provided by university professors, sometimes in combination with external examiners, sometimes by government-assigned boards and, in the United Kingdom and Ireland, by the Royal Colleges of Surgeons, who have been active in that way for more than four centuries.
Most professional organisations considered the training programmes in their country as satisfactory.
The working conditions of orthodontic specialists are shown in Table 3. By far the majority work in private practices, with the exception of the Scandinavian countries and Poland.
The number of orthodontic specialists working full-time or mainly in education is on the average 5 per cent, or slightly higher.
In some countries, a large number of the orthodontic specialists work for a state health system as in most Scandinavian countries, Poland and the United Kingdom, and mostly in the status of employee.
The conditions regarding fees for orthodontic treatment, the average fees, the relationship of the fees to the severity of the malocclusion and the feelings of the national professional organisations concerning the maximum fee payable are shown in Table 3.
In approximately 50 per cent of the countries the fees are fixed mostly by the government. The fees are free in the other half of the countries.
The average fee charged for a fixed appliances treatment, not including radiographs, varies between 1400 and 4000 Euros. When radiographs are included, the fee is sometimes moderately higher.
In approximately half of the countries the fee depends on the severity of the malocclusion.
The fee is considered reasonable in about half of the countries and too low in the other half.
The insurance and refunding systems differ markedly and are complex, as can be seen from Table 4. To understand the large diversity, additional information is provided in the table.
Table 1 Size of population, number of general dental practitioners and orthodontists, and their ratios to the population; percentage of patients treated by orthodontic specialists, need for orthodontic specialist manpower, and working of general dental practitioners, dental hygienists and dental assistants in orthodontic specialist practices
| Country | Number of inhabitants | Number of general dental practi-tioners | Ratio of general dental practi-tioners/ population | Number of ortho-dontists | Ratio of orthodontists /population | Percentage of patients treated by ortho-dontists | Too few or too many ortho-dontists * | General dental practi-tioners in orthodontic practices | Dental hygienists in orthodontic practices | Dental assistants permitted to under-take work in the oral environ-ment |
| Austria |
7.000.000 |
3730 |
1 : 1.877 |
250 |
1 : 28.000 |
20% |
- |
Yes |
No |
No |
| Belgium |
10.260.000 |
8536 |
1 : 1.202 |
350 |
1 : 29.314 |
70% |
+ |
No |
No |
No |
| Cyprus |
900.000 |
600 |
1 : 1.500 |
24 |
1 : 37.500 |
70% |
+ |
Yes |
No |
No |
| Denmark |
5.200.000 |
4880 |
1 : 1.066 |
150 |
1 : 34.667 |
80% |
- |
No |
Yes |
Yes |
| Finland |
5.100.000 |
4800 |
1 : 1.250 |
156 |
1 : 32.692 |
70% |
± |
Yes |
Yes |
Yes |
| France |
59.000.000 |
40000 |
1 : 1.475 |
1711 |
1 : 34.483 |
66% |
± |
No |
No |
No |
| Germany |
82.000.000 |
62000 |
1 : 1.322 |
2950 |
1 : 27.779 |
70% |
+ |
Yes |
Yes |
Yes |
| Greece |
11.000.000 |
13000 |
1 : 846 |
353 |
1 : 31.161 |
50% |
+ |
Yes |
No |
No |
| Iceland |
280.000 |
300 |
1 : 933 |
14 |
1 : 20.000 |
95% |
± |
Yes |
Yes |
Yes |
| Ireland |
3.700.000 |
1800 |
1 : 2.056 |
80 |
1 : 46.250 |
60% |
+ |
Yes |
Yes |
No |
| Israel |
5.500.000 |
6000 |
1 : 917 |
130 |
1 : 42.307 |
85% |
- |
Yes |
Yes |
No |
| Italy |
58.000.000 |
45000 |
1 : 1.289 |
850 |
1 : 68.235 |
20% |
+ |
Yes |
Yes |
No |
| Luxembourg |
450.000 |
300 |
1 : 1.500 |
15 |
1 : 30.000 |
70% |
± |
Yes |
No |
No |
| Netherlands |
16.000.000 |
7000 |
1 : 2.286 |
260 |
1 : 61.538 |
70% |
- |
Yes |
Yes |
Yes |
| Norway |
4.500.000 |
4000 |
1 : 1.125 |
180 |
1 : 25.000 |
100% |
- |
No |
Yes |
Yes |
| Poland |
39.000.000 |
18000 |
1 : 2.167 |
