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___ _____________ ___EU Manual of Dental Practice: version 4.1 (2009) 1

Council of European Dentists

MANUAL OF DENTAL PRACTICE

Version 4.1 (2009)

Authors:

Dr Anthony S Kravitz

OBE and

Professor Elizabeth T Treasure

Dental Public Health Unit in Cardiff Dental School,

Cardiff University, Wales, United Kingdom

© The Council of European Dentists

October 2009

EU Manual of Dental Practice: version 4.1 (2009)___________________________ 2 ___ _____________ ___EU Manual of Dental Practice: version 4.1 (2009) 3

Preface

The revised Manual of Dental Practice (Version 4) in the EU was commissioned by the Council of European Dentists1 in November

2007. The work has been undertaken by the Dental Public Health Unit in Cardiff University, Wales, United Kingdom. Although the

unit had editorial control over the content, most of the changes were suggested and validated by the member associations of the

Committee.

This edition (4.1) corrects a number of errors identified after publication. All data are as was inserted by October 2008 and have not

been updated to 2009.

About the authors

2

Anthony Kravitz graduated from the University of Manchester, England, in 1966. Following a short period working in a hospital he

has worked in general dental practice ever since. From 1988 to 1994 he chaired the British Dental Association"s Dental Auxiliaries"

Committee and from 1997 until 2003, was the chief negotiator for the UK"s NHS general practitioners, when head of the relevant

BDA committee. From 1996 until 2003 he was chairman of the Ethics and Quality Assurance Working Group of the EU Dental

Liaison Committee. He is an Honorary Research Fellow at the Dental School,Cardiff University, Wales and his research interests include healthcare systems and the use of dental auxiliaries.

President of the BDA from May 2004 until May 2005, he was awarded an honour (OBE) by the Queen at the end of 2002.

Elizabeth Treasure graduated from the University of Birmingham in 1979, following which she completed a PhD. She then worked

in the community dental service before emigrating to New Zealand to become a full-time academic in 1990. She returned to Wales

in 1995. She is Dean of the Dental School of Cardiff University and is Professor and Honorary Consultant in Dental Public Health.

She has been a scientific advisor to the Department of Health in London.

Her research interests include clinical effectiveness, epidemiology and clinical trials. She has been a member of the UK Medical

Research Council group on fluoridation and on a European Union Expert group reviewing the concentration of fluoride in paediatric

toothpaste. She is one of the authors of the 1998 UK Adult Dental Health Survey and has chaired a review of dental workforce in

Wales. She was the leader on the oral health specialist branch of the National Electronic Library for Health.

Acknowledgements

The authors would like to express their thanks to the staff from all the dental associations of the EU for their contribution. They

would also like to acknowledge and thank: The dental associations of 31 EU/EEA countries and Croatia

The dental councils of several countries

The Secretariat of the CED

Rob Anderson

Dr Kenneth Eaton (CECDO)

Ms Ulrike Matthesius (British Dental Association)

The Federation Dentaire Internationale (FDI)

The European Commission, including Eurostat

The Chief Dental Officers of the EU (CECDO)

Conference of Orders and Assimilated Bodies of Dental Practitioners in Europe (CODE)

The World Health Organisation (WHO)

The Union Bank of Switzerland (UBS)

The Organisation for Economic Cooperation and Development (OECD)

The CIA Worldfactbook

The International Monetary Fund (IMF)

Disclaimer

The Manual was sent for publication in October 2008, when ratification of the Treaty of Lisbon (2007) had not been completed.

