healthcare
Article
Exploring Dental Health and Its Economic Determinants in
Romanian Regions
Andor Toni Cigu 1 and Elena Cigu 2, *
Citation: Cigu, A.T.; Cigu, E.
Exploring Dental Health and Its
Economic Determinants in Romanian
Regions. Healthcare 2022, 10, 2030.
https://doi.org/10.3390/
healthcare10102030
Academic Editors: Ce Shang, Amanda
J. Quisenberry and Yingning Wang
Received: 5 September 2022
Accepted: 12 October 2022
Published: 14 October 2022
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Attribution (CC BY) license (https://
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4.0/).
Healthcare 2022, 10, 2030. https://doi.org/10.3390/healthcare10102030
1 Faculty of Dental Medicine, Apollonia University of Ias, i, 700511 Ias, i, Romania
2 Faculty of Economics and Business Administration, Alexandru Ioan Cuza University of Ias, i,
700505 Ias, i, Romania
* Correspondence: elena.chelaru@uaic.ro; Tel.: +40-745666028
Abstract: Sustainable dental health is reflected in the high quality of the medical act and the high
quality of the medical service, which cannot be achieved without considering the existing social
context, especially the economic development of a state, where certain economic variables can become
real levers of influence. The goal of this paper is twofold—theoretical and empirical. Firstly, at the
theoretical level, we provide the context and the development of the health legal framework and the
state of the Oral Health System and the provision of dental medical services in the eight Romanian
Regions of Development. The second aim is to evaluate the relationship between dental health and
well-being for the case of regions of Romania over the period 2001–2015. To review the dental health
care in Romania, we will use descriptive analysis as the methodology, and to explore the relationship
between dental health and economic determinants, we will use an econometric model, the OLS
model. Our working hypothesis is that dental health care is influenced by the economic variables in a
country. The results show a positive and significant relationship between dental health care and the
most important indicator of well-being, the level of income. Of course, an important role is played by
the complexity of education, expressed by research and development, which determines a significant
positive relationship with dental health in the development regions of Romania.
Keywords: dental medical services; Oral Health System; socio-economic development
1. Introduction
Medical services show permanent changes because of multi-factor interventions,
among which we highlight technological evolution, health policies, demographic changes,
etc. In the case of Romania, the health policies and, hence, the quality and quantity of
medical services recorded major changes during the period 1990–2022. One of the medical
services with a sharp evolution is dental medicine, because there is a greater recognition that
oral health has important spillover effects on physical health more generally. Additionally,
there are both economic and medical developments of good oral health. Dental health
can be appreciated fundamental in managing the whole health system because it allows
for the proper nutrition of the body through proper chewing, and it is an important
psychological contributor—having healthy teeth gives a pleasant appearance and develops
proper self-confidence.
From the perspective of literature, oral health is a determining factor in the sustain-
ability of human capital. Michaela Grossman [1] declared that health is a durable capital
good which is inherited and depreciates over time. From the perspective of economic
appreciation, the author [1] considers that investment in health takes the form of medical
care purchases and other inputs, and depreciation is interpreted as the natural deterioration
of health over time. Therefore, from an economic and social perspective, state authorities
are challenged to develop sustainable health policies based on public health spending, a
health insurance system with permanent access to health services and medical education,
https://www.mdpi.com/journal/healthcare
Healthcare 2022, 10, 2030 2 of 13