770 |
1 : 50.649 |
80% |
- |
Yes |
Yes |
No |
| Portugal |
10.000.000 |
6000 |
1 : 1.666 |
50 |
1 : 200.000 |
5% |
- |
Yes |
Yes |
No |
| Spain |
40.000.000 |
16500 |
1 : 2.424 |
400 |
1 : 100.000 |
40% |
± |
No |
No |
No |
| Sweden |
9.000.000 |
8000 |
1 : 1.125 |
290 |
1 : 31.034 |
50% |
- |
No |
No |
Yes |
| Switzerland |
7.100.000 |
4000 |
1 : 1.775 |
163 |
1 : 43.558 |
50% |
± |
Yes |
Yes |
No |
| Turkey |
67.800.000 |
12000 |
1 : 5.6650 |
230 |
1 : 294.783 |
80% |
- |
Yes |
No |
Yes |
| United Kingdom |
55.000.000 |
30000 |
1 : 1.833 |
750 |
1 : 73.333 |
60% |
- |
Yes |
No |
No |
* - : shortage; + : surplus; ± : balanced
Table 2 EFOSA-membership, formal and legal aspects regarding recognition of speciality, title protection of orthodontic specialist, specialist register, responsible authority, the exclusion to do other treatments, the possibility to be recognised in more than one speciality, opportunities for postgraduate training, content of programmes, education at universities, final examination and considered level of training.
| Country | Member EFOSA | Ortho-dontic speciality recognis-ed | Title protected by law | Specialist register | Responsible authority | Exclusive to ortho-dontics | More than one speciality | Ade-quate training facilities | Training con-forms to Erasmus Pro-gramme | Only at uni-versities | Final exam, if yes, by whom | Training con-sidered satis-factory |
| Austria |
Prov. |
No |
No |
No |
No |
Yes |
No |
No |
No: Brenner Institut (Austrian Medical institution) |
No |
No |
|
| Belgium |
Yes |
Yes |
Not yet |
Ministry of Health |
Yes |
Yes |
Yes |
Yes |
Yes |
Recogn. Comm. of University professors |
Yes |
|
| Cyprus |
Aff. |
Yes |
Yes |
Yes |
Ministry of Health |
Yes |
No |
No |
No training centre in Cyprus |
|||
| Denmark |
Act. |
Yes |
Yes |
Yes |
Danish Nat. Health Board |
No |
Yes |
No |
Yes |
Yes |
National Health Board |
Yes |
| Finland |
Act. |
Yes |
Yes |
Yes |
National Authority for Medico-legal Affairs |
No |
Yes |
No |
Yes |
Yes |
Ministry of Social Affairs and Health |
Yes |
| France |
Act. |
Yes |
Yes |
Yes |
French Administration |
Yes |
No |
Yes |
Yes |
Yes |
University |
Yes |
| Germany |
Act. |
Yes |
Yes |
Yes |
Local Dental Body (Zahnäzte-kammer) |
No |
Yes |
Yes |
No |
No: In approved private practices |
Two pro-fessors, one external ortho-dontist |
Overall: Yes |
| Greece |
Act. |
Yes |
Yes |
Yes |
Ministry of Health |
No |
No |
Yes |
Yes |
Yes |
Orthod. Ex. Comm. Min. Of Health |
Yes |
| Iceland |
Act. |
Yes |
Yes |
Yes |
Ministry of Health |
Yes |
Yes |
No |
Yes |
|||
| Ireland |
Act. |
Yes |
Yes |
Yes |
Dental Council |
No |
Yes |
Yes |
Yes |
No: Possible part-time with regional con-sultants |
Royal colleges and uni-versities |
Yes |
| Israel |
Yes |
Yes |
Yes |
Ministry of Health |
Yes |
Yes |
Yes |
Yes |
No: Recognis-ed institutes, army |
The institutes and the Ministry of Health |
Yes |
|
| Italy |
Act. |
Yes |
Yes |
Yes |
Minister of Instruction |
No |
Yes |
Yes |
Almost |
Yes |
University professors |
Yes |
| Luxembourg |
Prov. |
No |
No |
No |
No |
No |
No |
No |
||||
| Netherlands |
Act. |
Yes |
Yes |
Yes |
Dutch Dent. Soc. / Government (C.C.) |
Yes |
No |
No |
Yes |
Yes |
One professor, two external ortho-dontists |
Yes |
| Norway |
Act. |
Yes |
Yes |
Yes |
Ministry of Health |
Yes |
No |
No |
Yes |
Yes |
University professors |
Yes |
| Poland |
Prov. in 2004 |
Yes |
Yes |
Yes |
Ministry of Health |
No |
Yes |
No |
Almost. |
No: Municipal clinics |
Commis-sion of the Ministry of Health |
Almost |
| Portugal |
Act. in 2004 |
Yes |
Yes |
Yes |
Ordem Dos Medicos Dentista (OMD) |
No |
No |
No |
Yes |
Yes |
The professors of the two ortho-dontic depart-ments |
Yes |
| Spain |
Prov. |
No |
No |
No |
Yes |
No |
Yes |
No: Private short pro-grammes |
University teaching staff |
Yes |
||
| Sweden |
Act. |
Yes |
Yes |
Yes |
Nat. Board for Health and Welfare |
No |
Yes |
No |
Yes |
No: 4 approved county council clinics |
Ext. exam. Other clinics |
Yes |
| Switzerland |
Aff. |
Yes |
