The healthcare system and the provision of oral healthcare in European Union member states. Part 8: Italy

Shows that although there is a well-developed publicly funded health service in Italy, well over 90% of dentistry is provided under private contract. Suggests the economic crisis has led to a reduction in the number of dental visits and treatments provided. Demonstrates that caries prevalence in children appears to have improved between 1980 and the first decade of the current millennium. Shows that although there is a well-developed publicly funded health service in Italy, well over 90% of dentistry is provided under private contract. Suggests the economic crisis has led to a reduction in the number of dental visits and treatments provided. Demonstrates that caries prevalence in children appears to have improved between 1980 and the first decade of the current millennium. In Italy healthcare is provided for all Italian citizens and residents and it is delivered mainly by public providers, with some private or private-public entities. Italy's public healthcare system – the Servizio Sanitario Nazionale (SSN) – is organised by the Ministry of Health and administered on a devolved regional basis. It is financed by general taxation that provides universal coverage, largely free of charge at the point of service. The central government establishes the basic national health benefits package, which must be uniformly provided throughout the country, through services guaranteed under the NHS provision called LEA – (Livelli Essenziali di Assistenza [Essential Level of Assistance]) and allocates national funds to the regions. The regions, through their regional health departments, are responsible for organising, administering and delivering primary, secondary and tertiary healthcare services as well as preventive and health promotion services. Regions are allowed a large degree of autonomy in how they perform this role and regarding decisions about the local structure of the system. Complementary and supplementary private health insurance is also available. However, as in most other Mediterranean European countries, in Italy oral healthcare is mainly provided under private arrangements. The public healthcare system provides only 5–8% of oral healthcare services and this percentage varies from region to region. Oral healthcare is included in the Legislation on Essential levels of care (LEAs) for specific populations such as children, vulnerable people (medically compromised and those on low income) and individuals who need oral healthcare in some urgent/emergency cases. For other people, oral healthcare is generally not covered. Apart from the national benefits package, regions may also carry out their own initiatives autonomously, but must finance these themselves. The number of dentists working in Italy has grown rapidly in the last few years. In December 2014, there were 59,324 practicing dentists with a ratio of one dentist every 1025 inhabitants, about 90,000 dental chair-side assistants, about 26,000 dental technicians and about 4000 dental hygienists. To enrol in an Italian dental school a student must pass a competitive national entrance examination after obtaining a high school leaving certificate. For entry in the 2015–2016 cycle, there were 792 places for dentistry. In comparison with dental schools in other EU member states, the number of dental students per school is low with an average of 20 students per year, per school and a range of 10 to 60. The aims of this paper are to give a brief description of the organisation of healthcare in Italy, to outline the system for the provision of oral healthcare in Italy and to explain and discuss the latest changes


Introduction
The geographical area of Italy is the sixth largest in Europe and with 60,656,000 residents on January 1 2016, it is the member state with the fourth largest population in the European Union (EU). [1][2][3][4] In addition, on 1 January 2016 there were 5,540,000 non-nationals residing in Italy and they represented 8.3% of the total population. 5 The country is subdivided into 20 regions, five of these having a special autonomous status. 1,[6][7][8][9] In Italy healthcare is provided for all Italian citizens and residents and it is delivered mainly by public providers, with some private or private-public entities. Italy's public healthcare system -the Servizio Sanitario Nazionale (SSN) -is organised by the Ministry of Health and administered on a devolved regional basis. It is financed by general taxation that provides universal coverage, largely free of charge at the point of service. The central government establishes the basic national health benefits package, which must be uniformly provided throughout the country, through services guaranteed under the NHS provision called LEA -(Livelli Essenziali di Assistenza [Essential Level of Assistance]) and allocates national funds to the regions. The regions, through their regional health departments, are responsible for organising, administering and delivering primary, secondary and tertiary healthcare services as well as preventive and health promotion services. Regions are allowed a large degree of autonomy in how they perform this role and regarding decisions about the local structure of the system. Complementary and supplementary private health insurance is also available. However, as in most other Mediterranean European countries, in Italy oral healthcare is mainly provided under private arrangements. The public healthcare system provides only 5-8% of oral healthcare services and this percentage varies from region to region. Oral healthcare is included in the Legislation on Essential levels of care (LEAs) for specific populations such as children, vulnerable people (medically compromised and those on low income) and individuals who need oral healthcare in some urgent/emergency cases. For other people, oral healthcare is generally not covered. Apart from the national benefits package, regions may also carry out their own initiatives autonomously, but must finance these themselves. The number of dentists working in Italy has grown rapidly in the last few years. In December 2014, there were 59,324 practicing dentists with a ratio of one dentist every 1025 inhabitants, about 90,000 dental chair-side assistants, about 26,000 dental technicians and about 4000 dental hygienists. To enrol in an Italian dental school a student must pass a competitive national entrance examination after obtaining a high school leaving certificate. For entry in the 2015-2016 cycle, there were 792 places for dentistry. In comparison with dental schools in other EU member states, the number of dental students per school is low with an average of 20 students per year, per school and a range of 10 to 60. The aims of this paper are to give a brief description of the organisation of healthcare in Italy, to outline the system for the provision of oral healthcare in Italy and to explain and discuss the latest changes Four of these five regions (Sardinia, Sicily, Trentino/Alto Adige and Valle D'Aosta) were designated in the Italian constitution in 1948 and a fifth (Friuli Venezia Giulia in 1963). Apart from the two islands (Sardinia and Sicily) the other regions were historically part of Austria, France and Yugoslavia. Their autonomous status recognises their cultural and historical differences to the rest of Italy. It is highly unlikely that any of the other 15 regions will be given this status. The five autonomous regions are permitted to retain a proportion of the taxes paid, which in other regions go directly to the central government. Regions differ in size and population and marked regional differences in most health indicators, between northern and southern regions, mainly reflect socioeconomic and cultural factors that are unlikely to be changed by the healthcare system. 1,3,5,8,10 Although in the time of the Roman empire Italy was one country, in modern times it has only been unified as one country since 1861. It was a founder member of the EU.