all of which contribute to sustaining individual health as human capital and the main
resource of sustainable development. Of course, the field of health includes oral health and,
especially, dental health care. Grossman [1] developed an economic model of individual
health behavior or demand for health and found that individual behavior is determined
by the balancing of the benefits and opportunity costs of health change. The Grossman
model of health demand [1] provides a way of understanding individual behavior and
emphasizes the need to design healthy public policies in ways that respond to the varying
contexts and circumstances of individuals. Glied and Neidell [2] found that the impact of
the oral health status on earnings differs between women and men.
Dental health policy is one of the branches of health policy, and, therefore, the in-
teraction with the economic dimension is inevitable. Lalloo, Myburgh and Hobdell [3]
found that there is a relationship between the level of socio-economic development and
dental caries, where dental caries can be considered a good proxy measure for socio-
economic development.
Few studies have tested for the existence of supplier-induced demand in dental mar-
kets or a positive correlation between the number of dentists in an area and the utilization
of dental care [4–6]), on the assumption that more dentists generate more demand [7].
Trohel et al. [8] consider that oral health inequalities based on socio-economic character-
istics can be identified in many countries. The determinants include educational level,
occupational background, income [9–14] and place of residence [15,16]. In the opinion
of Costa et al. [17], the most frequent socioeconomic indicators associated with caries are
schooling, income and socioeconomic status. Steel et al. [18], based on multiple linear or
logistic regressions, concluded that income sometimes has an independent relationship
with inequalities, but education and area of residence are also contributory. The authors [18]
consider that appropriate choices of measures in relation to age are fundamental for under-
standing and addressing inequalities.
Our paper aims to present empirical evidence on the relationship between dental
health and the well-being of the individual for the eight Romanian Regions of Development
without legal personality, as established by law over the period 2001–2015, using a linear
regression model. In the first part of the paper, we review the literature and we present
the status of the dental health care system in Romania based on a legal framework and
the provision of dental medical services. The second part of the paper will be focused on
empirical evidence based on the econometric model.
Our hypothesis is that dental health care is influenced by the economic status of
the country. Thus, the more developed the state, the better founded and implemented
health policies are, and the more willing citizens are to pay attention to their overall health,
including dental health. In this context, the more developed the state, the more citizens will
be willing to give up part of their income for the maintenance of dental health by paying
for their dental health care.
The novelty of the paper is given by the fact that we study the relationship between
dental health and a series of economic indicators in the eight regions of Romania, and, to
our knowledge, so far, the methodology used and this relationship have not been studied.
The paper is structured as follows: Section 2 provides a review of dental health in
Romania; Section 3 describes the method, variables and data sources; Section 4 summarizes
the results of the empirical study conducted in Romanian regions; Section 5 discusses the
results and how they can be interpreted from the perspective of previous studies and the
working hypotheses. The paper ends with conclusions and references.