Yes |
Yes |
Swiss Dental Society |
No |
Yes |
No |
Yes |
Yes |
No |
Yes |
| Turkey |
Aff. |
Yes |
Yes |
Yes |
Ministry of Health |
No |
Yes |
No |
Yes |
No: State Dental Institutions |
Five professors |
Yes |
| United Kingdom |
Act. |
Yes |
Yes |
Yes |
General Dental Council |
Yes |
Yes |
No |
Yes |
Yes |
Royal Colleges of Surgeons |
Yes |
Table 3 Working conditions of orthodontic specialists in percentages, regulations of treatment fees, average fee, and their relationship to severity of malocclusion and whether the fees were considered reasonable
| Country | Per-centage working in private practices | Per-centage full time or mainly in education | Per-centage working for State Health System | Per-centage working as em-ployees | Are fees free? If not, then fixed by whom? | Average fee (€) fixed appl. without radiographs | Average fee (€) fixed appl. with radiographs | Fee depends on severity mal-occlusion | Fee considered too high / too low |
| Austria |
80% |
10% |
5% |
5% |
Yes |
2.900 |
3.600 |
No |
Reasonable |
| Belgium |
95% |
5% |
0% |
5% |
Yes |
2.040 |
2.160 |
No |
Too low |
| Cyprus |
100% |
0% |
0% |
0% |
Yes |
2.700 |
2.700 |
Yes |
Reasonable |
| Denmark |
25% |
5% |
70% |
70% |
Yes |
2.500 – 3.000 |
2.500 – 3.000 |
Yes |
A little too low |
| Finland |
40% |
10% |
51% |
63% |
No, government |
2.500-3.000 |
2.600 – 3.100 |
No |
Reasonable |
| France |
99% |
1% |
20% |
0% |
Yes |
600 per 6 month period |
Variable |
No |
Always too low |
| Germany |
95% |
5% |
2% |
10% |
No, government |
3.500 |
4.000 |
Yes |
Reasonable |
| Greece |
95% |
10% |
10% |
5% |
Yes |
2.000 |
2.100 |
Yes |
Too low |
| Iceland |
50% |
5-10% |
40% |
40% |
No, government |
3.000-5.000 |
3.000 – 5.000 |
Yes |
Reasonable |
| Ireland |
80% |
10% |
10% |
20% |
No, government |
2.500 |
2.600 |
Yes |
Reasonable |
| Israel |
95% |
5% |
50% |
2% |
No, government |
2.000 |
2.200 |
No |
Too low |
| Italy |
98% |
2% |
5% |
5% |
Yes |
2.500 – 4.000 |
2.700 – 4.500 |
Yes |
Reasonable |
| Luxembourg |
100% |
0% |
0% |
0% |
Yes, but not for removable appliances |
3.500 |
3.700 |
Yes |
Reasonable |
| Netherlands |
95% |
5% |
0% |
0% |
No, government |
2.000 |
2.200 |
No |
No reply |
| Norway |
90% |
5 - 10% |
5 - 10% |
2% |
Partly, government |
2.300 |
2.500 |
Yes |
Reasonable |
| Poland |
10% |
8% |
80% |
2% |
Yes |
200 / Private 1.350 -1.800 |
1.470 |
Yes |
Insurance fees are too low |
| Portugal |
90% |
10% |
0% |
0% |
Yes |
2.000 |
2.075 |
No |
Reasonable |
| Spain |
100% |
20% |
0% |
10% |
Yes |
3.500 |
Variable |
No |
Fair |
| Sweden |
5% |
8-10% |
85% |
95% |
Partly, government |
2.000 |
2.100 |
Fee related to treatment time |
Reasonable - too low |
| Switzerland |
95% |
5% |
1% |
1% |
No in Health System/ Private: Yes |
No reply |
No reply |
No |
Depends on the individual |
| Turkey |
78% |
13% |
5% |
3% |
Minimum by dental Org. |
1.200 - 2.400 |
1.200 – 2.400 |
No |
Satisfactory |
| United Kingdom |
60% |
5% |
95% |
40% |
No for National Health System/ Private: Yes |
1.400 |
1.445 |
Only for number of ap-pliances |
Too low |
Table 4 Insurance and refunding systems covering orthodontic care, with additional information
| Country | Insurance for orthodontic care | Refunding system and additional information on the insurance coverage of orthodontic care |
| Austria |
Yes |
The patient pays the whole fee to the orthodontist and gets part of the fee refunded by the insurance company. |
| Belgium |
Yes |
Health system and private insurances. Partial coverage by the Health Service (± 25%) and private insurances (± 25%). |
| Cyprus |
No |
Private insurance coverage based on the suggestions of the Cyprus Orthodontic Society. |
| Denmark |
Yes |
0-18 years: Free service under public Health Service when needed (~25%). Orthognatic surgery: Free service at hospital. Over 18 years: No insurance |
| Finland |
Yes |
Communal health care system offers needed treatment for free for children up to 18 years, and treatment of malocclusions in need of orthognatic surgery for adults. Social Insurance Institutions refund partially treatment of malocclusions in need of orthognatic surgery done in private practices. |