Aims
The aims of this paper are to give a brief description of the organisation of healthcare in Italy, the system for the provision of oral healthcare in Italy and to explain and discuss the latest changes.
To achieve these aims this paper will cover the following aspects: • Organisation and funding of healthcare • Oral healthcare -system and funding • Oral epidemiology • Oral health workforce • Dental education, training and registration.

Organisation of healthcare
Healthcare is delivered mainly by public providers, with some private or privatepublic entities. 3,7,11 Italy's public health-care system -the Servizio Sanitario Nazionale (SSN) -is regionally based and is financed by general taxation that provides universal coverage, largely free of charge at the point of service. 3,12 Complementary and supplementary private health insurance are also available. 3,7 Servizio Sanitario Nazionale (National Healthcare System) Modelled on the British National Health Service, the National Health Service (Servizio Sanitario Nazionale -SSN) replaced a Bismarckian system of health insurance funds in 1978 (Decree 833/1978). 3,7,13 The SSN is founded on the principles of universal coverage, social financing through the use of general taxation and non-discriminatory access to the healthcare services. 14 In Italy healthcare is provided for all Italian citizens and residents. 3,11 EU citizens/residents and citizens of countries with bilateral or multilateral agreements are eligible to have direct access to public healthcare services under the same conditions as Italian citizen or residents. 7,11,[13][14][15][16] Non-EU citizens/residents during a temporary visit can receive health services by paying for the full costs of treatment or by registering with the SSN in the circumstances listed in the national and local regulations. 15,16 Some basic healthcare services such as 'urgent/essential outpatient and hospital care' and 'essential minimum benefits' (preventive medicine programs to safeguard collective and individual health) are granted also to temporarily undocumented people if they pay the full costs of treatment (which in some cases may be reduced or exempted in the case of clear lack of economic resources). 7,[13][14][15][16][17] The SSN is organised into three levels: national, regional and local. 3 The central government establishes the basic national benefits package which must be uniformly provided throughout the country, that is, the type of services guaranteed under the NHS provision called LEA (legislation on essential levels of care), and allocates national funds to the regions through the National Health Plan (NHP). 3,13 The whole process is based on consultation and on the agreement with the regional governments through the so-called 'Conferenza Stato/Regioni' (Standing Conference on the Relations between the State, the Regions and the Autonomous Provinces). 3,7 'Conferenza Stato/ Regioni' should agree the criteria to be used to define the level of funding for the delivery of LEAs annually. 7 Essential levels of care are a political definition which is taken to limit health expenditure and to determine which aspects of healthcare are essential. They form a uniform core benefit package that must be guaranteed free of charge or with cost-sharing, for those who can afford it, throughout the country. Following the State/Regions Agreement of 23 March 2005, the state and the regions have to commit themselves to ensure compliance with the principle of uniform delivery of the LEAs in line with the planned resources provided by the NHS. Defined annually during the Standing Conference on the Relations between the State, the Regions and the Autonomous Provinces, the LEA system is the backbone of the Italian health benefit catalogue ensuring that the population has equal access to high quality care. Positive and negative lists (that is, lists of covered and excluded services) were developed to mandate the coverage of certain services based on criteria related to medical necessity, effectiveness, human dignity, appropriateness, and efficiency in delivery. Positive lists explicitly define the services with regard to pharmaceuticals, inpatient care, ambulatory care, home care, primary care, preventive medicine etc. Negative lists apply to three areas of exclusion: services that are ineffective or not within the province of the SSN, such as cosmetic surgery or certain types of physical therapy; services that are only covered on a case-by-case basis, such as orthodontics and laser eye surgery; and inpatient services classified by diagnosis related groups (DRGs) for which hospital admissions are likely to be inappropriate, such as for cataract surgery or hypertension care. Regions can choose to offer non-LEA services, but must finance these themselves. Regions are allowed to provide services not included on the positive list, but are prohibited from using national resources to do so. This leads to inequality between regions. For example, Lombardy raises more regional tax than Calabria and as a result offers more publicly funded healthcare services. Healthcare services uniformly covered by the Italian healthcare system are delivered through public health services, community health services, primary care and hospital care. The LEA system is subject to continuous revision, and appropriate indicators against which to assess regional compliance with the LEAs are regularly updated.
Th e regions, through their regional health departments and through the Regional Health Plan (RHP), are responsible for organising, administering and delivering primary, secondary and tertiary healthcare services as well as preventive and health promotion services. 3,7,12,13 Regions are allowed a large degree of autonomy in how they perform this role and regarding decisions about the macro structure of the system. 3,7,12 Regional governments underwrite the 'Pact for Health' that links additional resources to the achievement of healthcare planning and expenditure goals. 7,13 The organisational structure of each of the 20 regional services is provided by ' Aziende sanitarie locali' (local health public enterprises) and 'aziende ospedaliere' (hospital public enterprises). 13 LHUs (Aziende Sanitarie Locali) are funded mainly through per capita budgets and deliver primary care, public health and community health services directly, and secondary and specialist care directly or through either public hospitals or accredited private providers (private hospitals must be accredited by the region in which they operate in order to contract with the SSN; public hospitals must also undergo the accreditation process). 3,7,9 The SSN and the regional budgets are funded by national and local taxation, together with a very small amount of self-financing through the application of tickets, co-payments and services provided on a private payment basis. 3,7,9,[18][19][20][21] All people have to pay a co-payment fee up to a maximum of €66 per eight prescriptions if treated in their region of residence before undergoing laboratory and diagnostic services and specialist examinations, except for a wide range of people who are entitled to exemption. 11 These include those with: physical and mental disabilities, low income, some chronic diseases. They receive tickets which enable them to receive free treatment from publically funded medical practices and hospitals but, as described elsewhere in this paper, very limited publicly funded oral healthcare, if they are adults.