2. Review on Dental Health Care in Romania

The legal perspective of the dental medical system and oral health in Romania is a
complex one, which presupposed an evolution in time and which represents a process in
continuous development. What is certain is that the very fundamental law of Romania [19]
establishes, in Article 34, the right to health care, which is guaranteed for every citizen;
furthermore, the state is obliged to take measures to ensure hygiene and public health.
 [19] establishes, in Article 34, the right to health care, which is guaranteed for every citizen;
furthermore, the state is obliged to take measures to ensure hygiene and public health.
In 1990, the Romanian government embarked on a fundamental, albeit slow-paced,
Healthcare 2022, 10, 2030 3 of 13
health care reform, shifting the health system towards a more decentralized and plural-
istic social health insurance system, with 18 health systems and Romanian contractual re-
lationships between health insurance houses as purchasers and health care providers.
In 1990, the Romanian government embarked on a fundamental, albeit slow-paced,
The main legislative acts were introduced between 1995 and 2002. In 2006, these were
health care reform, shifting the health system towards a more decentralized and plural-
replaced
istic socialby the Law
health 95/2006
insurance on Health
system, with Care Reform
18 health [20], and
systems which is still incontractual
Romanian place today. This
harmonized the national legislation with the acquis communitaire.
relationships between health insurance houses as purchasers and health care providers. In this context, Law
95/2006
The main[20] islegislative
considered actsthe
were key legal act between
introduced governing 1995Romanian
and 2002. health,
In 2006, which consists of
these were
19 titles by
replaced thatthecover almost all
Law 95/2006 on aspects
Health Careof the health[20],
Reform sector,
which including
is still in (i) its today.
place financing,
This organ-
ization and the
harmonized governance; (ii) the provision
national legislation with theof services
acquis encompassing
communitaire. public
In this health,
context, Law primary
95/2006 [20] is considered
care, emergency the key legal
care, specialized act governing
outpatient Romanian
care, hospital carehealth,
and which consists care;
pharmaceutical
of 19the
(iii) titles that cover almost
consideration all aspects
of health of the health practice;
care professionals’ sector, including
(iv) the (i) its financing,
coordination and har-
organization
monization of the Romanian social health insurance system with the social health,
and governance; (ii) the provision of services encompassing public health insur-
primary care, emergency care, specialized outpatient care, hospital care and pharmaceutical
ance systems of other EU Member States. The Law 95/2006 [20] has been subject to over
care; (iii) the consideration of health care professionals’ practice; (iv) the coordination
1300 amendments since it came into force in 2006.
and harmonization of the Romanian social health insurance system with the social health
insuranceIn 2012,systemsa new of health
other EU law was proposed,
Member States. Thefollowing
Law 95/2006 numerous[20] has studies that had
been subject to shown
poor1300
over performance
amendments of since
the health
it camesystem,
into forcealong with mounting pressure from the general
in 2006.
public and health professionals.
In 2012, a new health law was proposed, following The proposal envisaged
numerousreplacing
studies that the hadsystem
shownof con-
trolled
poor resource allocation
performance of the health with regulated
system, alongcompetition
with mounting at both
pressurethe health
from the insurer
generaland ser-
public and health
vice provider professionals.
levels (after the Dutch The proposal
model), envisaged
introducing replacing
the ‘money the system
followsofthe con-insured’
trolled resource allocation with regulated competition at both the
principle and modifying the structure and functioning of service providers to enable ser- health insurer and service
provider levels (after
vice integration andthe Dutch model),
improved introducing
continuity the ‘money
and quality whilefollows the insured’
also ensuring costprin-
efficiency.
ciple and modifying the structure and functioning of service
The proposal was rejected amidst protests and calls for the resignation of the president.providers to enable service
integration and improved continuity and quality while also ensuring cost efficiency. The
The most recent reforms focused mainly on introducing cost-saving measures.
proposal was rejected amidst protests and calls for the resignation of the president. The
The main institutions at the Romanian national level are the Ministry of Health, the
most recent reforms focused mainly on introducing cost-saving measures.
National
The main Health Insurance
institutions House
at the and the
Romanian professional
national level areorganizations.
the Ministry of The Parliament
Health, the has
a key position
National Healthin the policy
Insurance process,
House representing
and the professionalthe legislative power
organizations. and controlling
The Parliament has the
aactivities
key position of the government.
in the policy process, The representing
Ministry of the Public Finances
legislative oversees
power the financial re-
and controlling
sources
the activitiesraised of theforgovernment.
and spent on Thehealth careofand
Ministry plays
Public a key oversees
Finances role in decisions
the financial on health
resources
sector reforms raised when for andthey spent on health
involve care and
changes plays afinances.
in public key role in The decisions
Court of onAccounts
health con-
sector
trols thereforms
formation,when administration
they involve changes in public of
and utilization finances. The Court
state financial of Accounts
resources in the public
controls the formation, administration and utilization of state
sector. The Ministry of Transport, Ministry of National Defense, Ministry of Internal financial resources in the Af-
public sector. The Ministry of Transport, Ministry of National Defense, Ministry of In-
fairs, Ministry of Justice and Romanian Intelligence Agency also play a role in the health
ternal Affairs, Ministry of Justice and Romanian Intelligence Agency also play a role in
system by operating their own parallel health systems, as well as through intersectoral
the health system by operating their own parallel health systems, as well as through
cooperation.cooperation.
intersectoral
InInorder
order to to understand
understand Romania’s
Romania’s status,
status, we will wecarry
willoutcarry out Romania’s
Romania’s Human Devel- Human De-
opment Index (HDI) [21] (Figure 1), which places the human individual at the center ofthe
velopment Index (HDI) [21] (Figure 1), which places the human individual at all center
of all developmental
developmental flows, being flows, being a composite
a composite indexthe
index measuring measuring the averageinachievement
average achievement three
in three
basic basic dimensions
dimensions of human development—a
of human development—a long and healthylong and healthy
life, knowledge andlife, knowledge
a decent
standard of living. An HDI value closer to 1 indicates very
and a decent standard of living. An HDI value closer to 1 indicates very high human high human development, and de-
an HDI value closer to 0 reflects low human development.
velopment, and an HDI value closer to 0 reflects low human development.

