Vastus pöördumisele

Suur-Ameerika 1 / 10122 Tallinn / ESTONIA / +372 626 9301 / [email protected] / www.sm.ee / Reg. no 70001952

National Health Service [email protected]

Your ref. 26.02.2024 No 16-7/3964/2024/ Our ref. 29.02.2024 No 1.5-1.1/526-2

Response to information request Dear Mr Āris Kasparāns The Estonian Health Insurance Fund (EHIF) reimburces dental care for insured persons under the age of 19. After the child has reached the age of 19, free dental care is provided for one year if the need for treatment arose during the patient’s last visit before the age of 19. Free services for prolonged time are available at the same dental care provider where the need for treatment was identified. A parent has the right to choose a dentist for their child, but EHIF finances dental treatment of children only when contractual partners provide it. According to the data of 2023, approx. 82% of dental care service providers are contractual partners of the EHIF. If the dental care provider does not have a contract, the parent must pay for the service in full and this money cannot be claimed from the EHIF. The EHIF only pays for the services in the EHIF’s health care services list established by the regulation of the Government of the Republic "List of health care services of the Health Insurance Fund"1. For orthodontic treatment (including braces) for children under 19 years of age, the EHIF pays for the services established in the regulation mentioned above only in the case of the following diagnoses (approved by the Estonian Society of Orthodontists):

 Prognathic occlusion with sagittal bite of 9 mm or more.  The lower jaw reaches further than the upper jaw (progenia).  There is no contact between the front teeth and only the posterior molars are in

contact (open bite with only molars in contact).  The incisors or canines have not erupted in time (retained incisors or canines).  If more than one permanent tooth has not formed on one side of the jaw (if there is no

incisor, canine or more than one tooth on each side of the jaw).  Cleft lip and cleft palate and other congenital malformations of the maxillofacial

system.  Dental anomaly in the case of severe or moderate obstructive sleep apnoea when

adenotonsillectomy and positive air pressure therapy (CPAP) have not been effective.  Deep traumatic bite in which case the lower incisors are in direct contact with the oral

mucosa.  Lateral cross-bite along three or more teeth on one side of the jaw, in which the

symmetry of the face and the development and growth of the jaws are significantly impaired.

1 https://www.riigiteataja.ee/akt/120122023023

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The EHIF pays for the orthodontic treatment of adults with cleft lip and palate, other congenital malformations of the maxillofacial system and a rare disease if:

 surgical treatment cannot be planned before the age of 19;  a doctor has decided that it is necessary to delay orthodontic treatment until the end

of the development of the maxillofacial system. In other cases, EHIF does not pay for paediatric orthodontic services. Please note that for EHIF-funded services, the service provider must be a contract partner. In Estonia, orthodontic treatment is provided only by orthodontists, but orthodontists prefer to provide services fully paid by the patient rather than by the EHIF. To access the EHIF-funded orthodontic service, a longer waiting time must be considered because most orthodontic care providers are not in contract with EHIF. Dental care, both children's and adults', is focused on treating consequences and less on prevention. Analysis of services provided to children confirms this. The patients come to the dental office more with a specific reason and complaint, less for preventive measures and regular check-ups. Conventionally, it is assumed that children who regularly visit the dentist will need less treatment because problems are detected and eliminated early. However, we see the opposite trend: as the frequency of visits to the dentist increases, the total number of visits increases, the total cost of the visits increases, and the number of filling placements increases. We also see that the earlier the child arrives at the first visit to the dentist, the more he/she visits the dentist later and the greater his/her treatment needs (treatment with fillings) and treatment costs. In 2023, 65% of the children aged 3-19 in Estonia went to the dentist, including 20,643 children who received orthodontic treatment reimbursed by EHIF. The EHIF paid 52.5 million euros (19.5% more than a year earlier) for preventing and treating dental diseases in 169,270 children. We assume that the need for treatment is high and even higher in those children who do not visit the dentist annually. Analysis of services paid by EHIF confirms that it does not matter how early children start seeing the dentist; the need for treatment is, in any case, very high, and children's dental health could be better. We assume that parents support children's oral health care few, and dentists focus more on treatment than prevention and prophylaxis. In the case of children, in 1/3 of the cases, the first visit is already a treatment visit when lesions requiring treatment have already developed in the oral cavity. According to the study of the health behaviour of Estonian schoolchildren, 34.5% of schoolchildren brush their teeth only once a day or even less often. Based on this, the EHIF has paid more attention to prevention. In children's dentistry, we have a national Oral School project (Suukool.ee), which educates children and parents on the prevention of oral and dental diseases and has launched tooth brushing in kindergartens. “Oral School” is funded by EHIF. The project aims to raise awareness of oral health so that children in Estonia grow up with healthy teeth. In January 2024, EHIF started piloting and funding mobile dental services (a mobile dental care bus in areas where the service is less available) near schools and kindergartens. We have included myofunctional therapy to fund services for children. In the longer term, including a clinical psychologist in the dental treatment team is planned as a preventive activity. This is to alleviate the dental fear of children and parents. Fear of dental treatment and postponing the treatment due to it affects about 6% of children and 16% of parents. In both children's and adults' dental care, the long-term plan is to develop a dental specialist service, which includes increasing the number of oral hygiene assistants, nurses, or oral hygienists (education and recognition as a healthcare professional) and is funded accordingly. Currently, a dentist is the provider of all services, which increases the cost of the service. Implementing the dental specialist service helps make the dental care system more

