Economist report on socio-economic impact of periodontitis. The Netherlands: eliminating gingivitis is most cost-effective approach

The recent report on the financial and human cost of periodontitis, commissioned by the EFP and published by the Economist Intelligence Unit (EIU), suggests that in the Netherlands an approach aimed at eliminating gingivitis would deliver the best return of investment of the five scenarios analysed.

The report, Time to take gum disease seriously: The societal and economic impact of periodontitis, shows that – compared to the baseline or “business as usual” scenario – the 10-year costs of an approach based on eliminating gingivitis (and thereby preventing its progression to periodontitis) would be more than 40% cheaper (€10.9 billion compared with €18.7 billion), representing a return on investment ratio of 18.7.

In contrast, the approach of achieving 90% periodontitis diagnosis and treating all diagnosed cases would be much more costly (72.4 billion), while delivering a lower return on investment, of 13.4.

One key factor in the Netherlands, according to the report, is that most periodontal and dental treatment is provided by the private sector – although there is a national scale of maximum fees set by a government-appointed body. Nonetheless, says the EIU, such costs are “a barrier to receiving treatment early for many of the general public. Because of these costs, people are more likely to access the dentist when there is something wrong rather than for check-ups or preventative treatment which is essential for avoiding periodontitis.”

Ilara Zerbo, president of the Dutch Society of Periodontology (NVvP), and Nicky Beukers, the society’s EFP delegate, welcomed the report. In the interview below, they comment on its findings.

Q: How important do you consider the publication of this report to be? What effect is it likely to have on public-health policy and awareness of the importance of preventing and treating periodontitis?

A: The publication of this report is of upmost importance for the Netherlands, where the diagnosis and treatment of gingivitis and periodontitis is not part of the basic medical insurance, at least not for adults. Adults must apply on a voluntary basis for an additional dental insurance if they want a part of their dental costs covered by the insurance. Especially for young people (18+) with severe periodontal problems (those who have a strong genetic predisposition) periodontal treatment should be covered by the basic medical insurance, also because periodontitis is a lifelong disease without a clear endpoint.

Avoiding treatment, because they are unable to pay for the costs themselves, will lead to progression of the disease and loss of teeth, not to mention the potential impact of poor oral health on their general health and quality of life – a relationship that is largely unknown, ignored, and undervalued (in terms of both costs and effect). 

We can only hope that this paper will help convince politicians, policy makers, and insurance companies that prevention is key, and especially so in the case of prevention of periodontitis. By weighing up the costs of prevention versus treatment, the evidence is clear.

However, since the dental costs and especially the costs of periodontal treatment are largely paid by the patient themselves (the private sector), it is unfortunately still too easy for the policy makers to ignore the message, as the government is not directly affected. Obviously, this is shortsighted. The indirect effect is in fact huge!

Q: What are the most important findings of this report in relation to your country?

A: We were surprised about the effect of managing gingivitis. This scenario provides the biggest return on investment in the case of the Netherlands. This is an important message for our oral professionals, as prevention of gingivitis is a relative affordable treatment for most patients.

Improving affordability

Q: The report calls for improving the affordability of dental/periodontal care and calls for policy makers to review the provision of publicly covered care for periodontitis. What difference would it make in the Netherlands if periodontitis care were provided free to users via publicly funded care? What is the NVvP doing or likely to do to advance this case?

Decreasing the cost of dental/periodontal care is a complex process. In the Netherlands, the prices for dental treatment are fixed and defined by the government. This means that the costs are already partially regulated. However, periodontal care is still beyond the means of many people.

Reducing prices while maintaining a healthy business is difficult. Regulations for dental professionals have been increasing for years and there are no signs that they will be decreasing. This brings with it so many hidden costs to running a practice that the margin between profit and cost decreases every year. One the one hand, this stimulates efficiency, but on the other hand it decreases individual care and adds increasing stress and strain within the personnel. Deregulation and simplifying care are the answer, but the balance between state-of-the-art care and cost management is a fragile one.

If the affordability of dental/periodontal care is improved, it would mean more people have access to dental care and that will improve the prevention and treatment of gingivitis and periodontitis. Importantly, it will lead to an increased number of people seeking dental treatment. Nowadays, in the Netherlands, there is a shortage of dental professionals (periodontists, dentists, oral hygienists, and dental assistants). Therefore, improved access to dental care should go together with training of more dental professionals. Our government is aware of the shortage of dental professionals, but at the moment is not willing to invest in increasing those numbers. In addition, for periodontists the costs of the postgraduate programme should be covered by the government and the periodontist should become a recognised dental specialist.

Campaigns

Q: The report says that “a synergy of societal and individual public health campaigns is needed” and in particular a focus on less affluent communities and on embedding prevention and early treatment in community settings such as schools and health centres. What is being done in the Netherlands in this area, what work has your society done in terms of public-health education, what work does it plan to do, and what more is needed in terms of government/health authority involvement in prevention and early treatment?

A: There are several campaigns to improve toothbrushing in children and promoting good oral health and there have also been campaigns aimed at promoting oral health in elderly patients.

The campaign “Hou je mond gezond” (keep your mouth healthy) from Ivoren Kruis, the Dutch Association for Oral Health, has been successful in working together with different dental professionals to give oral-hygiene instructions at schools. Via this campaign there have been more than 300,000 instructions at different schools reaching almost one million children of different ages. Ivoren Kruis has also carried out a campaign aimed at promoting oral health in elderly patients, with information for staff and carers in old people’s homes in how they can help their residents prevent disease and maintain their mouths.

The NVM association of dental hygienists organizes a yearly “Week van de mondhygienist” (week of the dental hygienist) and arranges activities at schools and old people’s homes including free treatment and advice.

Both the NVvP and the KNMT (the Dutch Dental Association) have websites with information for patients. The KNMT’s website “Alles over uw gebit” (all about your dentition), offers advice from basic information about caring for your teeth to how to seek dental care and what to expect, making the hurdle to seek treatment less steep.

Here at the NVvP, our website provides basic information about oral health and periodontal problems, who can help, and where you can find treatment. We also provide oral-health professionals with material for patients (folders and illustration cards) to explain periodontal problems, prevention, and treatment. Furthermore, the NVvP supports the improvement of the awareness of dental health to the public in the Netherlands via its activities on Gum Health Day. The effect of this has been slow. In 2020 we meant to launch a bigger campaign to reach people that do not come to dental practices, however because of Covid the campaign had to be aborted. We hope to pick up where we have left off in 2022.

The EIU report is just out, so the NVvP does not yet have any set plans how to act on it. We will however think about how to use this information to improve the oral health of our patients.

Q: How is the NVvP going to use the information provided in this report (e.g., in lobbying and campaigning work)?

A: Again, too soon to have a set plan. However, the Dutch Society of Periodontology would like to use this information to inform the Dutch government about the economic aspects of prevention and treatment of periodontal problems. This is further evidence for the need for investing in the education of dental professionals to be able to improve the periodontal health of the Dutch population, as well as making prevention and treatment financially possible and raising public awareness.

READ EIU REPORT