0.85
0.828
0.805 0.806 0.811
0.8 0.797 0.802 0.802

0.75

0.708
0.7 0.701

0.65

0.6
1990 2000 2010 2012 2014 2015 2016 2017 2019

Figure1.1.Human
Figure Human Development
Development Index
Index (HDI).
(HDI). Source:
Source: computed
computed by authors
by authors using
using HDI HDI [21].
[21].
Healthcare 2022, 10, 2030 4 of 14
Healthcare 2022, 10, 2030 4 of 13

According to the HDI, Romania ranks 49th out of 66 countries at the Very High Hu-
manAccording
Development to the level,
HDI, Romania ranks 49th of
with a minimum out0.701
of 66in
countries
1990 and at the Very High
maximum ofHuman
0.828 in 2019.
Development level, with a minimum of 0.701 in 1990 and maximum of
Every year, Romania’s position in the ranking increases, positioning itself better 0.828 in 2019. Everyand bet-
year, Romania’s position in the ranking increases, positioning itself better and better, but
ter, but this positioning is dependent on the human development paradigm which em-
this positioning is dependent on the human development paradigm which emphasizes two
phasizes two simultaneous processes—firstly, the building of human abilities and how
simultaneous processes—firstly, the building of human abilities and how people use them
people
to functionuseinthem
societytoand,
function in society
secondly, making and,
choices secondly,
between making choices
options that between
they have in alloptions
that they
aspects havelives
of their in all aspects of their lives [22].
[22].
One of the relevant indicators
One of the relevant indicators thatthat justifies
justifies the status
the status of health
of health care incare in Romania
Romania is the is the
currenthealth
current health expenditure
expenditure (%GDP)
(% of of GDP) in Romania
in Romania (Figure(Figure 2). The Romanian
2). The Romanian health sys-
health system
istem is financed
financed from
from four foursources,
main main sources, namely,health
namely, national national healthfunds
insurance insurance
as thefunds
most as the
important
most importantsource of revenue
source for health
of revenue for(almost
health67%),
(almostthe 67%),
state budget, local
the state budgets
budget, andbudgets
local
OOP (out-of-pocket) payments as the second source of revenue
and OOP (out-of-pocket) payments as the second source of revenue for health. for health.

6.

5. 5.0
4.7
4.2 4.2 4.2 4.3
4. 4.1 4.1 4.0 4.1 4.0 4.0 4.0
3.8 3.9
3.5 3.6 3.6
3.2 3.3 3.3
3.
2.4 2.3 2.4
2. 1.9

1.

0.

Figure2.2.Current
Figure Current health
health expenditure
expenditure (%GDP)
(% of of GDP) in Romania.
in Romania. Source:
Source: computed
computed by authors
by authors using using
theEurostat
the Eurostat database
database [23].
[23].