Legislation
The main sources of LEAs (Livelli Essenziali di Assistenza) are Legislative Decree n. 502 of 1992 (updated by the legislative decree n. 229 of 1999) and Law No. 405 of 2001. [22][23][24] These laws and updates from central government define the minimum national benefits package to be offered to all residents, the 'essential levels of care' .

Health expenditure in Italy
In 2014, total health expenditure accounted for 8.9% of GDP. In 2014 public financing accounted for 77% of total health spending, while 23% was privately financed, mainly in the form of OOP (out-of-pocket) payments, especially for pharmaceuticals, outpatient care and dental services, voluntary health insurance coverage and nonprofit institutions serving households. 3,6,7,13,25 Both public and private health spending have shown continuous falls since 2011. 3,6,7,26 As a result, per capita spending on health in Italy remains at a level below that prior to the economic crisis. 26 A number of cost-containment measures have been taken in the wake of the economic crisis to reduce public spending on health. 6 In August 2012, the national parliament passed a law aimed at curbing and rationalising public expenditure (the so called 'spending review'). 7 The law further promoted the prescription of generic drugs, cut the hospital bed ratio from four per 1,000 people to 3.7, and reduced the public financing of the SSN by €900 million in 2012, €1.8 billion in 2013, €2 billion in 2014, and €2.1 billion in 2015. 7 Cost cutting measures have included closing some smaller hospitals and, as mentioned above, reducing the number of beds in others. In recent years, higher co-payments for outpatient/ambulatory care, diagnostics and drugs have been introduced, adding to private spending on health. 3 Currently Italy spends less than the OECD average on healthcare in relation to its GDP ( Fig. 1 and Table 1). 3,25,26 Oral healthcare In Italy, the public healthcare system provides only 5% of oral healthcare services. However, this percentage varies from region to region. 7,18,25,27 Oral healthcare is included in the LEAs for specific populations such as children, vulnerable people (medically compromised and those on low income) and individuals who need dental healthcare in some urgent/emergency cases. 7,24,28,29 For other people, dental care is generally not covered. 7,24,28,29 Despite this, in many areas, only emergency dental treatment is provided within the SSN. 31 Thus, dentistry should be considered as being in the private sector as the greatest number of dental treatments are purchased privately, mainly via outof-pocket (OOP) payments, by patients. 3,7,14 The estimated percentage of GNP spent on oral health in Italy has been reported as 0.82% in 2010. 30 In 2015, total dental expenditure was estimated to be about €15 billion, about €250 per capita. 30 Public expenditure on dentistry was estimated in 2003 to be only approximately €500 million. However, public dental expenditure has increased slowly in recent years.

