The practice of Dentistry in the European Community is regulated by the Council Directives of 1978 which provide for the activities of and training programmes for dental practitioners, and the mutual recognition of qualifications to facilitate the right to freedom of movement and the establishment of dental practices by non-nationals. In this article the author describes the dental health and the dental manpower in Malta and E.C.peer-reviewe

Portelli, John M.

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Maltese Medical Journal 45 Volume V Issue I 1993 MALTESE DENTISTRY IN THE E.C. CONTEXT PORTELLI J.M. B,CH,D.,M.D.S(MANCH) F.P.S.R.C.S.(ENG) DEPT. OF DENTAL SURGERY, UNIVERSITY OF MALTA,MsIDA. The practice of Dentistry in the European Community is regulated by the Council Directives of 1978 which provide for the activities of and training programmes for dental practitioners (1), and the mutual recognition of qualifications to facilitate the right to freedom of move­ment and the establishment of dental practices by non­nationals (2). Together these directives establish the concept of the Eurodentist by providing for a, course in dental surgery similar to that offered by the University of Malta. That is, one integrated with the medical sciences but inde­pendent of a medical qualification. Prior to 1978 this was not the norm in a number of European countries where a qualification in medicine was necessary to practice den­tistry, training in dentistry not being a prerequisite to practice. This was particularly the case in Italy where the practice of dentistry was limited to medical graduates with no dental training and to physicians specialising in dentistry by virtue of a two year post graduate course. In view ofthis, when the directives were published in 1978, member countries, then eight in number, were given eighteen months in which to comply, with the exception of Italy which was allowed a period of six years. In 1980 Italy established a degree in odontology and limited practice to dental graduates. However in 1988 the Italian Constitutional Court ruled that medical practitioners could practice dentistry, thus effectively overruling the E.C. directive. The matter is before the European Parlia­ment. (3) The EC recognises two specialists in dentistry: oral surgery and orthodontics. As the case in Malta, regula­tions are non restrictive, holders of a basic dental quali­fication may practice oral surgery and orthodontics. The only restriction is in Denmark where the law prohibits dentists for treating malignancies. In practice this is no restriction as the treatment of these conditions is gener­ally undertaken by a team of medical and dental practi­tioners. The law in Denmark being satisfied by the inclusion of a medical practitioner, the dental specialist is not excluded from heading the team. (4) FREEDOM OF MOVEMENT There are in the community some 151,000 dental prac­titioners treating approximately 320 million people. An often expressed, but unnecessary, cause for concern is the freedom ofmovement ofpractitioners between mem­ber states and establishment of practices by non-nation­als. There are presently no figures available to indicate how many practitioners have availed themselves of the op­portunity to set up practice in acountry not oftheir origin. The present indications, except for the traditional flow of Irish dentists to the UK, are that the figure is negligible. The number ofEC nationals (except Irish dentists) on the UK Dental Register is currently 168 (5). Out of 600,000 medical practitioners practising in the EC, it is estimated that only 2,000 work in a member state otherthan the one they qualified in. Despite the emphasis being placed on the removal of artificial barriers to movement ofworkers between mem­ber states, language is and will remain the single most important barrier to movement. Governments have to date regarded foreign language skills as a personal mat­ter and have not effectively invested in this field in educational institutions. It is therefore very unlikely that future generations of European dental practitioners will benefit from multi language education. That movement of workers between member states has not materialised is perhaps best exemplified by Luxem­bourg, the smallest, with a population of 389,800 (6) and one of the wealthiest countries in EC, which has not attracted an influx of any category of worker (7). DENTAL HEALTH, MALTA AND THE EC As an indication of dental health in Malta and EC two parameters have been selected on the basis offrequency in reporting. Maltese Medical Journal 46 Volume V Issue I 1993 The World Health Organisation in collaboration with the International Dental Federation established a number of global goals for oral health by the year 2,000 (8). The global goals of3 DMF (Decayed, Missing or Filled) teeth at 12 years and a25% reduction in the present levels of edentulousness at the age of 65 and over are consid­ered. Malta, with