1 CED Brussels Office, Avenue de la Renaissance 1, B - 1000 Brussels, Tel: +32 - 2 736 34 29, Fax: +32 - 2 732 54 07

2 The authors may be contacted at denhealth@cardiff.ac.uk

EU Manual of Dental Practice: version 4.1 (2009)___________________________ 4 ___ _____________ ___EU Manual of Dental Practice: version 4.1 (2009) 5

Contents

Preface 3

Part 1: The European Union......................................................................................................................................................................11

Chart 1 - GDP per capita at PPP in 2007 (some countries 2006): ...........................................................................................................13

Chart 2 - Comparitive prices, including rent, in 2008 - based on Zurich = 100 - also compared with wages net of tax.........................13

Chart 3 - Comparison of Domestic Purchasing Power, in 2008 - based on Zurich = 100 (also compared with 2003 data)...................14

Part 2: The Dental Directives, Acquired Rights & the Freedom of Movement...........................................................................................15

Part 3: Other Directives directly relevant to dentists..................................................................................................................................21

Part 4: Healthcare and Oral Healthcare Across the EU/EEA....................................................................................................................25

Chart 5- (Active) Dentist to Population ratio ..............................................................................................................................................25

Chart 4 - percentage of GDP spent on health by governments in 2004-05 as reported by the OECD in 2008........................................25

Chart 6 - (Active) Dental Clinical Worker to Population ratio....................................................................................................................25

Table 1 - Healthcare systems in EU/EEA countries ..................................................................................................................................27

Table 2 - Patient re-examination periods...................................................................................................................................................28

Chart 7 - the average Decayed, Missing, Filled Teeth at the age of 12 years (DMFT)............................................................................28

Chart 8 - the proportion of children of 12 years of age with no Decayed, Missing, Filled Teeth (DMFT).................................................28

Chart 9 - the proportion of adults 65 years (or older) with no teeth (edentulous).....................................................................................29

Table 3 - Community fluoridation...............................................................................................................................................................29

Part 5: The Education and Training of Dentists.........................................................................................................................................31

Table 4 - Dental schools, numbers of students and gender.....................................................................................................................31

Table 5 - Undergraduate Training greater than 5 years............................................................................................................................32

Table 6 - Mandatory Vocational Training..................................................................................................................................................32

Table 7 - Mandatory Continuing Education...............................................................................................................................................33

Part 6: Qualification and Registration........................................................................................................................................................35

Table 8 - Regulation of dentists (2008)......................................................................................................................................................36

Part 7: Dental Workforce............................................................................................................................................................................37

Table 9 - Numbers of dentists....................................................................................................................................................................37

Chart 10 - the number of "active dentists" in each country.......................................................................................................................38

Table 10 - Gender of dentists ....................................................................................................................................................................38

Chart 11 - the gender of "active dentists" in each country........................................................................................................................38

Chart 12 - the proportion of "overseas dentists" in each country (ie dentists who first qualified in another country)..............................39

Table 11 - Types of specialties, and numbers in each ..............................................................................................................................40

Table 12 - Types of auxiliary recognised in each country..........................................................................................................................42

Table 13 - Regulators of dental auxiliaries ................................................................................................................................................43

Table 14 - The numbers of dental auxiliaries............................................................................................................................................44

Part 8: Dental Practice in the EU...............................................................................................................................................................45

Table 15 - Percentage of dentists who are practising in general practice (source: the dental associations)............................................45

Chart 13 - Dental practices "list" sizes......................................................................................................................................................45

Table 16 -Dentists working in public dental services................................................................................................................................46

Table 17 - Countries without public clinics.................................................................................................................................................47

Part 9: Professional Matters......................................................................................................................................................................49

Table 18 - Membership of the dental associations....................................................................................................................................49

Table 19- Advertising not permitted..........................................................................................................................................................50

Table 20- Indemnity Insurance mandatory ...............................................................................................................................................51

Table 21 - Indemnity Insurance may extend for work in another country.................................................................................................51

Table 22 - Corporate practice permitted...................................................................................................................................................51

Table 23 - Inoculation against Hepatitis B mandatory ..............................................................................................................................52

Table 24 - Mandatory continuing education relating to ionising radiation.................................................................................................52

Table 25 - Amalgam separators mandatory..............................................................................................................................................52

Part 10: Financial Matters..........................................................................................................................................................................53

Table 26 - normal (state) retirement ages - ..............................................................................................................................................53

Part 11: Individual Country Sections..........................................................................................................................................................55

Austria .....................................................................................................................................................................................................57

Belgium .....................................................................................................................................................................................................65