Levels of essential care (LEAs)
The range of services and treatments offered by the SSN is defined by DPCM ('Decreto del Presidente del Consiglio dei Ministri) November 2001 and updates.
They are defined by DM (Ministerial Decree) 1996, by DPCM ('Decreto del Presidente del Consiglio dei Ministri) November 2001 and by DM December, 2015. 22,24,29,31 Regions have exclusive authority in planning and delivery of healthcare and determine the entity and type of public dental services supplied in accordance with the LEA. 3,18,22,29,31 All regions are obliged to deliver all the services listed in the annual LEA for all healthcare, including oral health services.
The services theoretically offered by the different regional health systems vary, although  Care programs for all patients aged 0-14 years including: periodic dental and orthodontic visits; dental extractions; conservative care/endodontic treatment/tooth reimplantation/indirect pulp capping in post dental trauma cases; periodontal surgery; surgical removal of odontogenic lesions; fissure sealing; oral hygiene, and splinting 2. Dental and prosthetic care in special circumstances (social and/or health): 3,31 • Social vulnerability: social and economic disadvantage generally related to the low income or social exclusion which prevents access to private dental treatment. 30 The regions and other self-governing provinces should evaluate the socioeconomic situation, and the criteria to select the socially vulnerable populations, as receivers of specific dental services (ie people aged 65 years and over, who live in households with a gross income below a nationally defined threshold, prisoners, etc). 29 All socially vulnerable subjects are guaranteed: dental examinations; dental extractions; fillings and root canal therapies; oral hygiene/scaling; surgical removal of odontogenic lesions; provision of prosthetic appliances (but not including the laboratory cost of the prosthetic appliances); provision of orthodontic treatments and other dental services to persons with an IOTN index 4 or 5 (but not including the laboratory cost of the appliance). • Those with major health risks: health conditions which make oral care essential or necessary. ˚p atients born with severe physical, sensory and psychiatric conditions. 3. Immediate treatment of dental emergencies (oral infections presenting as dental emergencies with pain and bleeding) for any patient in need 32 4. Pregnant women (but not nursing mothers) 5. Dental examinations, in order to ensure the early diagnosis of neoplastic pathologies of the oral cavity for all citizens/residents/EU visitors. 29 Apart from the services listed in the LEA, regions may also fund additional services, but must finance these themselves. 8,[18][19][20][21]24,29,31 For example, the north-eastern and central regions have already implemented some projects involving either the public or private sector to obtain a higher level of dental health care. 8,[18][19][20] In case of joint public/private care, accredited private providers costs are determined through a set scale of fees for individual dental treatments.

Private insurance for dental care
There are some private healthcare insurance plans that include routine oral care and prosthetic appliances. 3,9 The numbers of patients covered increased steadily from 2000 to 2009 and then declined with the outset of the economic crisis. 3 Since 2013, this market has changed. Previously, private dental insurance was not included in general private medical insurance. However, in the last three years there has been a trend to develop dental plans as a part of overall private medical insurance cover and there are financial limits on the level of payment for items of treatment. A number of employers, such as the Italian telephone network, include private dental insurance in the private medical insurance package provided for their employees. 3,9 Private insurance reimbursement is typically subject to a limit, per operation or per annum and may also be on a percentage basis or to 'benefit limits' for individual items. 28 In the future, such complementary SSN insurance funds could gain greater relevance to secure financial sustainability of the SSN and to promote integration between health and social care. 3

Quality of care
Both public and private practices are inspected or 'authorised' by the District Health Service. This means that they must comply with specific professional and structural standards that may differ from region to region. Over and above the mandatory standards, some regions, for example Lombardy and Emilia-Romagna, have developed and applied further, higher standards of accreditation to allow work on behalf of SSN. 8 In 2014, 'Clinical Recommendations' elaborated by a technical group, coordinated by Ministry of Health, and   consisting of the leading scientific organisations and dentists associations, were issued. 33,34 Such higher standards include lower levels of mercury in suction units in some regions than in others. Generally, these higher standards are set in wealthier northern regions where the costs of purchasing new equipment to meet them can be financed more easily.

