Efficiency of dental health care in Federation of Bosnia and Herzegovina

© 2013 Š. Ciloviæ-Lagarija, M. Selimoviæ-Dragaš; licensee University of Sarajevo Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT


INTRODUCTION
Dental health care as a part of the health care system in general, is essential for promoting, improving and maintaining oral health of the population.Th rough an effi cient dental health service, patients can be advised of risks factors whose modifi cation could reduce the incidence of oral diseases, and further, how controlling such factors can contribute to maintain a good quality of life.Comparing with developed countries, where most of dental clinics are equipped with the latest technical facilities and supported by health professionals from various specialties that allow their cooperation to benefi t the patient, dental health services in developing countries, are mostly directed to provide emergency care only or interventions towards certain age group popula-tion.Th e most common diseases are dental caries and periodontal disease and frequently intervention procedures consists of treating existing problems and restoring teeth and related structure to normal function (1).Bosnia and Herzegovina with the principle of organization of the dental health care is no exception.Federation of Bosnia and Herzegovina (FBH) is organized in 10 Cantons covering an area of 26 110,5 km 2 with the population of 2 338 277 people (2).Health care system in FBH is organized on federal level, cantonal level and municipality level that have diff erent jurisdiction, determined by law.Th e organization of health care system on Cantonal level with the coordination from Federal level represents a real situation with the possibility of decentralization of health care system according to the experiences of developed countries.Oral health care in FBH is organized as insurance funded public health services and private practice.Accessibility to oral health care facilities diff ers between administrative units (3), which has it's repercussion on oral health of population in general.Dental health care in FBH is organized as a primary, secondary and tertiary oral health care and all dental profesionals are obliged by law to fulfi ll the report forms about deseases, conditions and injuries according to the "International Statistical Classification of Diseases and Related Health Problemstenth revision" (ICD-10) (4).Th e aim of this study is to evaluate the effi ciency of dental health care in FBH presented by number of visits and performed dental treatments during the time period of six years from 2005-2011.

Procedures
Monthly rates of total dental care procedures, preventive procedures, collective procedures, restorations and extractions for every single dental offi ce were collected and presented as a unique anual report of dental care in FBH published by Institute for Public Health of FBH in their publication "Health statistics annual of Federation of Bosnia and Herzegovina" (5).Th e data for this study were colected from "Health statistics annual of Federation of Bosnia and Herzegovina " during the time period of six years, from year 2005 to 2011.Th e data includes number of dentists graduating during the time period year 2005 to 2011, number of doctors of dental medicine (DDM) employed in public sector, between years 2005 and 2011 and visits and delivered services in dental care for the same time period.Th e lack of data of number of doctors of dental medicine employed in the private sector was partially determined, indirectly, by the number of graduate doctors of dental medicine.Th e assumption is that one part of graduates is employed in the private sector, but that data were not available yet.Variables, number of doctors of dental medicine (DDM) have been analyzed as the number of DDM per 100.000population, morbidity data as number of disease per 10.000 population and number of visits and performed treatments per doctor of dental medicine.

Statistical analysis
Relationship between variables is computed by analyzing Pearson coeffi cient of linear correlation.Preliminary analyzes were conducted to prove the satisfaction of the assumptions of normality, linearity and homogeneity of variance.

RESULTS
Th is section outlines the main characteristics of outcome data in dental service in FBH over the six years based on publication "Health statistics annual of Federation of Bosnia and Herzegovina".Table 1 shows how the number of graduated doctors of den-  tal medicine and the number of doctors of dental medicine employed in public sector changed during the period from 2005-2011.Visible reduction of number of dentists employed in public sector in years 2008 and 2009 is not statistically significant.Pearson coeffi cient of linear correlation shows positive correlation between an increased number of dentists employed in public sector and an increased number of graduate dentists where r = 0.012, n = 7 and p = 0.979 (Table 1) (5).It is noteworthy that there is no evidence of number of doctors of dental medicine employed in the private sector so total number of employed dentists can be estimated only.periodontal diseases (K05) showed a little variation compared to the observed time period (Figure 1) (5).
Table 3 shows number of visits and performed treatments per doctor of dental medicine in public dental service during the time period years 2005 to 2010.It is interesting to note a small number of fi lled deciduous teeth (30 per doctor of dental medicine in 2010.)comparing with the number of extracted deciduous teeth in the same time period (119 per doctor of dental medicine in 2010.)Having in mind that early extraction of deciduous teeth usually leads to loss of space, a large number of extractions of primary teeth can be partly considered as the cause of increased number of dentofacial anomalies (KO7) (5).A strong positive correlation has been seen between the increased number of dentofacial anomalies (K07) and increased usage of removable orthodontic appliances where r = 0.126, n = 7, and p =0.788 (Figure 2) (5).Very interesting information, from the dentist's point of view, is the almost equal number of fi llings in permanent dentition and extracted permanent teeth, which certainly increased the number of patients who needs partial dentures or even total prosthesis as a treatment (Table 3) (5).