Croatia ......................................................................................................................................................................................................85

Cyprus ......................................................................................................................................................................................................95

The Czech Republic.................................................................................................................................................................................103

Greenland and the Faroe Islands............................................................................................................................................................120

Estonia ....................................................................................................................................................................................................123

Finland ....................................................................................................................................................................................................131

EU Manual of Dental Practice: version 4.1 (2009)___________________________ 6

France ....................................................................................................................................................................................................141

German ....................................................................................................................................................................................................153

Greece ....................................................................................................................................................................................................169

Iceland ....................................................................................................................................................................................................189

Ireland ....................................................................................................................................................................................................197

Italy ....................................................................................................................................................................................................207

Latvia ....................................................................................................................................................................................................221

Malta ....................................................................................................................................................................................................247

The Netherlands ......................................................................................................................................................................................255

Norway ....................................................................................................................................................................................................265

Poland ....................................................................................................................................................................................................275

Spain ....................................................................................................................................................................................................327

Sweden ....................................................................................................................................................................................................339

The United Kingdom................................................................................................................................................................................355

The British Dependent Islands.................................................................................................................................................................371

Annex 1 - Information collection and validation.......................................................................................................................................373

Annex 2 - EU Institutions.........................................................................................................................................................................375

Annex 3 - European Health Strategy......................................................................................................................................................379

Annex 4 - Directive 2005/36/EC..............................................................................................................................................................381

Annex 5 - Content of undergraduate training and education..................................................................................................................383

Annex 6 - Diplomas and Qualifications...................................................................................................................................................385

Annex 7 - Dental Specialist Diplomas & Qualifications...........................................................................................................................389

Annex 8 - Dental Specialist Qualifications (OMFS)................................................................................................................................391

Annex 9 - Acquired Rights; Freedom of Movement................................................................................................................................393

Annex 10 - Data Protection.....................................................................................................................................................................397

Annex 11 - Code of Ethics for Dentists in the EU...................................................................................................................................399

Annex 12 - Code of Ethics for Dentists in the EU...................................................................................................................................401

for Electronic Commerce.........................................................................................................................................................................401

Annex 13 - (Proposed) Directive on patients" rights in cross-border healthcare ....................................................................................403

Annex 14 - Consultation on Patient Safety.............................................................................................................................................405

___ _____________ ___EU Manual of Dental Practice: version 4.1 (2009) 7

Introduction

Background

In common with many other professionals, dentists are increasingly seeking opportunities to work and live in other countries. Within the EU, the ability for dentists to move and work in any country has never been greater and national dental associations have experienced a considerable increase in the number of enquiries from members about practising abroad. The problems and expense of answering these questions on an ad hoc basis, and the need for associations to conduct their national political negotiations in the context of international experience, resulted in the European Union Dental Liaison Committee (EUDLC) commissioning the Dental Public Health Unit of the University of Wales Dental School in Cardiff (UK), in 1993, to produce a comprehensive reference document describing the legal and ethical regulations, dental training requirements, oral health systems and the organisation of dental practice in 18

European (EU and EEA) countries.

Following publication of early drafts, the first full edition of this review was published as a Manual of Dental Practice in the EU in 1997, and this was updated in January 2000. The EUDLC again commissioned the University of Wales, in November 2002, to further update the Manual and extend it to embrace the countries which were acceding to membership of the EU in May 2004 and January 2007. The EUDLC became the Council of European Dentists (CED) in May 2006 and the University of Wales became Cardiff University in 2005. The CED commissioned Cardiff University in November 2007 to update the 2004 Manual and produce another version relevant to 2008 - to include Bulgaria (missing from the 2004 version) and Croatia which was expected to join the EU in January 2009.