Romania
Romaniahas a lower
has a lower share of its
share of national
its nationalwealth devoted
wealth to health
devoted care than
to health careother
than other
countries.
countries. The share of health in GDP fluctuated between 1995 and 2019, wherethe
The share of health in GDP fluctuated between 1995 and 2019, where the mini-
minimum level was 1.9% of GDP in 1997 and the maximum was 5.0% of GDP in 2019. The
mum level was 1.9% of GDP in 1997 and the maximum was 5.0% of GDP in 2019. The
European average is around 9%. Of course, with the onset of the SAR-CoV-2 pandemic,
European average is around 9%. Of course, with the onset of the SAR-CoV-2 pandemic,
all states have been challenged to allocate additional funds to the health care system for
all states
proper have beenand
management challenged to allocate but
to avoid bottlenecks, additional
for now,funds to the
these data arehealth care system
not available at for
proper
the management and to avoid bottlenecks, but for now, these data are not available at
moment.
the moment.
With regard to dentistry, the functioning of the dental offices is performed based on
Withofregard
the Norm to dentistry,
31/07/2007 regarding thethefunctioning
structure and of operation
the dentalofoffices is performed
the medical and dental based on
offices,
the Normpublished in the Official
of 31/07/2007 Gazette,the
regarding Part I no. 575 and
structure of 22/08/2007
operation[24]. Additionally,
of the medical and the dental
National General Assembly
offices, published of the College
in the Official Gazette,of Dentists adopted
Part I no. 575 ofthe Code of Ethics
22/08/2007 [24]. [25] for
Additionally,
Dentists, published in the Official Gazette in August 2005. The Code of Ethics
the National General Assembly of the College of Dentists adopted the Code of Ethics [25] [25] contains
the rules of moral and professional conduct regarding the exercise of the dentist’s rights and
for Dentists, published in the Official Gazette in August 2005. The Code of Ethics [25]
duties. Among the functions of the deontological code, the following are more important:
contains the rules of moral and professional conduct regarding the exercise of the dentist’s
the promotion of a trusting relationship between doctors and patients, the guarantee of the
rights and
quality duties. Among
of professional thethe
training, functions
promotion of the deontological code, the following
of professional-deontological behavior as are more
important:
well the promotion
as the guarantee of a trusting
of professional secrecy. relationship between doctors and patients, the
guarantee
The profession of dental technicians istraining,
of the quality of professional based onthe Law promotion
no. 96/2007 of professional-deonto-
regarding the
logical behavior
exercise as wellofasdental
of the profession the guarantee
technicians, of republished
professionalonsecrecy.
24/04/2009 [26].
The
All profession
dentists of dental
who wish technicians
to practice in Romania is based
shouldon Law no.
become 96/2007
members regarding
of the Romanian the exer-
College of Dentists or have a temporary or occasional practice
cise of the profession of dental technicians, republished on 24/04/2009 [26]. notice, having the rights
and obligations
All dentists established
who wishbytolaw [20]. The
practice Romanian
in Romania College
should of Dentists
become operates
members on Roma-
of the
the basis of Title XIII of Law no. 95/2006 on health care reform [20],
nian College of Dentists or have a temporary or occasional practice notice, having the republished with
subsequent amendments and completions, as well as the Organization and Functioning
rights and obligations established by law [20]. The Romanian College of Dentists operates
Regulation adopted by the Decision of the National General Assembly no. 5/2007 [27],
on the basis of Title XIII of Law no. 95/2006 on health care reform [20], republished with
with subsequent amendments and completions. The Romanian College of Dentists is a
subsequent amendments and completions, as well as the Organization and Functioning
Regulation adopted by the Decision of the National General Assembly no. 5/2007 [27],
with subsequent amendments and completions. The Romanian College of Dentists is a
professional, apolitical, non-profit body under public law with responsibilities delegated
 Healthcare 2022, 10, 2030 5 of 13

professional, apolitical, non-profit body under public law with responsibilities delegated
by the state authority in the field of the authorization, control and supervision of the
dentist profession as a liberal profession and authorized public practice with institutional
autonomy in its field of competence, as well as normative and professional jurisdiction [28].
Healthcare 2022, 10, 2030 The Romanian College of Dentists involves, as its main attributes [28]: (i) the control 5 of 14
and supervision of the exercise of the profession of dentists; (ii) the application of the laws
and regulations that organize and regulate the exercise of the profession; and (iii) represent-
ing the interests of the dental profession and maintaining the prestige of this profession in
by the state authority in the field of the authorization, control and supervision of the den-
social life.
tist profession as a liberal profession and authorized public practice with institutional au-
In the Romanian territory, almost 26,723 dentists are registered at the RCD (The
tonomy in its field of competence, as well as normative and professional jurisdiction [28].
Romanian College of Dentists) in 2022 (see Figure 3). A total of 6245 are in Bucharest, which
is 23.37%Romanian
The of the totalCollege
numberofofDentists
dentists involves, as its(almost
in the country main attributes
a quarter).[28]:
Ias, i (i) the control
county has
and
2114supervision
dentists, andofCluj,
the exercise of the profession
Timis, , Constant , a and Bihorof dentists;
counties (ii)
have the
overapplication
1000 dentists, of the
which laws
and regulations that organize and regulate the exercise of the profession;
is 30% of dentists. The remaining 47% of dentists are in the other 36 counties. Practically, and (iii) repre-
senting the interests
more than ofdentists
half of the the dental profession
(53%) practice and maintaining
the profession in the
onlyprestige of thisinprofes-
five counties the
sion in social
country and life.
the Municipality of Bucharest [29].