Access
Frequency of treatment (that is, the number of dental visits per person per year) is estimated to be low compared to that in north-western European countries, but not in comparison with other Mediterranean countries such as Greece and Spain. 9 Furthermore, the data may be underestimated due to dental treatment performed but not officially declared. The available data suggest that access to dental care has declined throughout the economic crisis years and all indicators of access to dental care and oral health show social inequalities due to socioeconomic, financial and education levels. 4,35 The percentage of population who visited a dentist or orthodontist in the last twelve months decreased from 39.3% in 2005 to 37.9% (percentage of people older than three years) in 2013 (Table 2 and Fig. 2). 4 In contrast, the percentage of people who visited a dentist in a longer period of time, that is, from one to three years, appears to have increased from 24.0% to 29.2%. 4 These percentages are low and may reflect the fact that in times of economic crisis, although the socioeconomically deprived do not have money to pay for oral healthcare, the better off can still afford to pay. Hence the apparent increase between one to three years in the percentage of people who visited a dentist. It may also reflect sampling errors, bearing in mind that the data are derived from population surveys, rather than fee claims to a publicly funded service.
The number of treatments provided has decreased as visits to private dentists have decreased from 34.7% in 2005 to 32.3% in 2013. 4 At the same time, the proportion covered by the SSN remained stable compared to 2005. 4,9 The decrease in dental private treatment occurred for children aged 6-14 years (from 41.8% in 2005 to 38.4% in 2013), those aged 15-24 years (from 37% to 33.5%) and adults aged 25-44 years (from 39.3% to 35.7%). 4 In these same age groups, there was an increase in the use of dental public or accredited sector although it did not offset the decline in private practice ( Table 2). 4 In 2013, 12% of people aged 14 years and over did not receive a dental examination or treatment due to economic reasons. 4 However, all of these data need to be interpreted with care because the majority of oral care is funded privately. As mentioned previously, they arise from surveys and not from dentist fee claims to a state (publically) funded system.
It should be stressed that there is a strong imbalance in access to dental care between north, central and south Italy (Fig. 2). 3,4 By 2013 oral health appeared to have improved compared to 2005. 4 The proportion of people aged 14 years and older that still have all their natural teeth (more than 28) increased from 37.8% to 41.4%, while those with no natural teeth decreased from 12.0 to 10.8% (Fig. 2). 4 However, in 2013, the available data showed a paradox which was that although those from the north of Italy were more likely to have accessed dental care than those in the south (45% v 27.7%), slightly fewer had at least 28 teeth (39.3% v 42.9%) and slightly more were edentulous (11.7% v 10.2%). This may have been because the population samples that were assessed may not have been representative of the total population or because a higher percentage attended a dentist, they were more likely to have had teeth extracted than those in the south where attendance rates were far lower. All indicators of access to dental care and oral health show social inequalities due to education level. 4,35 In addition, the percentage of foreign children (3-14 years) who have never been to the dentist was 46%. 4 There are no programmes in Italy to fluoridate water and little reliable information on sugar consumption. The authors have also been unable to find data on toothpaste sales.

Prevention and oral health promotion
Taking into account the epidemiological situation and the need to promote prevention programs at a national level, pending the introduction of a 'National Plan for Oral Health' , the Ministry of Health has introduced a number of initiatives to encourage good clinical practices at any level. 29,36.37 In particular, in

Fig. 2 Main indicators of access to dental care, oral prevention and dental health by geographical area -Year 2013, standardized rates. 4 Reproduced from 'Il ricorso alle cure odontoiatriche e la salute dei denti in Italia' 2015, ISTAT, published under CC BY 3.0 https:// creativecommons.org/licenses/by/3.0/legalcode
2008, 'evidence based' recommendations for clinical practice were issued, applicable to the daily activities of all health professionals involved in ensuring and restoring good oral health. 30,33 Nine national guidelines on oral health promotion and oral disease prevention were issued: three on clinical prevention (prenatal, childhood and adulthood), one on the clinical management of dental trauma, one on the prevention and treatment of the sleep-apnoea syndrome, one on the prevention of bisphosphonates-related osteonecrosis of the jaws, one on oral health promotion in secondary schools, and two on the clinical management of drug-addicted patients and patients undergoing chemo/radiotherapy. 33 Furthermore, in order to improve the availability of dental services and ensure greater access to dental care, an agreement was reached between the Ministry of Health and private dentists which made it possible to provide some services to help some categories of socioeconomically vulnerable citizens (as well as pregnant women) at much lower fees than those usually charged. 38

Oral epidemiology
Currently, systematic and representative data are lacking. Existing data are derived from studies carried out some years ago, in only some regions and, therefore, are not representative of the entire country.
There are data for edentulism and for the percentage of adults with 28 or more teeth. 4 They show regional variations and an apparent improvement between 2005 and 2013. 4 As far as oral cancer is concerned the most recent reported data show 9,200 new cases/year (2015 estimate) and 4422 deaths/year (2012). 39 In Italy, there is no water fluoridation but there are many springs whose water contains natural fluoride of volcanic origin. 9

