Oral Health in Portugal: Small Steps in the Right Direction

A B S T R A C T

Oral diseases remain a major public health problem, due to its high prevalence and consequences, however, in Portugal, oral health indicators have been improving over the last few years. This is associated with the implementation of various strategies in health promotion, prevention and early treatment of oral diseases, with an important reinforcement of public sector intervention. It is important to revisit what measures have been implemented, how effective they are and how to improve them.

Keywords

Oral diseases, prevention, public health services

Oral diseases have a high prevalence and represent major consequences on the general health and quality of life of the population, remaining a major public health problem [1, 2]. Dental caries and periodontal disease are the most prevalent oral diseases [3, 4]. Dental caries affects up to 90% of school-age children and the vast majority of adults, while periodontal disease affects about 20-50% of global population [4, 5]. Oral cancer is also another important global oral health problem that needs to be monitored [5, 6]. Behavioural risk factors are multiple and quite common, such as an unhealthy diet high in free sugars, poor oral hygiene, tobacco use and harmful use of alcohol [5]. There is a very strong and consistent association between socioeconomic status (income, occupation and educational level) and the prevalence and severity of oral diseases [7, 8]. A lack of financial support has often been a serious obstacle, in most countries, to permit an adequate and sufficient dental care [1, 2, 8]. In Portugal, most oral health services are provided by private dentists who are not associated with nor have any agreement with public health protection mechanisms. Thus, in case of illness, it is often the patients who pay the full cost of treatment, which often creates problems in accessing oral health care [9]. The Portuguese National Health Service (NHS), when created in 1979, left out dental care [9, 10]. Nevertheless, the promotion of oral health has started to be recognized and considered relevant and since 1985 a National Program for Oral Health Promotion (NPOHP) was created as part of the NHS and was designed to a global intervention strategy based on health promotion, prevention and treatment of oral diseases. This program started with the promotion of oral health in schools and, subsequently, preventive and curative measures were introduced, with the integration of oral hygienists in the NHS and the expansion of the partnership with private dental services [10, 11]. In 2008 the “Dental Voucher” strategy was added to the program, with an extension of beneficiary groups and a model of contracting between the NHS and private providers in the dental area [10, 12]. Dental Vouchers are awarded by primary care health centers to certain beneficiary patients, allowing access to a range of preventive and curative treatments provided, free of charge, by any private dentist that has agreement with the NHS [9]. Specifically, the beneficiary patients are children and adults with active dental problems included in some specific populations: children aged 6 years and under, children and young people of intermediate ages (children and young people from the age cohorts of 8, 9, 11, 12, and 14 years old), 16- and 18-year-olds, pregnant women followed in the NHS, receivers of specific social protection benefits, namely, the complementary income for elderly, and people diagnosed with human immunodeficiency virus / acquired immunodeficiency syndrome (HIV / AIDS) [10-12].

Finally, another strategy was implemented since 2016, namely, oral health consultations were created, on an experimental basis, in NHS primary health care, with the integration of dentists in primary care health centers, in order to provide treatment to patients referred by the primary care physicians [12]. Consequently, oral health indicators used to measure the prevalence of oral diseases have been improving over the years, with greater expression in the last decade [13-15]. As an example, considering the 12 years old group, the number of individuals with healthy gums increased from 29% in 2006 to 51.7% in 2013; and inversely the DMFT index (decayed, missing and filled teeth) decreased from 2.95 in 2000 to 1.18 in 2013. Also very relevant was the increase of the percentage of children and young people brushing their teeth at night before bedtime, which, between 2006 and 2013, increased from 35%, 51% and 45% to 84%, 87% and 84%, at ages 6, 12 and 15 years old, respectively [13]. We can even say that, with regard to oral health indices in children, Portugal is approaching the most developed countries in Europe.

On the other hand, in adults the situation is quite different. Recent data show that almost all adults, in Portugal, have at least one of the three major chronic oral diseases: dental caries, periodontitis or peri-implant pathology [12]. Nevertheless, another survey with 1,102 interviews found that 32.7% of individuals never visited a dentist or only in case of emergency, 41.6% have not visited a dentist for over a year. Of these, 53.6% say they have no need and 31.7% have no money [15]. Globally, the improvement of oral health is considered one of the most important achievements in health and quality of life. However, in Portugal and around the world, due to their high prevalence, dental diseases remain one of the major health problems of the population with strong socioeconomic asymmetries [1, 12, 14, 15]. Despite the evident improvements described in Portugal, it is essential to continue improving oral health promotion policies and, across all these political measures, it is essential to maintain the focus promoting health literacy, particularly in the areas of oral health and nutrition by empowering citizens of different socioeconomic and age groups, especially from the most disadvantaged groups, for health-friendly choices and practices [7, 10, 11].

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Bernardete Machado Carlos Albuquerque

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References

1. Watt RG, Daly B, Allison P, Macpherson LMD, Venturelli R et al. (2019) Ending the neglect of global oral health: time for radical action. Lancet 394: 261-272. [Crossref]
2. Kisely S, Lalloo R, Ford P (2018) Oral disease contributes to illness burden and disparities. Med J of Aust 208: 155-156. [Crossref]
3. Marcenes W, Kassebaum NJ, Bernabé E, Flaxman A, Naghavi M, et al. (2013) Global burden of oral conditions in 1990-2010: a systematic analysis. J Dent Res 92: 592-597. [Crossref]
4. Frencken JE, Sharma P, Stenhouse L, Green D, Laverty D et al. (2017) Global epidemiology of dental caries and severe periodontitis–a comprehensive review. J Clin periodontol  44: S94-S105. [Crossref]
5. Petersen PE (2003) The world oral health report 2003: continuous improvement of oral health in the 21st century - the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol: 3-24. [Crossref]
6. Hummel J, Phillips KE, Holt B, Hayes C (2015) Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health.
7. Watson CA, Nilam S (2017) Educational level as a social determinant of health and its relationship to periodontal disease as a health outcome. J Dent Sci Ther 1: 8-11
8. Hobdell MH, Oliveira ER, Bautista R, Myburgh NG, Lalloo R, et al. (2003) Oral diseases and socio-economic status (SES). Br Dent J 194: 91-96. [Crossref]
9. Lourenço A, Barros PP (2016) Oral Healthcare – Universal Coverage. Nova Healthcare Initiative – Research / Universidade Nova de Lisboa.
10. Programa Nacional de Promoção da Saúde Oral (2019) Ministério da Saúde. Direção-Geral da Saúde. 
11. Portaria n.º 301/2009, de 24 de Março. Diário da República, 1.ª série - N.º 99 de 23 de maio de 2011. Funcionamento do Programa Nacional de promoção de Saúde Oral.
12. Simões J, Augusto GF, Céu A, Ferreira MC, Jordão M, et al. (2018) Ten years since the 2008 introduction of dental vouchers in the Portuguese NHS. Health Policy 122: 803-807.
13. Direção-Geral da Saúde (2015) III Estudo Nacional de Prevalência das Doenças Orais (resultados). Lisboa (Portugal).
14. Calado R, Ferreira CS, Nogueira P, Melo P (2017) Caries prevalence and treatment needs in young people in Portugal: the third national study. Community den Health  34: 107-111. [Crossref]
15. Barómetro da Saúde Oral (2018) Ordem dos Médicos Dentistas.