Dentistry in the Czech Republic. How are we doing?
Dentistry in the Czech Republic. How are we doing?
Despite the high quality of Czech dentists, we have in comparison with some developed countries a higher level of dental carries in both children and adults. It is due mainly to insufficient prevention. Prof. MUDr. René Foltán, Ph.D. points out that we do not actually know the state of dental health of the Czech population. ‘Statements in the media about dental care improving are in fact just guesses. The last large population study was undertaken under the last regime and after 1989, research focused only on a narrow group of socially disadvantaged children’, explains the head of the Department of Dentistry of the First Faculty of Medicine of the Charles University and the General University Hospital. So, dentistry in the Czech Republic: how are we doing?
In the media, we quite often read about problems with accessibility of dental care in our country. According to information from the Eurostat, Czech universities have been producing, in a long term, 3.1 new dentists per 100,000 people. For comparison, in neighbouring Germany universities produce annually only 2.9 new dentists per 100,00 people. Recommendations of the European Union state that to maintain accessibility of dental care, the education system in each country should produce 3 new dentists a year per 100,000 people. From this perspective, the Czech Republic is thus doing well. Nevertheless, in some parts of the Czech Republic, there is a shortage of dentists.
Professor Foltán explains why this is so: ‘Based on data from almost all Czech faculties, we assessed this problem from a sociological perspective and analysed the numbers of students who start their studies of dentistry according to the districts they come from. In other words, we tried to find out how many dentistry students we accept from individual districts. The results clearly showed that we have very few students from districts that complain about the shortage of dentists the most. From this, one can draw two possible conclusions: Either, the district is really sparsely populated, or, and that is more serious, local secondary schools are of such a poor quality that their graduates are not sufficiently well equipped to pass entrance exams for a medical faculty.’
Professor Foltán views the pressure on increasing the overall number of dentistry students as rather counterproductive: ‘Once again, it will be students from areas where there are enough dentists already now who will pass the entrance exams, so this would only further deepen the regional disbalance in the distribution of dentists. It is quite unlikely that a person born and bred in Prague would open a dentist’s office in Šluknovský výběžek.’
What is therefore crucial, adds the head of the Department of Dentistry of the First Faculty of Medicine, is focus on education. ‘If local authorities in the affected regions want to have more dentists, they must start in their regions and dedicate maximum effort and resources to improvements in elementary and secondary education, which is in their jurisdiction,’ emphasises Professor Foltán.
The unfortunate limitation of amalgams
Amalgams are used in dentistry as filling materials, that is, to replace tooth material damaged by carries. Their main advantages are long-term high mechanical durability, outstanding workability, the anti-carries effect of the silver they contain, and low price. Thanks to these properties, amalgams in the course of the nineteenth century gradually replaced gold fillings. Currently, though, they are being replaces by composite materials, for instance for aesthetic reasons. In recent years, the use of amalgams has been limited also legislatively: the European Union has banned its use as of July 2018 in children under 15 and in pregnant and nursing women, and by 2030, amalgam should be phased out completely. These limitations are given primarily by controversies regarding the toxicity of mercury, which accounts for about 50% of amalgam’s weight. Opponents of amalgam link this material to a wide range of undesirable effects, but a majority of scientific studies found no significant links between their occurrence and amalgam fillings. ‘Here, we must unfortunately conclude that the scientific community had failed. Amalgam is now due to the adopted legislation viewed by the public automatically as something very harmful. But we do not have a single study proving any negative effect of amalgam on patient’s overall health. On the contrary, there is a long-term study which had shown that female patients with mainly amalgam fillings are, after 30 years of a follow-up, healthier than those who have less or none of those fillings. The current very strict limitations on amalgam use are due to a most unfortunate synergy of pressure of companies producing other filling materials and the fact that dentists who saw this as an opportunity to make profit were better at presenting their point in the media,’ says Professor Foltán.
MDDr. Antonín Tichý, Ph.D., graduate of the First Faculty of Medicine of the CU, currently works at the Department of Dentistry of the First Faculty of the CU and General University Hospital, where he is active, among other things, in research of fillings materials. On the subject of amalgam, he notes that provably unfavourable effects are rare and mostly local, for instance in the form of lichenoid changes in mucous membranes of the mouth due to oversensitivity to metals contained in the amalgam. ‘In such cases, it is recommended that amalgam fillings be replaced by composites, but otherwise professional societies agree that the use of amalgam is safe, and they do not recommend replacement of otherwise functioning amalgam fillings solely due to fears of their toxicity,’ explains MDDr. Tichý.