(a) Top 10 counties with the highest number (b) Top 10 counties with the lowest number
Arad 706 Caras-Severin 181
Mures 734 Olt 176
Brasov 818 Salaj 170
Dolj 990 Teleorman 136
Bihor 1144 Covasna 135
Constanta 1195 Mehedinti 131
Cluj 1772 Tulcea 125
Timis 1838 Giurgiu 96
Iasi 2114 Ialomita 93
Bucuresti 6245 Calarasi 93

0 1000 2000 3000 4000 5000 6000 7000 0 50 100 150 200

Figure
Figure3.3.Number
Numberofofdentists
dentists registered by The
registered by TheRomanian
RomanianCollege
Collegeofof Dentists.
Dentists. Source:
Source: computed
computed by by
the authors based on the RCD database [28].
the authors based on the RCD database [28].

InThe
thecomparative
Romanian territory,
approach almost 26,723
of the total dentists
number are registered
of doctors at the RCD
and the number (The Ro-
of dentists
manian CollegeofofRomania
in the regions Dentists)ininthe2022 (see Figure
period 3). Aastotal
2001–2015, wellofas6245 are intoBucharest,
the ratio one-hundred-which
isthousand
23.37% ofinhabitants, reflects aofrelatively
the total number dentists similar distribution
in the country for the
(almost Bucharest-Ilfov
a quarter). region,has
Iași county
which
2114 has the and
dentists, highest number
Cluj, Timiș,of Constanța
doctors in both
and categories (see Figure
Bihor counties have4).over
Bucharest is the
1000 dentists,
capital of Romania and, at the same time, is an important university center with
which is 30% of dentists. The remaining 47% of dentists are in the other 36 counties. Prac- medical
education.
tically, more Bucharest
than half ofalso
thehas the largest
dentists (53%)population
practice thecompared
professionto in
other
onlyurban areas of in
five counties
the country. The West Region is better in
the country and the Municipality of Bucharest [29]. terms of both categories of doctors relative to
one-hundred-thousand inhabitants, and the North-West Region is better in terms of the
global number of doctors. The North-East region is in third place in the global number
(a) Medical doctors (b) Dentists
of doctors in both categories, but relative to the population (per one-hundred-thousand
inhabitants), it is in sixth place among doctors and in fourth place among dentists. The
South-Muntenia region ranks last in almost all categories.
From the perspective of the way the dentists carry out their activities, dental care is
provided by the Individual Medicine Offices (IMO) in general, as can be seen in Figure 5.
Overall, dental care represents a fascinating mix of the public and private spheres [30].

(c) Medical doctors/one-hundred-thousand inhabitants (d) Dentists/one-hundred-thousand inhabitants

 In the Romanian territory, almost 26,723 dentists are registered at the RCD (The Ro-
manian College of Dentists) in 2022 (see Figure 3). A total of 6245 are in Bucharest, which
is 23.37% of the total number of dentists in the country (almost a quarter). Iași county has
2114 dentists, and Cluj, Timiș, Constanța and Bihor counties have over 1000 dentists,
which is 30% of dentists. The remaining 47% of dentists are in the other 36 counties. Prac-
Healthcare 2022, 10, 2030 6 of in
tically, more than half of the dentists (53%) practice the profession in only five counties 13
the country and the Municipality of Bucharest [29].

(a) Medical doctors (b) Dentists

Healthcare 2022, 10, 2030 6 of 14

The comparative approach of the total number of doctors and the number of dentists
in the regions of Romania in the period 2001–2015, as well as the ratio to one-hundred-
(c) Medical doctors/one-hundred-thousand
thousand inhabitants,inhabitants (d) Dentists/one-hundred-thousand
reflects a relatively similar distribution for theinhabitants
Bucharest-Ilfov re-
gion, which has the highest number of doctors in both categories (see Figure 4). Bucharest
is the capital of Romania and, at the same time, is an important university center with
medical education. Bucharest also has the largest population compared to other urban
areas of the country. The West Region is better in terms of both categories of doctors rela-
tive to one-hundred-thousand inhabitants, and the North-West Region is better in terms
of the global number of doctors. The North-East region is in third place in the global num-
ber of doctors in both categories, but relative to the population (per one-hundred-thou-
sand inhabitants), it is in sixth place among doctors and in fourth place among dentists.
The South-Muntenia region ranks last in almost all categories.
FigureFrom the perspective
4. Number of doctors inofRomanian
the way Regions.
the dentists carry
Source: out their
computed byactivities,
the authorsdental
based care is
on the
Figure 4. Number of doctors in Romanian Regions. Source: computed by the authors based on the
provided by the Individual Medicine
Eurostat database [23] using Stata 15.1. Offices (IMO) in general, as can be seen in Figure 5.
Eurostat database [23] using Stata 15.1.
Overall, dental care represents a fascinating mix of the public and private spheres [30].

