May 17, 1983 was the day my recent trip to Norway was determined. Just three weeks before dental school graduation and board exams, my
second daughter, Marit, was born. Syttende Mai (May 17) is Norwegian National Day, celebrating the signing of their Constitution, declaring them independent of Swedish rule. The date has always carried special significance in my family. My mother’s side of the family came from an inland area of high mountain plateaus and valleys to settle in northern Minnesota. (Random Norway fact: There are more Norwegian descendants living in the U.S. than there are Norwegian people in Norway - 6 million vs. 4.6 million.) It seemed a sign from the Norse gods to have a child born on Syttende Mai! Yet it was only this spring that we were able to actually celebrate her birthday in Norway.
With the trip finally a reality, I had two other goals: Look for my Norwegian relatives, and, what-the-heck, check out what dentistry is like in the Motherland!
On Friday, May 15, I was graciously received for a conversation about dentistry in Norway with the Director of Public Relations for the Norske Tannlegeforening (NTF), Mr. Morten H. Rolstad. We spent a comfortable, casual 90 minutes sharing information and inspiring conversation about dentistry in our respective associations.
Norway is an acknowledged leader in social welfare legislation, and its current system is among the most comprehensive in the world. The
health insurance piece is underwritten by individuals, employers, and the state, and is mandatory for everyone. This supports prenatal and maternity care and child care for working mothers at no charge. Within this understanding of the word, education, including college/university, is “free”. As well, 1967’s National Pension Scheme, which is mandatory, covers benefits including old age, disability/rehabilitation, widow/widower, one-year paid maternity leave, and universal child support. The pension phase begins at age 67, and pays approximately two-thirds of a recipient’s earnings at their highest level.
As nearly everything that is written about dentistry in Norway is in written in Norwegian, most of what I learned about dentistry came from speaking and corresponding in English with Mr. Rolstad, along with a few English language links and resources he was able to provide. However, the basic impression with which I left was how similar were our practices of dentistry.
The NFT will celebrate its 125-year anniversary this year. The vast majority of practicing dentists belong to the NFT, which over the years has been a strong voice for dentistry and the oral health of Norway’s citizens. Not unlike our situation in Minnesota, it faces significant new challenges in these times. In this fall’s national elections, the NTF will be working hard to represent its members and protect the dental benefits of the population.
Norway’s wealth and high standard of living translate into very generous health care coverage for its citizens. Most of the public health care system is directed toward ages 0-18; dental care is provided at no cost from birth to age 18. At 19 and 20, care is very inexpensive. The disabled or those with special care needs also receive free care. Beyond that, citizens are responsible for the costs; there is no dental insurance in Norway. (A previous effort was unsuccessful.)
There are 4,700 dentists for the country’s population, working in two main types of practice - private and public. Approximately two-thirds of dentists are engaged in private practice. The other one-third practice in a variety of different public systems and are employees of the government.
The Norwegian dental team consists of dentists, dental hygienists, and dental assistants. There are no mid-level practitioners in Norway. Dental hygienists are permitted to engage in private practice and, in that setting, within their scope of practice. However, there are only a very small number doing so. Dentists are trained at one of the dental schools located in Oslo or Bergen, and in a new program in the far northern city of Tromsø. Students in Oslo follow an independent course of dental study, whereas in Bergen medical and dental students are trained together until they separate in the third year. Tromsø has an established medical school program; its small, newly established dental program will begin with 10 graduates, increasing to 20 and a maximum of 40, with the majority chosen from applicants of the region in the hope they will choose this or other more remote and underserved regions.
Access to dental care/distribution of dentists is an issue in Norway. Rugged, remote, harsh, and sparsely populated areas contribute to the problem. Norway has the lowest population density in continental Europe, with 15 persons per sq km (39 per sq mi), and distribution is extremely uneven. About half the population is in the southeast, and more than three-quarters of all Norwegians live within about 10 miles of the sea, 80% in urban areas. The coastline offers good transportation links and a moderate climate.
Here too dentists tend to congregate in larger population centers, creating a problem supplying a dental workforce for certain regions. Additionally, there can be a lower salary or earning potential for the public practice dentists. Not unlike Minnesota, surveys in Oslo and Bergen indicate their dentists would like to be busier.
Private practice dentists set their own fees, with some anti-pricefixing measures in place. Orthodontic reimbursement for ages up to 18 is covered under a general system. Even with free public health providers, people may choose private dental practice. They are then responsible for the costs of their treatment.
Norway’s provincial arrangement of governance includes a dental director and organization for each, with local dental public health dental personnel in the approximately 420 kommune (like our counties).