‘Genes are not responsible for your rotten teeth’
Another repeatedly scientifically refuted myth is the claim that carries and periodontitis (inflammatory disease of the gums) are genetically conditions and there is nothing one can do about it. ‘Carries is caused by certain types of bacteria which metabolise sugars in the food to organic acids. These subsequently decalcify tooth surface and long-term exposure to this action leads to a defect of hard tooth tissues which we call carries. Other kinds of bacteria produce substances which cause an inflammation of the gums and gradually lead to the emergence of periodontitis, which affects the entire apparatus that holds the tooth in its place. This implies that both of these diseases can be effectively prevented by regular tooth brushing which removes bacteria from tooth surface. But it is also crucial to use a correct technique of tooth brushing and not forget interdental spaces, which are often overlooked,’ says Antonín Tichý, adding that the risk of carries can be lowered also by lowering the consumption of sweet foods and drinks or by the use of preparations containing fluoride ions, which increase the resistance of tooth tissues against acids. ‘Patients very often assume that carries or periodontitis are genetically conditions because their relatives also have “bad teeth”. But the contribution of genetics in the emergence of these diseases is minor and their spread in families is rather linked to habits passed down in families, be it habits concerning dental hygiene, dietary habits, or other issues,’ explains MDDr. Tichý. Prof. Foltán also stresses that the old cliché that a clean tooth does not rot is clearly true. ‘Unfortunately, the healthcare system does not take this into account. Instead of focusing primarily on prevention of disease, it spends astronomic sums of money on treatment. This balance should be adjusted and people positively motivated to take better care of their teeth,’ adds the head of the Department of Dentistry, Prof. Foltán.
The incidence of oncological diseases is increasing
For a long time, it was assumed that oncological diseases in the mouth cavity affect mainly older heavy smokers who drink hard liquor and tend to come from disadvantaged social classes. In the past one or two decades, however, one can follow in dentistry a growing trend, both in the Czech Republic and abroad, where it is ever more frequently the young people, non-smokers, and people active in sports who come to their dentists with this serious and potentially deadly disease. This phenomenon led to intensive research which had shown a direct link between infection with human papillomavirus (HPV) and increasing incidence of cancerous tumours in younger population. ‘Because papillomaviruses also cause a part of cervical tumours, we can assume that it is, in a broader context, in effect a sexually transmitted disease. As part of prevention, we therefore recommend vaccination against HPV not only in preadolescent girls but also boys,’ explains René Foltán.
The school produces finished dentists
The study of dentistry has one specific and little-known feature. The medical faculty must prepare future dentists to such an extent that they be able to start seeing patients on the day after graduation. ‘To be fully competent, our graduates must during their studies go through an incredible amount of practical training. Of the 5,000 hours of total study, practical training amounts to 2,500 hours, that is half of the study time. In this, dentistry is fundamentally different for instance from the study of general medicine: before starting a clinical practice, a graduate of general medicine must undergo postgraduate education focused on a particular medical speciality. Graduates can work independently only after passing a general or specialisation examination, or, as it used to be known, an attestation,’ explains Prof. Foltán. At the First Faculty of Medicine, students train for the first two years on simulators, so-called fantoms, and starting from year three, they see patients. This is highly demanding technically but also in terms of organisation and personnel support. At the First Faculty of Medicine, this training takes place, quite uniquely, in teaching halls where students function within a microenvironment of their own dentistry offices. Under their teachers’ supervision, they are learning the basics of dentistry so as to meet the letter of the law.
Science and research
Naturally, in dentistry, too, there is space for postgraduate education, science, and research. At the Department of Dentistry of the First Faculty of Medicine and the General University Hospital, there are several scientific teams which focus on various subjects. In the area of surgery of face and jaw and dental surgery, they key topics are oncological diseases in the head and neck area, diseases of the jaw joint, or research into absorbable materials for the treatment of bone defects. Other groups focus on laboratory or clinical study of diseases of the mouth cavity, and properties of dental materials form another important topic. This is also an area into which belongs the research of MDDr. Tichý, about which you can read more on page six.