85.90

14.10

Private Public

Figure 5.
Figure 5. Dental
DentalCare
CareFacilities in Romania
Facilities (%).(%).
in Romania Source: computed
Source: by the authors
computed using theusing
by the authors database
the
[28,29].
database [28,29].

The trend
The trend ofof European
European countries
countries is is that
that dental
dental care
care is
is predominantly
predominantly performed
performed by by
private medical practices,
private practices, and
and this
thistrend
trendisisalsoalsofound
foundininRomania.
Romania. Most
Mostpractices areare
practices or-
ganized in in
organized thethe
form of internal
form medicine
of internal medicinepractices or in or
practices theinform
the of medical
form clinics. clinics.
of medical Dental
care incare
Dental Romania is provided
in Romania through
is provided a network
through of 15,100
a network ambulatory
of 15,100 ambulatory facilities, most
facilities, mostof
of them
them private
private (12,127;86%),
(12,127; 86%),which
whichare areorganized
organizedas as private
private dental
dental practices (11,931) or or
medical
medical dentists’
dentists’ civil
civil societies
societies (a
(a form
form of of professional
professional organization
organization forfor liberal
liberal professions
professions
in Romania) (196).
in Romania) (196).
The
Thesize
sizeofofthe
thedevelopment
developmentisisoftenoftenestimated
estimated byby
GDPGDP per capita
per byby
capita thethe
economists,
economists,so
Figure 6 reflects
so Figure the dynamics
6 reflects of thisofindicator
the dynamics in the period
this indicator 2001–2015
in the period in Romanian
2001–2015 regions.
in Romanian
According to the data in the graph, we can observe the detached and very fluctuating
regions.
evolution of the Bucharest-Ilfov Region compared to the other regions of Romania. Signifi-
cant fluctuation, in the sense of decreasing GDP per capita, is registered during the world
economic recession (2008–2011). The other regions also register a slight decrease in GDP per
capita during the economic crisis, but it is not as marked as in the case of the Bucharest-Ilfov
Region. The lowest level of GDP per capita is registered in the North-East Region, with a
slight increase towards the end of the period. Four of the regions have a slightly higher
 The trend of European countries is that dental care is predominantly performed by
private medical practices, and this trend is also found in Romania. Most practices are or-
ganized in the form of internal medicine practices or in the form of medical clinics. Dental
care in Romania is provided through a network of 15,100 ambulatory facilities, most of
Healthcare 2022, 10, 2030 them private (12,127; 86%), which are organized as private dental practices (11,931) 7 of 13 or
medical dentists’ civil societies (a form of professional organization for liberal professions
in Romania) (196).
Thecapita
GDP per size ofthan
thethe
development
North-East is often but
Region, estimated
they areby
notGDP
veryper capita by the
differentiated. Theeconomists,
West
so Figure
region 6 one
is the reflects
withthe
thedynamics
highest GDPof this indicator
per capita, but in
thethe period
high gap is2001–2015 in Romanian
still maintained in
relation
regions.to the Bucharest-Ilfov region.

