Assessment of oral health and cost of care for a group of refugees in Germany: a cross-sectional study

Oral health is essential for well-being and is a quality-of-life determinant [1]. There is a strong relationship between oral health and general health. For example, severe periodontal disease is associated with type 2 diabetes [2]. Moreover, periodontal disease and dental caries are the two most prevalent oral afflictions worldwide [2]. Effective prevention of these diseases is related to access to oral healthcare, periodic assessment of oral health and individual oral health behavior [2]. Therefore, it may be assumed that refugees are a high-risk group for developing oral disease because of their limited access to dental care. Various factors, such as limited access to oral healthcare, oral care products and to nutritious food and clean water could lead to poor oral health status, including the development of periodontal disease or dental caries. Moreover, factors such as access to and organization of healthcare in the country of origin could contribute to the poor oral health of refugees, which is shown in the oral health database provided by the World Health Organization (WHO) [3].

By the end of 2016, there were approximately 22.5 million refugees and 2.8 million asylum seekers worldwide [4, 5]. Over 55% of these refugees originate from South Sudan, Afghanistan, and Syria countries with human rights violations [4, 5]. In Europe, there were approximately 5.2 million refugees, and 669,500 refugees had entered Germany by the end of 2016 [5]. In Germany, the asylum policy has no limit regarding the entry of refugees. The entitlements to medical care by refugees in Germany are detailed in the Asylum-Seekers’ Benefits Act (AsylbLG), and §4, 6 AsylBLG specifically regulates the access to health care, which is limited [6, 7]. These laws detail what types of health problems allow for access to healthcare. According to §4 AsylBLG, these constitute acute diseases and pain that requires medical or dental treatment [6].

Different systematic reviews show a research gap concerning the evaluation of the oral healthcare of refugees [8, 9]. Therefore, the aim of this study was to evaluate the oral health of refugees in one region in Germany and to estimate the costs of oral care on the basis of regular and restricted access.

The currents study was conceptualized as a pilot study with a cross-sectional design.

One hundred and two refugees and asylum seekers participated in the pilot study and attended a dental screening. The total number of refugees residing in the participating collective living quarters and reception center is unknown. Therefore, no response rate can be calculated. Table 2 presents the sociodemographic characteristics of the participants. More than 80% of the responding refugees were male. The mean age was 28.6 years (SD = 10.3). Participants were from nine different countries; over 24% migrated from Afghanistan, 18% migrated from Iraq, and 14% migrated from Syria.

Our results present an initial overview of oral health status and the potential costs of oral healthcare of refugees in one region in the federal state of Schleswig-Holstein, Germany. The study was conceptualized as a pilot study to obtain preliminary data on the oral health status and costs of oral healthcare of refugees. The sociodemographic data obtained in the study concerning the origin of the refugees were comparable to the official statistics of Schleswig-Holstein, which show that Afghanistan, Iraq and Syria are the primary countries from which people immigrate [14]. Moreover, our results concerning the distribution of gender show a high proportion of male refugees, which coincides with another study on the oral healthcare of refugees [15]. There are multiple reasons for the gender imbalance. The official statistics from the Federal Agency of Migration and Refugees show that more men than women are refugees [16]. It can also be assumed that social values and standards, such as traditional gender roles and culture in the country of origin could influence the utilization of healthcare [17]. However, more information is needed to explain why men are more likely than women to utilize oral healthcare services, and this question should be investigated in further studies.

The evaluation of oral health revealed a low level of preventive behavior during childhood. Over 84% of the participants did not visit a dentist during their childhood. The professional recommendation is to visit a dentist at least once per year [18]. When accounting for the global health workforce statistics, the low number of dentists in countries such as Afghanistan, Iraq and Syria is likely to be an important barrier to oral healthcare access and therefore to adequate prevention [19]. However, it is well known that preventive dental visits in childhood influence one’s oral health in adulthood [20]. Our study sample presented a DMF-T index of 6.9, which is lower than that of the general population in Germany (11.2 for young adults) [21]. However, a comparison of the individual DMF-T components between the refugees and the general population showed similar results, with a lower proportion of DT and a higher proportion of MT and FT for the refugee population [21]. Similar results were also obtained in a different study on the oral healthcare of refugees in Germany [15]. Furthermore, our findings are comparable to a study from Australia that revealed that the oral health status of refugees is poorer than that of the general population [22]. Oral health status depends not only on access to care but also on the social status of an individual [21]. One possible explanation for the data could be that our study participants have a relatively high to moderate social status. Additional research would be helpful to clarify how the social status of refugees affects their oral health.

A dental care report by one statutory health insurance organization indicated that 8.9% of the insured adult population has had an extraction [23]. This is in contrast to our sample, where an extraction was recommended for 75.5% of the refugees. However, if the refugees were not experiencing pain, then no treatment was offered, according to the definition of restricted access in §4 AsylBLG [6]. This restricted access for refugees could have an impact on healthcare costs. The reimbursed costs for health insurance will be lower due to the restricted access, as not all refugees need treatment, and therefore, they will not incur any cost. However, the direct and indirect costs cannot be estimated. In our sample, 50 refugees stated that they currently suffered from toothache. In these cases, §4 AsylBLG would grant them treatment, and it would be more expensive than if there was no access limitation regarding toothache. Postponing treatment until there is pain is not preventive action. Therefore, it can be assumed that restricted access may lead to discrimination of refugee’s healthcare, and it may also lead to higher costs [24]. Moreover, it is possible that persons who have poor oral health, such as missing teeth, might have problems obtaining employment, which is an important part of the integration process for refugees in a foreign society [25].

There is a lack of population-based data that survey the oral health status of refugees. It should be considered whether an oral health screening could be part of an initial medical examination. Standardized tools for oral health assessments are available from the WHO that could be used by advanced-stage dental students. These assessments would aid in the prevention of oral disease.