Oral health workforce
Dentists Currently, the following may legally practise dentistry: • Graduates in dentistry; • Graduates in medicine and surgery enrolled in a university course before January 28 1980, with or without a specialisation in Dentistry; • Graduates in medicine and surgery enrolled in the university course after 28 January 1980, holding the diploma of specialisation in dentistry or authorised to practise dentistry according to Legislative Decree 386/98.
In 2014, the number of dentists registered by the Federazione Ordini dei Medici Chirurghi e degli Odontoiatri (FNOMCeO) was 59,324. Of these 32,964 were graduates in medicine and surgery, while 26,360 were graduates in dentistry.
There is some reported unemployment amongst dentists in Italy by ANDI (Italian National Dentists Association) and CAO (Italian Board of Dentists) because of a supply-demand imbalance and the uneven geographical distribution. 9,40 Recently, a number of dentists and doctors from other EU member states have come to work in Italy (mainly from Romania and Germany). 3 At the same time, some Italian dentists have recently graduated abroad. 3 According to the Board of Dentists (Albo degli odontoiatri) on 29 March 2016 there were 1123 Italian citizens who had graduated in dentistry abroad (799 male and 324 female), mainly in Spain and Romania who were authorised to work as dentists.
Relatively few Italian dentists appear to be working in other countries. For example, as of 31 December 2015, only 275 Italian dentists were registered with the General Dental Council and were available to work in the United Kingdom. 41 The majority of dentists are self-employed and work in about 41,000 private offices (practices), historically singlehanded. However, the structure of practice is slowly changing and more and more dentists share offices and establish multi-professional clinics or work in private dental centres. Because of the apparent oversupply of dentists and no increase in demand for oral care by the population, there is less work available for young dentists, in general, and for dentists working in poorer, rural areas. As a result, many now work part-time, for a salary, in existing practices instead of being self-employed dentists who are responsible for their practice overheads. Fees are largely unregulated. 28 The public dental service provides the only government funded primary care in line with the LEA. In Italy, there are about 3400 public dentists. 42 Some dentists are employed in hospitals (full or part-time) to treat hospitalised and non-hospitalised patients. 9,42 Each year, approximately 4,000,000 outpatient consultations and treatments are provided with 50,000 hospital admissions for dental care. 42 Within the Italian public dental service there are approximately 370 dental clinics with 2700 dental chairs, 50 surgical operating rooms used exclusively for oral and dental surgery, and 135 surgical operating rooms used not exclusively for oral and dental surgery. 42 Specialised care services within the SSN and dental care services can be directly accessed without a GP's referral. 3 Direct access is also guaranteed for private specialist services. 3 Dental school staff are all salaried and work either full-time or part-time (30 hours per week possibly supplemented by private practice). 9 Approximately 480,000 consultations and treatments are provided each year in dental school out-patient clinics, along with 21,000 day-case hospital admissions and 3,000 longer stay hospital admissions. These hospital clinics are staffed by 370 university employed dentists. 42 The number of staff in each of the 33 publicly funded dental schools is prescribed by the Ministry of Health and Education, as is the proportion in each grade. There are 35 dental schools in Italy two of which are private.
In comparison with dental schools in other EU member states, the number of students per school is low with an average of 20 students per year, per school and a range for the 2016-2017 academic year of ten (Catanzaro and Sassari) to 60 students (Roma Sapienza) per year, per school. 46 Some military hospitals, like 'Policlinico militare Celio' in Rome, have beds and offices for dental care. 9 These services are directly provided by military facilities financed and managed by the Ministry of Defence. 3 However, very few dentists are employed as full-time, while most are civilian dentists who contract to provide dental service to military personnel.
In Italy, orthodontics and oral surgery are the only dental two specialities that are recognised. Oral maxillo-facial (OMFS) surgery is a medical specialty. However, the recognition of other dental specialties is under consideration. Most specialists work in private practice and see patients on referral from private practitioners. The ratio of specialists to other dentists is estimated to be very low (up to 5%). 9

Standards
Other than complaints filed by dental patients, there is no formal monitoring system in either the public or private sectors. In the public service, complaints are first investigated by a clinical officer who, theoretically, has the power to suspend or discharge the dentist concerned. In practice this never happens and cases are instead examined by a regional board of specialists, who in extreme cases may refer them to the Ethical Committee.
In private practice these would be directed to the appropriate ethical committee.

Insurance and professional indemnity
A general national insurance policy does not exist. Instead, there are private insurance companies as well as insurance policies offered by professional associations (at different costs, depending on the specific professional activity the dentist practises). Liability (professional indemnity) insurances have been compulsory for dentists and physicians since August 2014.
Health and safety at work Public health services are immediately available to dental staff members (laboratory tests or preventive treatment) in the case of accidental inoculation or wounds from sharp instruments used on 'potentially high risk' patients. Each employee is furthermore protected by compulsory workers' national insurance (INAIL).