3 (3)

efficient: the number of people turning to the more expensive dental doctor's service decreases as people are first directed to the oral hygiene (dental specialist) service. Regarding waiting lists and accessibility, we generally can say that dental care is easily accessible, but we cannot say the same about orthodontics. The health care provider is responsible for maintaining queues. The EHIF does not periodically collect information about waiting lists from the contractual partners but has the right to ask the partners for this information (thereby, it cannot be excluded that service providers submit false information). The contractual partners of the EHIF shall ensure the availability of the service agreed upon in the contract to the extent agreed upon throughout the contract period. At the national level, the EHIF can measure the waiting times for specialties and services for those contractual partners who have interfaced with the national digital registration system. The interface is optional for dentistry. From the EHIF's point of view, dental care providers should join the digital registration system so that people can book an appointment with a dentist as conveniently as possible. This would also give the EHIF a better overview of queues and the demand for the service. In dental care, the EHIF has created flexible conditions for joining contracts for financing dental care or increasing the volume of contracts. Upon arousal of other questions, please contact. We would also like to know the challenges and future directions regarding funding and organizing public dental care and orthodontic treatment in Latvia. Yours sincerely, Kersti Esnar Head of Department Department of Health System Development

Lii Pärg [email protected]

Suur-Ameerika 1 / 10122 Tallinn / ESTONIA / +372 626 9301 / [email protected] / www.sm.ee / Reg. no 70001952

National Health Service [email protected]

Your ref. 26.02.2024 No 16-7/3964/2024/ Our ref. 29.02.2024 No 1.5-1.1/526-2

Response to information request Dear Mr Āris Kasparāns The Estonian Health Insurance Fund (EHIF) reimburces dental care for insured persons under the age of 19. After the child has reached the age of 19, free dental care is provided for one year if the need for treatment arose during the patient’s last visit before the age of 19. Free services for prolonged time are available at the same dental care provider where the need for treatment was identified. A parent has the right to choose a dentist for their child, but EHIF finances dental treatment of children only when contractual partners provide it. According to the data of 2023, approx. 82% of dental care service providers are contractual partners of the EHIF. If the dental care provider does not have a contract, the parent must pay for the service in full and this money cannot be claimed from the EHIF. The EHIF only pays for the services in the EHIF’s health care services list established by the regulation of the Government of the Republic "List of health care services of the Health Insurance Fund"1. For orthodontic treatment (including braces) for children under 19 years of age, the EHIF pays for the services established in the regulation mentioned above only in the case of the following diagnoses (approved by the Estonian Society of Orthodontists):

 Prognathic occlusion with sagittal bite of 9 mm or more.  The lower jaw reaches further than the upper jaw (progenia).  There is no contact between the front teeth and only the posterior molars are in

contact (open bite with only molars in contact).  The incisors or canines have not erupted in time (retained incisors or canines).  If more than one permanent tooth has not formed on one side of the jaw (if there is no

incisor, canine or more than one tooth on each side of the jaw).  Cleft lip and cleft palate and other congenital malformations of the maxillofacial

system.  Dental anomaly in the case of severe or moderate obstructive sleep apnoea when

adenotonsillectomy and positive air pressure therapy (CPAP) have not been effective.  Deep traumatic bite in which case the lower incisors are in direct contact with the oral

mucosa.  Lateral cross-bite along three or more teeth on one side of the jaw, in which the

symmetry of the face and the development and growth of the jaws are significantly impaired.