The scope and presentation of the review

The Manual aims to provide comprehensive and detailed information for dentists who are considering working in another country. The authors have endeavoured to construct a basic, minimum framework as an introduction to the most relevant topics, and a well-informed starting point for further questions which individuals may raise. It has been written as a practical "handbook" in which information is easy to find and to understand. The country chapters also aim to balance information about formal requirements including laws, codes of practice and other regulations with descriptions of how things work in reality. An introduction to the EU and dental practitioners The opening chapters outline the origins of the EU and its attitude to health; how the EU functions including descriptions of its formal institutions (for example, the Commission, the Council, the European Parliament, the Court of Justice) and the current membership of the EU. We have also described the EU Dental Directives which are directly relevant to dentists, and we have listed the titles and qualifications to which the Directives relate.

The comparative analysis

Further chapters provide a simple comparative analysis of the different systems for the delivery of oral healthcare service, the nature of education, training and the constitution of the dental workforce, different practising arrangements, and other regulatory frameworks and systems within which dentists work. We have briefly covered ethical codes, the monitoring of standards, specialist and auxiliary personnel, and the relative importance of oral health services provided outside general or private practice.

The country chapters

The bulk of the Manual contains the detailed descriptions of the oral health systems, and the ways in which dentists practise in each of 32 countries. In addition to the 27 countries of the EU, Iceland, Liechtenstein and Norway (the EEA), Switzerland and Croatia are included. Croatia is included as it is expected to join the EU in 2009. Greenland and the Faroe Islands are described in the chapter for Denmark. There are self-governing islands in the British Isles and these have been included in the UK section.

Each country chapter includes:

A brief description of the historical background, political system and any features of the country"s society, economy or geography that are significant for the organisation of health services. The main features of the health system, including: how it is funded, how health policy is decided, and how the provision of health services is organised. A section on oral healthcare which provides a general overview of the bodies responsible for its provision, the population groups who have access, and the services that are available to them. A description of entry to and content of dental school (undergraduate) education and training, and the requirements for registration - including the requirements for legal practice, the bodies which approve applications, the documents which need to be submitted, and any other conditions which need to be met. Additionally, any postgraduate education and training (including specialist training) is described. The paragraphs on Specialists list the dental specialties that are recognised, including the formal training required for each, and its location and duration. A section on what constitutes the dental workforce in each country, including numbers of dentists and specialists. There are several paragraphs on Dental Auxiliaries, which list the types of auxiliary that are recognised, what procedures they are allowed to carry out, where they work and the rules within which they may legally practise.

Paragraphs on Working in General Practice, Working in the Public Dental Service (where appropriate),

EU Manual of Dental Practice: version 4.1 (2009)___________________________ 8 Working in Hospitals, and Working in Universities and Dental Faculties. For each of these, there is a brief description of the staff titles and functions, the minimum formal qualifications required, and how dentists are paid. For general or private practice this usually involves details of the administration of any fee-scales, whether remuneration is part of a contract, rules for prior approval, and some practical details of how to join or establish a practice. A section on dentistry in each country which is described as "Professional Matters" and includes an explanation of the framework for dental practice in terms of professional organisations, ethical codes and any other systems for monitoring standards and handling complaints. A "Financial" section, which briefly introduces many financial considerations for practice. Finally there is an Other useful information section which provides the name, address, telephone and fax numbers of the main national dental associations, together with some other general data.

What"s new in Version 4?

Health data: more information has been collected, including information about Caries levels (in children),

edentulousness and fluoridation. More economic data and analysis relating to oral healthcare More information about dental schools and numbers of dental students More information about registration of dentists and dental auxiliaries Information about tooth whitening, ionising radiation rules and hazardous waste regulations

Information about dental workers" incomes has been dropped as the data was inconsistent and out of date

quickly

Information collection and validation

The original information was collected in early 1996, in three stages using a questionnaire to the main dental associations in each of the then 18 countries involved (the