Retirement pensions and healthcare
The professional retirement fund (shared both by dentists and physicians) is called ENPAM (National Social Security and Welfare Institution for Physicians and Dentists [Ente Nazionale di Previdenza ed Assistenza dei Medici e degli Odontoiatri]) and as well as the pension benefits based on individual contributions it provides coverage for ill-health retirement, maternity leave and survivors' pension benefits. In the public sector, dentists can practise until the age of 70 years, while for self-employed dentists retirement age is a free choice (if minimum requirements are reached).

Auxiliaries
The two recognised dental auxiliaries are dental hygienists and dental technicians; 9 Dental chair-side assistants (dental nurses) are not registered, but harmonised training for them is currently under debate. There are approximately 4000 dental hygienists, 26,000 dental technicians and 90,000 dental chair-side assistants.

Dental hygienists
The profession is governed by Law n. 43/2006. Education and training is provided by universities and dental hygienists graduate with a bachelor's degree. To attend the three year course, applicants must pass a competitive admission examination for a restricted number of training places at Italian Universities, which is established every year by the Ministry of Education, University and Research (MIUR). In 2015 there were 655 places at 27 dental hygienist schools (two private). 43 Upon qualification there is no compulsory registration and a dental hygienist may legally practice.
A two year postgraduate specialisation, leading to a master's degree, is available. The master's program is designed for dental hygienists who wish to coordinate or administer private or public practices, or teach.
Standard tasks that hygienists are allowed to undertake in Italy are: oral health education, primary prevention projects, compilation of patient records, technical and statistical data collection, removal of calculus and bacterial plaque, scaling and root planning, polishing restorations, salivary testing for the predictability of caries disease, tooth bleaching, topical application of fluoride varnish, fissure sealants, oral hygiene instruction, dietary advice, counselling patients (nutrition and smoking).
Approximately 2000 dental hygienists are registered with various associations. However, to date there is no professional board or register. Most dental hygienists work in private dental practices, approximately 140 work in the public dental service and 32 in universities. 42,44 Dental technicians Dental technicians are trained in technical schools and to obtain the diploma in dental technology they must have attended a three year course followed by a further two years. 9.45 After the first three years, the student must pass an examination to become 'Operatore meccanico odontotecnico' which will entitle practice exclusively as an employee; after the second two years, they must pass another examination, to obtain a licence to practise as a self-employed dental technician. 9,45 Students passing this examination will also achieve a 'high school' level diploma, which allows them to attend university courses. 9,45 Dental technicians cannot work at the chair-side or treat patients and they are only legally allowed to make dentures from a dentist's prescription. 9 Continuing education is not required.

Dental chair-side assistants (ASO -Assistente di Studio Odontoiatrico)
The training and responsibilities of dental chair-side assistants have not yet been clearly defined, organised or recognised in Italy. There is no register for dental chair-side assistants. They are generally trained by individual dental practitioners, but in some regions they may receive a certificate from an accredited regional school if they have attended for an eight month to two year training course. 9,10,46,47 Harmonisation of their training at a national level is currently under debate. Their duties, as stated by the National Collective Work Contract (CCNL), are assisting the dentist at the chair-side, sterilising instruments, mixing filling materials and undertaking some administrative duties. 9,46,47 Dental education

Undergraduate training
In Italy, dental training starts with the university course in dentistry (Corso di laurea in Odontoiatria e Protesi dentaria), which was introduced in 1980. Prior to 1980, all Italian dentists completed undergraduate medical training during which they attended a course in dentistry prior to undertaking postgraduate dental training.
To enter an Italian dental school a student must pass a national entrance examination after obtaining a high school leaving certificate. In the year 2015-2016, there were 792 places for entrants to dental schools in Italy. In the year 2016/2017 this figure rose to 941 places, of which 850 were for Italians and 91 for foreign (non-Italian students). 43,44 There are also restrictions on advancement to postgraduate levels. Details of entrants to and graduates from Italian dental schools are shown in Table 3.
All dental schools are located in universities as degree courses in dentistry in the Faculty

Registration
In order to register as a dentist an applicant must have a degree or diploma in dentistry as defined by the Annex of EU Directive 2005/36, or must be recognised both by the Ministry of Health (Foreign Affairs) and by a dental school. This means that a new graduate from another EU country, who is not yet practicing, must pass a post-qualification examination to register to practice dentistry; in the case of graduates from non-EU countries, the degree must be validated by Ministry of Health with a proper examination. The Dental Chamber may verify a foreign dentist's knowledge of language and professional rules, according to the Legislative Decree n. 206 dated 9 November 2007, and the decree of the Ministry of Health no. 268 dated 29 July 2010. To qualify for professional practice, the prerequisite is registration as a dentist by the related Provincial Chamber (of "residence"). With this, a dentist may practise anywhere in Italy. The registration process does not include regulatory tests and it is the same for all dentists; the registration list is held by the Federation of the Board of Physicians, Surgeons and Dentists (Federazione Ordini dei Medici Chirurghi e degli Odontoiatri -FNOMCeO) (the competent authority for registration, ethics and regulation of dentistry). The annual registration fee varies since it is decided by each provincial medical/dental board. It is about €140 for a Dental Board and about €250 for those enrolled by both the Board of Dentists and the Board of Physicians and Surgeons.

