“Oral health status and coverage of oral health care: A five-country comparison”

Anthropology compels us to explore how health systems not only reflect but also reproduce social values, structural inequalities, and cultural assumptions. The cross-country analysis of oral health outcomes and public coverage across five European nations, Belgium, Denmark, Germany, the Netherlands, and Spain, reveals a telling case of how oral health continues to be treated as a peripheral concern, even within advanced welfare states that are otherwise committed to Universal Health Coverage (UHC).

From a policy standpoint, the study makes clear that oral health care across Europe is unevenly integrated into national health systems. Some countries, such as Germany and Belgium, offer broader public coverage, while others, like the Netherlands and Spain, rely heavily on out-of-pocket spending or voluntary health insurance. This structural fragmentation reflects deeper ideological divides over whether dental care is a public good or a personal responsibility.

Anthropologically, the exclusion or partial inclusion of oral health care from national benefit baskets reveals more than economic decision-making. It reflects culturally ingrained hierarchies of care. The mouth, though essential for nutrition, communication, and social interaction, has long been separated from the rest of the body in medical systems. This split contributes to the treatment of dental care as optional, cosmetic, or discretionary, a perception that disproportionately harms low-income and vulnerable populations.

The article’s findings underscore the material effects of this divide. While oral health among children appeared relatively equitable, outcomes among adults and the elderly varied significantly, with older populations showing severe declines in functional oral health. The T-Health index, a more holistic measure that values not only treated but also preserved teeth, revealed that disparities are magnified with age. This suggests that access barriers in adulthood accumulate over time, resulting in compounded disadvantage in later life.

Particularly revealing is the data on prosthetic care. The higher prevalence of fixed dentures in countries like Germany and Denmark, where public or subsidized care is more accessible, suggests not only better functional outcomes but also higher quality of life for older adults. In contrast, reliance on removable prosthetics in Spain, where coverage is minimal and regionalized, reflects not just resource limitations but also how oral health is deprioritized in the broader architecture of care.

The use of the “coverage cube” to break down breadth (who is covered), depth (what is covered), and height (how much is covered) is analytically useful, but from an anthropological perspective, it is equally important to consider what these dimensions signify culturally. They reveal who is valued within the health system, whose pain is considered treatable, and which conditions are deemed essential versus elective. The study’s findings suggest that oral health is still not universally recognized as essential, despite growing evidence of its links to systemic diseases and its profound social implications.

What is particularly troubling is the reliance on voluntary health insurance in countries like the Netherlands, where adult dental services are largely privatized. This shifts oral health care further into the realm of market-based access, which anthropologists recognize as a powerful mechanism for reproducing inequality. The ability to buy coverage becomes a proxy for the ability to buy health, and by extension, dignity, functionality, and social inclusion.

Finally, the lack of robust, comparable oral health data across Europe reflects what medical anthropologists would call "epistemic neglect." That is, the failure to systematically track and monitor oral health outcomes is itself a reflection of the low priority assigned to the mouth in both biomedical and policy frameworks. Without meaningful data, it becomes harder to hold systems accountable, to evaluate progress, or to mobilize political will.

In sum, the study offers a compelling view into how structurally embedded disparities in oral health coverage manifest in differential outcomes across populations. From an anthropological lens, this is not simply a technical issue of health policy design. It is a reflection of deeper cultural logics about whose health matters, what counts as care, and how the body is fragmented by bureaucratic and ideological boundaries. Until oral health is fully recognized as both a public responsibility and a human right, these disparities will continue to shape not just mouths, but lives.

https://www.sciencedirect.com/science/article/pii/S0168851023001987