If a patient is not satisfied with the quality of care they receive, they are able to request that the dentist is assessed to determine their capacity and competence in undertaking such treatment. Complaints can be sent either to the Social Security Caisses, or to the departmental Council of the Ordre National.
In a conventional conflict, the dentist’s case is studied by a committee composed of dentists and, representatives of professional organisations, which have contracted to the convention. There is no lay (non-dental) representation on the committee. Sanctions range from financial penalties to temporary suspension or erasure from the register.
Continuing education has been mandatory since 2004. This is managed by a body, composed of the colleges (Ordre, Unions, Universities) which stipulates the required subjects and topics, as well as the content of the proposed training sessions. It also defines the number of required credits – points: 800 every five years with at least 150 per year. Since 2004, training in patient radiation protection has been mandatory. By 19 June 2009, every dentist was required to have undertaken this qualification. The qualification must be renewed every ten years.
Will have no experience of working with a dental hygienist, dental therapist, a clinical dental technician, nor an orthodontic therapist in France;
May have no knowledge of formal training processes for dental nurses or dental technicians.
Country : Germany
Population: 81,751,600 (2011)
Number of registered dentists: 86,428 (2010)
Number of active dentists: 67,808 (2010)
Qualified overseas : 2838 (2008)
Number of dentists registered in the UK in 2007: 474 in 2008: 477 in 2009: 475 in 2010: 466 in 2011: 439
Germany has the highest number of dentists of all EEA countries. Between 1500 and 1600 new dentists graduate each year and the number of dentists is increasing. However, this growth has slowed in the early years of this century. The German Dental Association believes that there are too many dentists and some minor unemployment of dentists in Germany has been reported. (5). Most dentists (98 per cent) have a contract with the statutory health insurance system (the Krankenkassen) and work independently in private dental practices. A limited number of dentists are employed in the Public Dental Service (PDS) (11).
There is a statutory health insurance system in which health care depends on mandatory membership of a state-approved “sick fund”. Employers contribute 52 per cent and employees 48 per cent and together pay a sum equal to about 14 per cent of an individuals´ total pay for health insurance. The majority of the German population (around 88.5 per cent) belongs to a sick fund which provides a legally prescribed standard package of oral health care that is managed jointly by the sick funds and the Associations of Statutory Health Insurance Dentists (KZV). In principle, membership of a statutory sick fund entitles all adults and children to receive oral care within the statutory health insurance system. In 2012, about 10 per cent of the working population, who had an income of more than 4,237 Euros per month were members of a private insurance scheme. However, the premium for private insurance is lower and private insurance schemes offer more flexible packages of care, it covers only one person and not spouses or children (11).
The range of auxiliaries is complex and includes dental chair-side assistants, dental prophylaxis assistants, specialized dental assistants, dental administrative assistants and dental hygienists (11). In Germany, auxiliary personnel can only work under the supervision of a dentist, who is always responsible for the treatment of the patient (5).
Summary of relevant points
1. Regulatory Mechanisms
The delivery of oral health care is organised nationally by the Federal dental authority (KZBV) and locally by the regional dental authorities (KZV). There are 17 KZVs in Germany and they represent all the dentists who can treat patients covered by sick funds.
The standards of dental care are monitored by a federal committee on guidelines for dental care.
The sick funds and the KZBV establish within the legal framework the range of treatments (and the value of them) which are necessary and can be legally provided as a part of the sick fund system.
Routine monitoring is carried out by the KZV and consists of checking invoices and the amount of work provided by each dentist.
The contract with the patient is usually verbal, but for complex treatments or those requiring prior approval from the sick funds, written consent and terms of payment must be recorded. All treatment carried out must be recorded by the dentist and must demonstrate informed consent.
Infection control is regulated by law and has to be followed by the dentist and his/her team.
Training in radiographic protection is mandatory for undergraduate dentists. Radiation equipment must be registered.
Amalgam separators have been obligatory since 1990.
2. Education and Training
To enter dental school a student has to have passed the general qualification for university entrance and obtain a successful result in a Medical Courses Qualifying Test.
All but one of the 31 dental schools are publicly funded and the undergraduate programme lasts five years.
The state examination certificate is part of the degree and is compulsory to obtain registration as a dentist.
In order to register as a dentist and provide care within the sick fund system, a German dentist with a German diploma must complete two years of approved supervised experience in a dental practice.
Training for all specialties lasts four years and takes place in University clinics or recognised training practices, except for dental public health.