There is no fluoridation of public water systems in the nation. The opinion expressed is that the fluoride contained in toothpaste is adequate. Fluoride tablets are available without a prescription and can be purchased off the shelf in the grocery store. Fluoride tablets are, however, recommended for special needs patients. Otherwise, the advice given is to “talk to your dentist”.
One interesting note relating to a specific impact on the practice of dentistry in Norway can be understood by some understanding of Norway’s economy, with its interesting combination of public and private enterprise under a strong degree of government supervision and control.
Norway was one of the first countries to establish a Ministry for the Environment (1977). Effective January 1, 2008, all use of mercury contained in products was banned in Norway — even in amalgam restorations. This initiative came directly from the Ministry of Environment. It was not directed at dentistry specifically, rather a blanket banning of mercury which had the effect of eliminating mercury-containing amalgams from dental use. The Ministry had been preparing industries over some years for this measure, and stages of preparation were involved. Director Rolstad said he expected to hear from the membership, but had just a handful of calls from dentists. He had no explanation other than the dental community had been informed this was going to happen, they did not necessarily like it, but they apparently prepared for it and gradually phased out its use to enable an easier conversion. His observation was that Norwegian dentists were coping “quite nicely”. One possibility for such a muted reaction may be that practitioners found themselves switching to doing more resins and crowns.
Then I Asked ...
What are the biggest challenges regarding oral health care in Norway, and what does the future hold for dentistry there?
Elections for the National Assembly happen in the fall of 2009. These will be important for the practice of the Norwegian dental
profession because politicians have begun to discuss dental issues. The country has been governed by the left wing socialist government for the past four years. In the recent history of national elections, the ruling party or coalition has seemingly frequently been replaced by their political opposite every four years ... the voters love them until they’re elected, then vote them out at the next opportunity!
Whereas dental care was not particularly in the public spotlight before, now there is a discussion about the cost of dental care being high. As they gear up the rhetoric prior to the elections, politicians are making campaign promises to reduce the cost of care to patients. Just as in this state and country, the economy and politics of the times has affected the ability of the government to pay for the public health system as it once did. And as persons over age 20 are responsible to pay for their own dental care without the assistance of any kind of dental insurance, citizens have become even more critical of the costs of care. Mr. Rolstad indicated that in a few instances people have been “screaming loudly about the high cost of dentistry” and more reports are heard of individuals traveling to other countries such as Poland or Hungary where expensive procedures (dental implants, crowns and bridges etc.) are less so. In light of this, instituting some form of dental insurance has become a topic of discussion again among politicians. For instance, there may be something similar to the insurance coverage all Norwegians have for general health (a basic benefit of NOK 1,700-1,800 per year with deductible with coverage of general medical visits and non-elective surgery).
The Norwegian Dental Association is looking forward and preparing for something new to happen. They are considering issues such as those relating to fees for service: Will there be governmental regulation? Regarding practice location: Will there be incentives or regulations to get dentists into rural areas? Of course, challenges exist within the profession in keeping the public and private practice dentists unified because they do not always have the same interests. Mr. Rolstad’s comments regarding the 2009 elections were that regulations of dentistry may follow. Although we did not discuss the details of what he thought these might be, he indicated that they might resemble Sweden’s system (i.e., institution of more regulations than Norway currently places upon dentistry, and more fragmentation among the groups of dental practitioners - private practice, public practice, dental educators, students). To learn more about “Norwegian Dental Care in the Future”, access the link to the Ministry of Health and Care Services found at the end of this article.
In summary, although there are some differences regarding the practice of dentistry between Norway and Minnesota, there seem to be many similarities. History, culture, and geography have left their distinctive marks upon both of us. There is a strong resemblance between our two populations, wherein many Minnesotans are indistinguishable from Norwegians in appearance, we have an affinity for nature and the outdoors, and value a strong work ethic. Common interest and pride of place are evident. And we all seem to be able to make the best of anything that comes our way ... including lutefisk!
Final comment: No lutefisk was endangered in the course of producing this article!
For more information on the Norwegian Dental Association and its professional journal:
The Norwegian Dental Association English language site: http://www.tannlegeforeningen.no/cda/zonepg.aspx?zone=110
The journal of the Norwegian Dental Association: http://www.tannlegetidende.no/pls/dntt/pa_dtdm.tidende
Ministry of Health and Care Services home page, “Norwegian Dental Care in the Future”:
* Dr. Lueth is a general dentist in private practice in Bemidji, Minnesota. E-mail is firstname.lastname@example.org