| France |
Yes |
Fixed appliance treatment with fees refunded with € 386 per year for patients without dental decay |
| Germany |
Yes |
The patient has to pay 20% of the total fees to the orthodontist during the treatment and will be reimbursed after the treatment has been successfully finished. Further private insurances. |
| Greece |
Yes |
Financed by patient: 50%, financed by government: 10%, financed by private insurance: 5%. Partially financed by patients and partially by private insurance: 35%. |
| Iceland |
Yes |
One system: Public Health Service refunds € 1.250 to each patient with fixed appliances. The orthodontist estimates the total fee, the patient pays for each visit, each bracket, archwire, radiograph, etc. |
| Ireland |
No |
Contract between patient and specialist |
| Israel |
No |
Free market |
| Italy |
Yes |
Mainly a private system. In some regions of Italy the health services refunds part of the fee for certain malocclusions. |
| Luxembourg |
Yes |
The patients pay the whole fees to the orthodontist and get back part of the fees from the insurance system until 17 years of age. |
| Netherlands |
Yes |
The fee system is based on a fixed amount for every month when the patient visits the orthodontist at least once. Besides the monthly amount there is an entrance fee at the start of each treatment. All work, costs for appliances and documentation - except radiographs - are includes in this fee. There are different fees for treatment with a)removable appliances b)partial fixed appliances (in one arch) c) full fixed appliances. The average coverage is 75%; cleft palate cases and cases of some severity 100%. |
| Norway |
Yes |
Based on a remuneration system from the Norwegian government. The amount of remuneration depends upon the severity of the malocclusion and is only for patients between 0 and 18 years of age. There are three scales of remuneration: 100%, 75% and 45%. |
| Poland |
Yes |
Insurance covers the cost of "standard treatment", only by removable appliances and given to children under 13 years of age. All methods and techniques exceeding "standard treatment" must be paid by the patients. |
| Portugal |
No |
Only private insurance system and public social security only for state employees for which the government pays only 25% of orthodontic care. |
| Spain |
No |
An increasing number of private insurance companies offer orthodontic treatment as a part of the services. Every private insurance has a different ranking of fees. |
| Sweden |
Yes |
The fees are free, but the refund is fixed. Free for patients up to 20 years of age in need of treatment. A general national insurance system will refund 40-50% of treatment related to general dental health. Prothetics and orthodontics will be refunded to about 20%. |
| Switzerland |
Yes |
All treatment aspects are defined in a list for dental activities. Based on this list the refunding takes place. Severe growth problems are covered by the federal insurance, the rest is left to the private insurance sector. |
| Turkey |
No |
There are some private insurances. Approximately € 1.200 – 2.400 is refunded. |
| United Kingdom |
Yes |
The National Health Service covers free charge for all patients under 18 years of age, adults pay a proportion up to a maximum of € 560. Fee scale is related to number and type of appliances used. |
Discussion
The 1992 survey was sent to one person, chosen by the author, in 26 European countries. Of these, 23 replied, including those of Romania, Hungary, Czechoslovakia and Yugoslavia. These countries do not belong to EFOSA and were not involved in the 2002 enquiry. Another difference between the two surveys is that the present data were not delivered by personal invitation but by the representative orthodontic specialist organisations of 21 countries that are, or soon will become members of EFOSA, and of Israel.