15 EU countries, plus Norway, Switzerland and Iceland).

For countries where there was no single main national association, more than one questionnaire was sent to obtain the most complete picture possible. After the initial exercise, validation interviews were conducted to clarify and extend the information provided by the questionnaires. The interview stage of the information collection process was essential for identifying important differences between countries, resolving potential ambiguities and exploring in detail those issues briefly covered by the questionnaire, which were more important for dental practice in a particular country. The first draft of each country chapter was written using the interview notes, questionnaire answers and any other documents which the national dental associations were able

to supply. The draft of each country chapter was then checked for clarity, completeness and accuracy, before

publication. This process was repeated for the second edition and the content was extended to include more information. The third edition was revised and updated using two methodologies: for the "candidate" (new) countries of the EU new questionnaires were devised, based on an analysis of the information supplied by the existing countries in the first and second editions. Interviews were then conducted by the authors, with the representatives of the relevant countries, at various international meetings during 2003. The data and information for the existing EU countries were analysed and cross-checked for common information and then the individual country sections were marked by the authors for clarification, modification, expansion and revision, before being sent to the dental associations in

February 2003.

Following receipt by the authors of the corrected country sections, clarification of any ambiguous information was undertaken, again at international meetings and by Email. The data was then validated with dental associations of the countries, many chief dental officers, and some dental councils and registration bodies, before publication. The same process - as in 2003 - was used for this (4 th) edition. The two new countries - Bulgaria and Croatia - were approached with questionnaires in December 2007 and then the exisiting countries were approached for new data from March until September 2008. International meeting in Slovenia (May) and Sweden (September) were used for direct data validation. Documentary sources of information used are listed in

Annex 1.

Additional explanatory notes

It was not possible to obtain a single, valid reference date for all data, across all countries of Europe. The collection of data took place during 2008, and so this should be assumed to be the reference year for the data, except where another date is shown. English language conventions have been used for expressing numbers and figures, so that:

Decimals are expressed with a point, eg 5.3

Millions are expressed with a comma, eg 1,000,000

"Billion" refers to One Thousand Million The sign for a Euro is € and this is placed before the number, eg €100 The term "Accession Countries" refers to the ten new

EU countries at May 2004: Cyprus, the Czech

Republic, Estonia, Hungary, Latvia, Lithuania, Malta,

Poland, Slovakia and Slovenia; and Bulgaria and

Romania, whose membership of the EU was from

2007. Croatia will join in 2011 or 2012..

Data was inserted into the Manual to October 1st 2008 and the severe financial and currency problems which arose after this date are not reflected here. ___ _____________ ___EU Manual of Dental Practice: version 4.1 (2009) 9

Definitions

Percentage of Gross Domestic (or National) Product (GDP/GNP) spent on oral health This refers the proportion of a country"s overall wealth which is spent on dentistry - through national health/social insurance AND private care, if known.

Private care

This refers to dental care that is paid for entirely by patients either directly to the dentist or through private dental insurance, without any government or social insurance subsidy or reimbursement. It does NOT refer to co- payments made through a national health or social insurance scheme.

Private insurance for dental care

This refers to insurance for dental treatment which patients buy from independent insurance companies not directly controlled by either the government or any social insurance scheme. Percentage of Oral Health (OH) expenditure private This refers to the total expenditure (in money terms) by patients on dentistry, using private care (as defined above) only. Expenditure by patients on co-payments in any state scheme or through any social insurance is NOT included in this figure.

Co-payments

These are payments made by patients towards the cost of their dental treatment in a state or social insurance scheme. Also, where the scheme involves reimbursement, the amount not reimbursed is a co-payment.

Vocational training

This refers to a period AFTER graduation, following registration with the competent authority, when the new dentist practises in a mandatory supervised environment (such as a training practice or public clinic or hospital department). The training period may - but not necessarily - include mandatory further education and a further examination before the dentist can practice in a non- supervised environment and own his or her own dental practice.

Cost of registration

This refers to the annual cost of registration with the competent body which registers dentists in a country

Specialists

These are dentists who have completed a further period of special training following their basic qualification as a dentist and then been registered with some national authority as a "specialist". The only EU-wide acknowledged specialists are orthodontists, oral surgeons and oral maxillo-facial surgeons - but many countries have additional classes of specialists.

Overseas dentists

This refers to dentists who have received their primary dental qualification in any country other than the listed (host) country, even if they are nationals of that country. A dentist who is not a national of the country, but has qualified in that country is an "overseas dentist" for the purpose of this Manual.

Active dentists

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