DISCUSSION
Th e biggest recent changes in European oral healthcare were found to have occurred in Eastern Europe, where there has been wide scale privatization of the previously public dental services (7).Bosnia and Herzegovina is no exception.Th is paper reports the fi ndings of retrospective study that was designed to deepen understanding about the impact of organization of dental health care in the observed time period; almost equal number of fi llings in permanent dentition and extracted permanent teeth, which certainly increased the number of patients who needs partial dentures or even total prosthesis as a treatment; it has been observed a small number of fi lled deciduous teeth (30 per doctor of dental medicine in year 2010) comparing with the number of extracted deciduous teeth in the same time period (119 per doctor of dental medicine in year 2010).More than 20 years after widespread adoption, the strategy of WHO "Health for All through primary health care" still has not been fully implemented.Bosnia and Herzegovina national capacity and resources like human, fi nancial and material, are still insuffi cient to ensure availability and open access to essential health services of high quality for individuals and population, especially in deprived communities.Th e health system in Bosnia and is characterized by centralized structure, providing treatments on demand, with increasing number of doctors specialist in diff erent areas, who basically provide health care on primary level.Organization of dental health sector in Bosnia and Herzegovina and the oral health of the population depend on method of fi nancing, on relationship between socioeconomic factors of dental health care and the level of utilization of dental services.Dental health care is based on the specifi c population group like pregnant women, preschool children, school chil-dren and adults.Th is kind of organization neglected population as a whole.
Changes in organization of oral health care in Federation of Bosnia and Herzegovina, which have happened lately, corresponds with recent changes in European oral health care.Bosnia and Herzegovina, like some EU member states, operate the Bismarkian system with health insurances which proclaim "Universal health insurance" off ering wide population coverage, comprehensive treatment and some benefi ts.Despite wide option for the people to get health care it is estimated that 15 % of population in general are not covered by health insurance.Population coverage with health care deviates in cantons and regions, deviations is even more noticeable in municipalities (8).In order to reduce inequities in access to oral health services and improves the effi ciency of the health system in general the process of change is indispensable.Limited access to oral health services can be considered as one of the reasons for such a big number of extracted primary teeth as well as permanent teeth (Table 3).Because of limited access to oral health services teeth were often left untreated and later extracted because of pain or discomfort.

Visits and performed treatments in dental service
Th e results of this study found that the extraction of permanent teeth is the most common treatment in  dental offi ces in FBH (Table 3.).Th ese results correspond with the results registered by WHO where 78 % of edentulous adults in Bosnia and Herzegovina, aged 65 years and more, present the biggest percentage of edentulous people in the world (9).Although, losing teeth as a natural consequence of aging, is still seen by many people throughout the world, those results indicates the need to reorient oral health services in Bosnia and Herzegovina towards prevention and oral health promotion.Having in mind a pain and suff ering that accompany oral diseases, impairment of function and reduced quality of life, those needs become more pronounced.Incidence rates of malignant neoplasms found in this study (Table 3) coincide with the incidence rates in most countries worldwide (10).Th ose incidence rates relate directly to risk behaviors such as smoking and alcohol consumption.It seems, while oral and pharyngeal cancers are both preventable, in BH, like in most countries, they remain a major challenge to oral health programmes.

Oral health personnel and morbidity
Th e issue of oral health personnel -which categories of personnel need to be educated, their duties and the numbers of each -has for many years been of great concern.Th e importance of this matter really has become evident in a number of dental caries (K02), diseases of pulp and periapical tissues (K04) and gingivitis and periodontal diseases (K05) recorded in time period years 2005 to 2011 (Table 2).According to the fact that oral health in Bosnia and Herzegovina can be considered as the worst in the Europe (11) it seems that the production of dentists in BH appears irrelevant to the oral health needs and demands.Severity of oral health burdens registered in this study partially can be considered as the result of changing of socio-demographic factors.
In order to improve oral health, the adjustment of existing oral health manpower structures with the training programmes for types of personnel which would match the oral health needs, are needed in Bosnia and Herzegovina.Reform of oral health services in Federation of Bosnia and Herzegovina should lead to increased interest in basic preventive oral health interventions (especially in high-risk populations) as an easy and reliable approach to reduce systemic load of curative dental treatments with the aim to improve not only oral health but the health in general.Unfortunately, the human, fi nancial and material resources are still insuffi cient to meet the need for oral health care services and to provide universal access, especially in disadvantaged communities.Having in mind evident accelerated aging of the population which will be intensify over the coming years, it is obvious that improving oral health for health authorities in Federation of Bosnia and Herzegovina will be a very challenging objective.

CONCLUSIONS
Th is study highlighted the importance of oral health in public health outcomes, with the goal of developing a comprehensive public health strategy that would include preventive oral health measures within overall prevention and wellness approaches.Th e need for strengthening disease prevention and health promotion programmes in order to improve oral health conditions in general is evident.

TABLE 1 .
The number of graduated doctors of dental medicine during the period from 2005 to 2011 and number of doctors of dental medicine/ number of DDM per 100.000populations employed in public sector during the same time period.

Table 2
(6)e per 10.000 population(5).Th ose results where coded and classifi ed by "Application of the International Classifi cation of Diseases to Dentistry and Stomatology (ICD-DA)"(6).It is derived directly from the Tenth Revision of the International Classi-fi cation of Diseases (ICD-10) (4) with the intention to provide a coherent system for coding and classifying data on oral and dental disorders.In

TABLE 3 .
Number of visits and performed treatments per doctor of dental medicine in public dental service during the time period year 2005 to 2010.Small number of fi lled deciduous teeth per doctor of dental medicine comparing with the number of extracted deciduous teeth in the same time period.