The trainee has the status of an employee and gets a salary from his or her employer.
After completion of specialised training the trainee has to pass an examination organized by the dental chamber.
In recent years, postgraduate Masters programmes have been established by the universities, mostly part-time, for example in implantology, functional therapy, periodontics, endodontics, orthodontics, surgery, aesthetics, and lasers in dentistry.
3. Support Systems
The Dental Chambers (associations) are the bodies which represent the interests of dentists working in all of the oral health systems.
The membership is compulsory for dentists.
The German Dental Association is the professional representative organisation for all German dentists, at a federal level.
The number of dental hygienists was 350 in 2007. Their duties include advice and motivation of patients in prevention, therapeutic measures for prophylaxis and scaling of teeth.
A feature of German dentistry is the high number of Dental Technicians (65,000). A dentist may employ a dental technician but most use independent laboratories. They produce prosthodontic appliances according to a written prescription from a dentist.
Dental nurses are able to obtain a qualification after three years work in dental practice, attendance at a vocational school and passing an examination set by the Dental Chamber.
There are three grades of dental chair-side assistant (nurse):
Zahnmedizinische Fachassistentin (ZMF): who have completed 700 hours training. Their duties include support in prevention and therapy, organisation and administration, and training of dental assistants.
Zahnmedizinische Prophylaxeassistentin (ZMP): who have completed a minimum of 400 hours training. Their duties include support in prevention/prophylaxis, motivation of patients and oral health information.
Zahnmedizinische Verwaltungsassistentin (ZMV): who have completed a minimum of 350 hours training. Their duties include support in organisation, filing and training of dental assistants.
5. Dental care Delivery
There is a long-established statutory health insurance system in which health care depends on membership of a “sick fund”.
Sick funds are state-approved health insurance organisations, and there are currently 146 in the country and 85.7 per cent of the population belong to them.
General dental practitioners in private practice provide almost all oral health care in Germany.
The Sick funds entitle all adults and children to receive care from the statutory health insurance system. For radiographic investigation, examinations, diagnoses, fillings, inlays, oral surgery, preventive treatments, periodontology and endodontics, the sick funds pay 100 per cent of the cost of the care. The cost of advanced treatment such as crowns and bridges and implants, are reimbursed via a system of fixed grants up to 50 per cent of the cost and orthodontics for children 80 per cent.
Children and spouses are covered without making any contributory payments. The unemployed make only a small contribution.
Before seeking general care from the state oral health system a patient must have an ehealth-card from a sick fund. This voucher is both a certificate to demonstrate entitlement to care, and to access a doctor or dentist’s practice.
Since January 2004, for each dental visit per quarter, adult patients must pay a 10 Euros “practice fee”, which the dentist has to transfer to the legal sick funds.
Fees are not standardised nationally. Negotiations between the national association for dental care (KZBV) and the major sick funds establish the standard care package for people insured with legal sick funds. Using a points system, relative values are allotted to each type of treatment.
There is a public dental service to oversee and monitor the healthcare of the total population. The care provided is restricted to examination, diagnosis and prevention.
Preventive programmes for groups of children started in 1989 and have become nationwide within the Social Security Code. At the same time, private dentists started their own programme in which they developed a preventive programme for local kindergartens and schools.
Less than 2 per cent of all dentists in private practice treat only patients with private insurance, they have no contract with the statutory sickness funds.
Quality assurance mechanisms
In Germany there is an ethical obligation to participate in continuing education (CE). The costs for participation in CE courses are tax deductible as a practice expense.
Since January 2004, compulsory CE and regular monitoring in the form of recertification has to be completed every five years.
A dentist must undergo regular five- yearly mandatory continuing training in ionising radiation protection.
If a patient complains about treatment, both the Dental Chamber and the KZV have grievance committees.
If they judge that the original care was unsatisfactory then the work must be repeated at no extra charge to the patient. Under both grievance procedures a dentist has a right of appeal to the grievance committee.
For serious complaints about malpractice the dental chambers have boards of arbitration. There are also the civil courts. The sanctions from a civil court may be: an oral or written rebuke or admonition, administrative fine (up to 50,000 Euros), or temporary or permanent withdrawal of the license to practice.
Key Points to Consider When Inducting or Supporting a Dentist Qualified in Germany
Dentists qualified in Germany :
May have limited experience of working in a publicly funded health service;
May have considerable experience of working in a multi practitioner environment;