a reported D MFT of2 is one offive European countries to have achieved the WHO/FDI goal, Table I. This comparatively low DMFT is one that has been reported in previous studies (9) (10). In the past this has been partly attributed to the naturally occurring level of fluoride in domestic tap water. This level has markedly decreased since the introduction, in 1984, of reverse TABLE I Average number of Decayed, Missing and Filled perma­nent teeth (DMFT) in 12 years old children in EC and European countries with pending application to join the EC. COUNTRY DMFf Austria 4 Belgium 3.1 Denmark 3.4 Germany (former F.R.) 6.2 Finland 3.0 France 3.4 Iceland 7.7 Italy 4.0 Luxembourg Malta 2.0 Netherlands 2.4 Norway 4.4 Sweden 3.4 U.K. 3.0 WHO Country Profiles on Oral Health in Europe 1986. TABLE 11 Percentage Edentulousness in 65 years olds and over in EC and European countries with pending application to join the EC. r- COUNTRY PERCENTAGE Austria 30 Denmark 60 Germany (former D.R.) 58 Finland 65 France 65 Ireland 72 Malta 50 Netherlands 70 Sweden 20 U.K. 79 WHO Country Profiles on Oral Health in Europe 1986. osmosis forwaterproduction(11). The DMFT in Europe ranges from 2.0 to 7.7. Ofgreater concern in Malta is the incidence ofperiodon­tal disease ofearly and late onset (12) (13) and as a major factor in adult tooth loss (14). The reported percentage edentulousness in 65 year old and over in Europe covers a wide range of 20% to 79%, reflecting not only present but also past, national socio­economic factors. Malta with 50% edentulousness is marginly below the mean value, Table H. DENTAL MANPOWER There are at present in Malta 99 dental practitioners of practising age, giving a ratio of 1 dentist for every 3629 population. The ratio in Europe varies from 1 to 1087 to I to 10,000, Table Ill. At the lower end of the scale are Portugal, where the illicit practice of dentistry is institu­tionalised, and Spain. Both these countries joined the EC in January 1986 and are undergoing the seven year period of adaptation. The situation in Spain is of significance and concern. Since joining the EC, Spain has introduced the required dental course catering for 1,000 dental graduates annu­ally from 8 dental schools. The number of dental practi­tioners has consequently increased from 7503 in 1988 to 14,000 in 1992 (15). Of particular concern to the EC are the bilateral agreements whereby Spain recognises de­grees from South American Dental Schools. This has allowed for the influx of4,000 foreign dentists into Spain and provides Spanish students unable to gain a place in a Spanish dental school, with the opportunity to follow a course of studies in South American Dental Schools and return to their country of origin. Another cause for concern is that even with a ratio of 1 dentist for every 5,000 popUlation in 1988, dentists in Spain were experi­encing unemployment, largely because of economic factors and the lack of a state dental service (16). At tbe other end of the scale are the Scandinavian countries where state organised dentistry has been a priority for a number ofyears. In Denmark with a dentist­population ratio of 1 to 1099, all children below the age of 18 have since 1971 been entitled to the full range of dental treatment free of charge together with an active programme ofprevention. This has resulted in 42% of 18 year olds having no caries experience (17). It is now recognised that the Scandinavian objective of 1 dentist for every 1,000 population, based as it was on the anticipated dental needs in pre-preventive days and older dental materials and techniques, with replacement and re-replacement of restorations, has resulted in overpro­duction of dentists. Scandinavian countries have offi­cially recognised this by restricting entry into dental schools. A more recent phenomenon, is being experienced in the UK, where with a dentist/population ratio of 1 to 3226 Maltese Medical Journal 47 Volume V Issue I 1993 and an ever decreas­ TABLE III ing state subsidised Dental-Population Ratios in EC and European Countries with pending application to dental service since join the EC. 1948, bankruptcies in dental practice are Country Inhabitants per Dentists per 10,000 Total No not uncommon (18). Dentist Inhabitants of Dentists I According to Chan­cery Court figures, Austria 2496 4.0 3004 approximately two Belgium (1) 1470 6.8 6688 dentists per week Denmark (2) 1099 9.1 4662 went bankrupt in the Germany (former F.R.) (2) 1562 6.4 39608 financial year 1990- Germany (former D.R.) (3) 1626 6.1 10390 91 (19). Greece (2) 1087 9.2 9206 Spain (2) 5263 l.9 7503 Clearly the question France (4) 1587 6.3 34946 of manpower is a Italy (3) 6400 1.6 9000 multifaceted one Ireland (2) 2941 3.4 1211 with national habits Luxembourg 2083 4.8 179 and economic fac­ Netherlands (2) 1886 5.3 7882 tors as important Portugal (2) 10000 1.0 1068 considerations. Per­ U.K. (2) 3226 3.1 17952 haps as a common denominator for the (1) E.C Official