The difference in providing information and countries involved restricts comparison of the two surveys. In addition, the validity of both surveys is limited as they contain subjective non-numerical data. The 1992 survey reported that in a number of countries the speciality was recognised and a register existed, which later provided to be incorrect.
In 1992 the outcome was that in 20 countries a register was kept and not in three: Austria, Belgium and Czechoslovakia. With the introduction of three different types of members of EFOSA in 1998 and the requirement that documents had to be supplied stating that the speciality of orthodontics was officially recognised and a formal register was kept, a number of countries, Belgium, Greece, Ireland, Italy, and the United Kingdom, were not eligible for the active membership status.
During in the last four years EFOSA has played an essential role in several EU-countries in realising the official recognition of the speciality of orthodontics, the setting-up of a legally supported register and the establishment of one professional organisation of orthodontic specialists of which at least 70 per cent of those registered have to be members. These requirements to attain the status of active membership have been realised by Finland, Greece, Iceland, Ireland, Italy and the United Kingdom. Portugal and the Czech Republic became active members in 2004 and Belgium is expected to become active member in 2005. That leaves only Austria, Luxembourg and Spain remaining as the last countries of the EU before 2004 where orthodontics is not yet recognised as a speciality.
In future years EFOSA will focus on incorporating more former East European countries as active or provisional members. In addition, special attention will be given to increasing the quality of orthodontic care using the Euro-Qual as a basis (Njio et al. 1999). Furthermore, the level of post-graduate training will be investigated and, where needed, improved, hopefully ending in a uniform final examination for Europe.
The training of orthodontic specialists is performed in most countries exclusively at universities as required by the Erasmus Programme. However, the content of the education provided has not been verified and it is unlikely that in the majority of the educational centres the Erasmus Programme is fully implemented. That particularly applies to the final examination. These limitations hold true especially for Germany, where the training requires only one-year at a university department and even that is not true for all states of Germany. In addition, the final examination leading to the recognition as an orthodontic specialist in Germany varies greatly among states, and has little meaning in some states.
The insurance or other renumeration for orthodontic treatments is important and a large variation exists. One may assume that the EU-authorities in Brussels will, at a certain time, propose the regulation of medial and dental care. EFOSA intends to formulate an approach to prevent that politicians and not the orthodontic specialists organisations take the leading role.
It is interesting to note that the average fees reported for orthodontic treatment are by and large the same in 2002 as in 1992, with some decrease in Belgium, Norway and Sweden, and a slight increase in Denmark, France, Greece, Ireland, Italy and Spain. Comparison of both surveys reveals that the situation regarding work in the oral environment by dental assistants has not changed and is permitted in about 40 per cent of the countries.
Finally, unfortunately the 2002 survey did not include questions on the caseload in orthodontic specialist practices, as did the 1992 survey.
Conclusions
During the last ten years the training of orthodontic specialists has improved in Europe. In that respect the implementation of the Erasmus Programme introduced in 1992, has been instrumental.
Over the last four years the speciality of orthodontics became officially recognised and a speciality register formally established in a number of countries in Europe, in which EFOSA has played an essential role.*
References
- Moss, J.P.: Orthodontics in Europe 1992. Eur. J. Orthod. 15: 393-401, 1993.
- Njio, B.J., Stenvik, A., Ireland, R.S., Prahl-Andersen, B.: European Orthodontic Quality Manual (EOQM). IOS Press 1999 (ISSN 0929-6743). Final document for the EURO-QUAL, BIOMED 2 program: A Program for developing a Quality Improvement System for the Orthodontic Professional funded by the European Union).
- Van der Linden, F.P.G.M. et al.: Three years post-graduate programme in orthodontics. The final report of the Erasmus Project. Eur. J. Orthod. 14: 85-94, 1992.
* More information on EFOSA can be found on its Web-site (www.efosa.org)
Note: Most of the content of this paper was published in the Dutch dental journal in January 2003, in a special issue on the occasion that fifty years ago the specialty of orthodontics was recognized and a register established in the Netherlands (Ned. Tijdschr. Tandheelk. 110: 14-19, 2003).
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