Further postgraduate and specialist training
Since 2002 life-long learning has been mandatory for dentists. 48 The validation rules are set by the Italian Ministry of Health and stipulate 150 units of CPE within a 3-year period (with a minimum of 30 and a maximum of 70 each year) 9,48,49 As previously stated, Orthodontics and Oral Surgery are the only two specialities recognised in Italy. In each case formal training lasts for three years and takes place in a university but unlike medical specialist trainees, dental specialist trainees are not paid. A new system for dental specialist training has been approved allowing a title in Orthodontics, Paediatric Dentistry, Oral Surgery and General Clinical Dentistry, but the rules have not yet been defined although it seems that, as for the medical specialty schools, the number of training places for dental specialists will be planned every year in accordance with SSN and RHS requirements. Master's Degree, Postgraduate training courses and PhD Programmes are also available.

Discussion
In Italy, as in other Mediterranean European countries, dental care is mainly provided under private arrangements. A paper published by ANDI (one of the two Italian dental associations) has suggested that as a result this led to the development of "a great attention to address patient needs and a considerable patient-dentist fidelity". 50 This relationship has been confirmed by satisfaction surveys about the level of care provided by family dentists in Italy. The results indicated that patients see the service as of high quality and that the relationship between a dentist and a patient is based on the feeling of trust rather than on a managerial model. 50 The justification for ANDI's position is that in a competitive financial climate, there is a strong incentive for private dentists to retain existing patients and to do so they must offer a high level of care to maintain patient satisfaction. Whereas, in a public service, where dentists receive a guaranteed salary and there may be long waiting lists for treatment, irrespective of the high professional standards that public service dentists may have, there is no financial incentive to retain patients.
A negative consequence of the largely privately funded Italian oral healthcare system is that because of cost, access to care for less well-off Italians is limited, in spite of a relatively good dentist to population ratio.
In the last decade the dental profession has evolved and the concept of team dentistry is accepted. While dentist, dental technician and dental hygienist are well defined professions, the training, roles and responsibilities of dental chair-side assistants are less clear and are currently being investigated with a view to harmonisation throughout Italy.
At present, almost certainly due to economic problems there is a the decrease in the number of patients seeking dental care. Paradoxically at the same time there has been an increase in the number of dentists. The latter problem may resolve, in time, because a large number of dentists are more than 56 years old. An increasing number of low-cost clinics, patients seeking dental care (dental tourism) abroad, illegal practice that still exists, a big increase in the operating costs of professional clinics and taxes are critical factors that undermine the traditional Italian private dental scheme, based on large numbers of small-or medium-sized clinics, where the dentist works autonomously, sometimes assisted by associates. It should be noted that there are sparse official data on illegal practice. However, the authors have observed that the Italian local and regional press regularly report cases of illegal dental practice and it appears that the frequency of such reports has not declined over the last ten years.
Dental services provided by the public sector are very limited and are provided in smallmedium-sized clinics. Similarly, the 35 universities which are located throughout Italy and the university dental clinics are useful public sector providers and help to ensure access to dental care in their regions, but to a relatively small extent. Dental insurance schemes are developing but not as fast as they were prior to the economic crisis.
Overall in the last few years there has been an evident decrease in dental visits and provision of oral care, not because of a general improvement in oral health, as the need for care still seems rather high, but due to the economic crisis in Italy. 4,27 As well as increasing social inequalities in both access to dental care and levels of oral health, the resulting lack of care appears to have had repercussions on the level of oral health as well as on the general health of the population. 4,27,51 Because oral health is integral to general health and a basic human right, oral health needs to be integrated into approaches to improve general health and to prevent and control non-communicable diseases. 51 As curative treatments are neither a realistic nor a sustainable approach to address the burden of oral diseases, prevention of oral diseases and promotion of oral health and healthier lifestyles must be at the core of national policies and programmes in Italy and in all other countries. 37,51 In conclusion, allocation of State funding for dental care should be aligned with the long-term benefits to the population as a whole and a more complementary approach between public and private sectors should be adopted. Furthermore, systematic studies must be conducted to obtain representative data on Italian oral health in order to assess treatment need.