Statistics. Brussels 1991 Basis Year 1987. demand for dental (2) E.C Official Statistics. Brussels 1991 Basis Year 1988. treatment and con­ (3) WHO Country Profiles on Oral Health in Europe 1986. Basis Year 1985. sequently man- (4) E.C Official Statistics. Brussels 1991 Basis Year 1986. power requirements is the amount spent by the state or dental services. TABLE IVTable IV shows Malta, with an annual per capita Expenses for State Dental Care 1982. E.C. and Euro­expenditure ofUS$ 1.55 compared to a European mean pean Countries with pending application to join the EC of US$ 60.33, lacking in this regard. A more realistic (1 ). figure for 1991 would be in the region of US$3.5 (20). Country Per person Per cent ofDENTAL MANPOWER SURVEY in US$ G.N.P. In July 1991 a questionnaire was mailed to all 92 dental Austria 35.46 0.39practitioners in Malta in order to establish present and Denmark 58.62 0.56future patterns of dental practice and manpower re­ Germany (former F.R.) 104.76 0.98quirements. The closing date for replies was extended Finland 41.80 0.42to March 1992 in order to reach more realistic conclu­ France 75.35 0.70sions. 87% of practitioners answered and the data Iceland 47.53 0.48obtained adjusted to take into consideration all dental Malta (2) l.55 0.041practitioners. Since March 1992 eleven new graduates Netherlands 48.45 0.51have joined the dental register and one dentist has Norway 67.30 0.50returned from abroad to start practice in Malta. Sweden 101.70 0.72 U.K. 22.36 0.26 Table V gives the results of this survey and indicates a reluctance on the part of dentists presently employed (1) Weber H. 1991. Dentistry in the 21 st century - Aon a full-time basis in the state dental service to move German View. Dentistry in the 21st Century - Ato full-time private practice. The majority of these Global Perspective. practitioners preferring to retain their employment (2) WHO Country Profiles on Oral Health in Europe with the state service and undertake private practice on 1986. a part-time basis. The reduction in the number of full­time practitioners will be more than made up for by new graduates whose employment with the state serv­ regrettably will have a negative, effect on further training ice is becoming increasingly restricted. and early exposure. With the present set up and funding of the state dental Table VI shows that the number of practitioners will rise service and the anticipated natural wastage it is unfor­ to 140 in the year 2001 giving a ratio of 1 dentist for every tunately not possible to absorb new graduates into this 2512 population or 4 dentists for every 10,000 popula­service except for a very limited duration, if at all. This tion. -------Maltese Medical Journal 48 Volume V Issue I 1993 This figure is in excess of that obtained in the UK, 3.1 3 dentists per 10,000 population. This figure will be dentists per 10,000 population, where under employ­ reached by 1995. ment of dentists and bankruptcies in dental practice are increasingly being reported. With this ratio it has become A further consideration in Malta is the age distribution of necessary to close three Dental Schools in the UK in dental practitioners. Table VII shows that 73% of prac­order to control over production. It is generally accepted titioners in Malta are below the age of40 and 46% below in dental circles that a realistic figure for Malta would be the age of 30. TABLE V Malta Dental Surgeons - Manpower Survey 1991. Adjusted. Employment Number of Dental Surgeons ------,---- -­-+~ ~97 2001 Full Time Private Practice 34 26 26 Full Time Private Practice (below 8 sessions/week) 7 14 19 Full time Government, no Private Practice 6 1 Full Time Government and Private Practice 34 37 26 Part Time Government and Private Practice 3 3 4 Retired 1 7 Don't' know 2 1 Total 84 84 Retired Not Practising Total ________ 1 :i TABLE VI Malta Dentist/Population Ratios: Dentists in Private Practice 1991-2001 Inhabitants per Dentists per 10,000 Number Of.. Practising Number of Dentist~ I • Yw Dentist Inhabitantsl _.Eent~ists in private practic1 1991 4129 2.4 , 84 78 1992 3629 2.7 96 82 1995 3266 3.1 107 101 1997 2969 3.4 118 114 1999 2721 3.7 129 125'",2001 2512 4.0 140 131 Population 359249, Economic Trends November 1991. Malta Government Central Office of Statistics. TABLE VII CONCLUSION Age Distribution of Practising Dentists. Malta 1992. The Oral Health of the Maltese population in 12 and 65 year olds compares favourably with that of other Euro­Age (Years) Percentage J pean cauntries. Numbef ' Below 30 44 45.8 The course of Dental Surgery at the University of Malta is constantly under review in the light of EC directives 30 - 40 26 27.1 and recommendations and it is anticipated that no change to the course content or structure will be needed if I40 - 50 14 14.6 Malta's application to join the EC is successful. The I university already employs the recommendation of the 50 - 60 I 8 8.3 Advisory Committee on the training ofdental