1 https://www.riigiteataja.ee/akt/120122023023

2 (3)

The EHIF pays for the orthodontic treatment of adults with cleft lip and palate, other congenital malformations of the maxillofacial system and a rare disease if:

 surgical treatment cannot be planned before the age of 19;  a doctor has decided that it is necessary to delay orthodontic treatment until the end

of the development of the maxillofacial system. In other cases, EHIF does not pay for paediatric orthodontic services. Please note that for EHIF-funded services, the service provider must be a contract partner. In Estonia, orthodontic treatment is provided only by orthodontists, but orthodontists prefer to provide services fully paid by the patient rather than by the EHIF. To access the EHIF-funded orthodontic service, a longer waiting time must be considered because most orthodontic care providers are not in contract with EHIF. Dental care, both children's and adults', is focused on treating consequences and less on prevention. Analysis of services provided to children confirms this. The patients come to the dental office more with a specific reason and complaint, less for preventive measures and regular check-ups. Conventionally, it is assumed that children who regularly visit the dentist will need less treatment because problems are detected and eliminated early. However, we see the opposite trend: as the frequency of visits to the dentist increases, the total number of visits increases, the total cost of the visits increases, and the number of filling placements increases. We also see that the earlier the child arrives at the first visit to the dentist, the more he/she visits the dentist later and the greater his/her treatment needs (treatment with fillings) and treatment costs. In 2023, 65% of the children aged 3-19 in Estonia went to the dentist, including 20,643 children who received orthodontic treatment reimbursed by EHIF. The EHIF paid 52.5 million euros (19.5% more than a year earlier) for preventing and treating dental diseases in 169,270 children. We assume that the need for treatment is high and even higher in those children who do not visit the dentist annually. Analysis of services paid by EHIF confirms that it does not matter how early children start seeing the dentist; the need for treatment is, in any case, very high, and children's dental health could be better. We assume that parents support children's oral health care few, and dentists focus more on treatment than prevention and prophylaxis. In the case of children, in 1/3 of the cases, the first visit is already a treatment visit when lesions requiring treatment have already developed in the oral cavity. According to the study of the health behaviour of Estonian schoolchildren, 34.5% of schoolchildren brush their teeth only once a day or even less often. Based on this, the EHIF has paid more attention to prevention. In children's dentistry, we have a national Oral School project (Suukool.ee), which educates children and parents on the prevention of oral and dental diseases and has launched tooth brushing in kindergartens. “Oral School” is funded by EHIF. The project aims to raise awareness of oral health so that children in Estonia grow up with healthy teeth. In January 2024, EHIF started piloting and funding mobile dental services (a mobile dental care bus in areas where the service is less available) near schools and kindergartens. We have included myofunctional therapy to fund services for children. In the longer term, including a clinical psychologist in the dental treatment team is planned as a preventive activity. This is to alleviate the dental fear of children and parents. Fear of dental treatment and postponing the treatment due to it affects about 6% of children and 16% of parents. In both children's and adults' dental care, the long-term plan is to develop a dental specialist service, which includes increasing the number of oral hygiene assistants, nurses, or oral hygienists (education and recognition as a healthcare professional) and is funded accordingly. Currently, a dentist is the provider of all services, which increases the cost of the service. Implementing the dental specialist service helps make the dental care system more

3 (3)

efficient: the number of people turning to the more expensive dental doctor's service decreases as people are first directed to the oral hygiene (dental specialist) service. Regarding waiting lists and accessibility, we generally can say that dental care is easily accessible, but we cannot say the same about orthodontics. The health care provider is responsible for maintaining queues. The EHIF does not periodically collect information about waiting lists from the contractual partners but has the right to ask the partners for this information (thereby, it cannot be excluded that service providers submit false information). The contractual partners of the EHIF shall ensure the availability of the service agreed upon in the contract to the extent agreed upon throughout the contract period. At the national level, the EHIF can measure the waiting times for specialties and services for those contractual partners who have interfaced with the national digital registration system. The interface is optional for dentistry. From the EHIF's point of view, dental care providers should join the digital registration system so that people can book an appointment with a dentist as conveniently as possible. This would also give the EHIF a better overview of queues and the demand for the service. In dental care, the EHIF has created flexible conditions for joining contracts for financing dental care or increasing the volume of contracts. Upon arousal of other questions, please contact. We would also like to know the challenges and future directions regarding funding and organizing public dental care and orthodontic treatment in Latvia. Yours sincerely, Kersti Esnar Head of Department Department of Health System Development

Lii Pärg [email protected]