practition­ers of the EC for a system of voluntary visitations to 4 4.2 Dental School (21). ~ The present intake of 12 students every second year into the course of Dental Surgery in Malta is in excess of the Maltese Medical Journal 49 Volume V Issue I 1993 island's needs and far in excess of the requirements of the State Dental Service in its present form. The over pro­duction of dentists in a number of European countries is recognised in the EC and remedial action has in some instances already been taken. It is suggested that the present student intake into the Dental School be retained but a number of the places offered to foreign students. Forreasons of hi storic devel­opment in dental education and also for logistic reasons Italy would appear to be one logical source,and appli­cants with a knowledge of English would not have a language problem either academically or socially. Re-References 1. 	 Council Directive 78/687/EEC. Official Jour. of the EC 1978: 1.233/24/24.8.78 2. 	 Council Directive 78/686/EEC. Official Jour. of the EC 1978: 1.233/24.8.78 3. 	 Martignoni M. The State of Dentistry in Italy. Dentistry in the 21st Century -A Global Perspective. 1992: Ed. Simonsen R.J. 4. 	 1II/D/1374/5/84-EN Report on the Field of Activity and Training Programmes for Dental Specialists. 1986 Commission of the European Communities. Brussels. 5. 	 Advice Sheet El. The British Dental Association. 1991 6. 	 Population and Social Conditions Eurostat Rapid Reports 1992:2. 7. 	 Weiss Gunter. Head of the Delegation of the Commission of the European Communities. The European Community after the Maastricht Summit.Public Lecture,AZAD, Malta. 1992 8. 	 FDI - WHO Global Goals for oral health in the year 2000. Int. dent. J. 1982: 32:74 - 77. 9. 	 Olivieri Munroe A study of the Oral Health of Maltese children. Br. Dent. J. 1968: 124: 177-182. 10. 	 Galea H. The dental need of seven year old children. St. Luke's Hosp. Gaz. 1971: 8: 112-114. 11. 	 Vella A.J. & Borg V. Change in Fluoride Content of Maltese Tap water: Implications for Oral Health. Malt. Med. J. 1989: 14:I:III. 14-17. 12. Mangion J.J. & Olivieri MUnroe C. Preliminary studies on oral health conditions in duction in local intake could take the form of the proven method of restricting entry to first preference applicants. The present level of dental manpower and the age distribution of dentists should, in the light offreedom of movement, be a consideration in EC entry negotiations. Funding of the State Dental Service should be increased in line with that obtained in EC countries with dental health delivery schemes. The establishment of priority groups for fee assisted dental services should be investi­gated. Malta. St. Luke's Hosp. Gaz. 1968: 5.164-176. 13. 	 Olivieri Munroe C. Diabetes mellitus and periodontal disease in Malta St. Luke's Hosp. 1968: 3:9-17. 14. 	 Camilleri G .E. The causes of tooth loss. St. Luke's Hosp. Gaz. 1966: 1: 13-14. 15. 	 Martin D.Qualifying for Europe. Symposium. Br. Dent.J. 1992: 172:291-2 16. 	 Gil J.A.21st Century Dentistry in Spain. Dentistry in the 21st Century - A Global perspective. 1991. Ed. Simonsen R.J. 17. 	 Melsen B. Dentistry and Science in the 21st Century. Developing New Paradigms. Dentistry in the 21st Century - A Global Perspective. 1991. Ed. Simonsen R.J. 18. 	 Matthews E. Former Dean, Turner Dental School, University of Manchester. Personal Communications 1992. 19. 	 Main J.R. "Is there anybody out there?" Br. Dent. J. 1992: 173: 87-88. 20. 	 Vassallo A. Chief Government Medical Officer, Malta. Personal Communications. 1992. 21. 	 III D/617 /5/86-En. Report on the definition of the basic occupational profile of the dental practitioner in the Member States of the EC and the recommendation to achieve a comparably high level of basic training in dentistry. 1987. Commission of the European Communities. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

1II/D/1374/5/84-EN Report on the Field of Activity and Training Programmes for Dental Specialists.

A study of the Oral Health of Maltese children.

Change in Fluoride Content of Maltese Tap water: Implications for Oral Health.

Chief Government Medical Officer, Malta. Personal Communications.

Dentistry and Science in the 21st Century. Developing New Paradigms. Dentistry in the 21st Century - A Global Perspective.

Diabetes mellitus and periodontal disease in Malta St. Luke's Hosp.

Head of the Delegation of the Commission of the European Communities. The European Community after the Maastricht Summit.Public Lecture,AZAD,

Is there anybody out there?&quot; Br.

Social Conditions Eurostat Rapid Reports

The British Dental Association.

The causes of tooth loss.

The dental need of seven year old children.

The State of Dentistry

WHO Global Goals for oral health in the year

Maltese dentistry in the E.C. context

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Maltese dentistry in the E.C. context

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