Healthcare 2022, 10, 2030 7 of 14

According to the data in the graph, we can observe the detached and very fluctuating
evolution of the Bucharest-Ilfov Region compared to the other regions of Romania. Sig-
nificant fluctuation, in the sense of decreasing GDP per capita, is registered during the
world6.economic
Figure
Figure Dynamicrecession
6.Dynamic ofofGDP
GDP per (2008–2011).
per capita
capita The other
in Romanian
in Romanian regions
regions.
regions. also register
Source:
Source: a slight
computed
computed by decrease
byauthors
the the authorsinbased
based
GDP
on
on the per capita
theEurostat
Eurostat during
database
database the
[23]
[23] economic
using
using Stata
Stata crisis,
15.1. but it is not as marked as in the case of the
15.1.
Bucharest-Ilfov Region. The lowest level of GDP per capita is registered in the North-East
The with
Region, real agrowth rate of regional
slight increase towards thegross
endvalue
of theadded
period.(GVA) at the
Four of basic priceshave
regions (seea
Figure 7) reflects that the North-East and South-West Oltenia regions recorded
slightly higher GDP per capita than the North-East Region, but they are not very differ- the lowest
performance
entiated. TheinWest
the period
region 2001–2015. The the
is the one with Bucharest-Ilfov
highest GDPregion stands
per capita, butout significantly,
the high gap is
registering an accentuated growth.
still maintained in relation to the Bucharest-Ilfov region.

Figure7.7.Real
Figure Realgrowth
growthrate
rateofofregional
regional gross
gross value
value added
added (GVA)
(GVA) at basic
at basic prices.
prices. Source:
Source: computed
computed by
by the authors based on the Eurostat database [23] using Stata
the authors based on the Eurostat database [23] using Stata 15.1. 15.1.

3. Materials
The realand Methods
growth rate of regional gross value added (GVA) at basic prices (see Figure
7) reflects that the
The paper North-East
provides and evidence
empirical South-Weston Oltenia regions recorded
the relationship the lowest
between dental perfor-
health and
mance
the in the period
well-being 2001–2015.for
of the individual The Bucharest-Ilfov
eight Romanian Regionsregionover
stands
theout significantly,
period 2001–2015.regis-
For
tering an evidence,
empirical accentuated we growth.
used OLS Model (Ordinary Least Squares Model). The eight regions
in Romania are not administrative-territorial units and do not have legal personality,
3. Materials
being and Methods
constituted on the basis of agreements made between the representatives of the
county Thecouncils. The development
paper provides regions, on
empirical evidence according to Law no.
the relationship 315/2004
between dentalonhealth
regional
and
development
the well-being in of
Romania [31], are the
the individual for framework for theRegions
eight Romanian development,
over theimplementation
period 2001–2015.and
evaluation
For empirical of regional development
evidence, we used OLS policies,
Modelas(Ordinary
well as the collection
Least Squaresof Model).
specific statistical
The eight
data, in accordance with the European regulations issued by
regions in Romania are not administrative-territorial units and do not have EUROSTAT forlegal
the second
person-
level
ality,ofbeing
NUTS 2 territorialonclassification,
constituted the basis of existing
agreementsin the European
made betweenUnion. The eight regions
the representatives of
are
theas follows:
county Nord-Vest
councils. (North-West),regions,
The development Centru according
(Center), Nord-Est
to Law no. (North-East),
315/2004 on Sud-Est
regional
(South-East),
developmentSud–Muntenia
in Romania [31], (South-Muntenia),
are the framework Bucuresti-Ilfov (Bucharest-Ilfov),
for the development, Sud-Vest
implementation
Oltenia (South-West Oltenia) and Vest (West). For empirical evidence,
and evaluation of regional development policies, as well as the collection of specific we used Pooled
sta-
tistical data, in accordance with the European regulations issued by EUROSTAT for the
second level of NUTS 2 territorial classification, existing in the European Union. The eight
regions are as follows: Nord-Vest (North-West), Centru (Center), Nord-Est (North-East),
Sud-Est (South-East), Sud–Muntenia (South-Muntenia), Bucuresti-Ilfov (Bucharest-Ilfov),
Healthcare 2022, 10, 2030 8 of 13

OLS regression. The chosen period (2001–2015) is justified by the availability of the official
databases of EUROSTAT [23].
The novelty of the research is justified by the relationships under study and the choice
of the determinants of dental health, as well. Our econometric model is in accord with the
literature [32] and is presented below in Equation (1):

yi,t = β 1i,t + β 2 X2i,t + β 3 X3i,t + ui,t (1)

where: i refers to the country (i = 1, 8); t refers to the year (t = 1, 15); y is the dependent
variable; X is the independent variable; β 1 , β 2 and β 3 are the coefficients of the explanatory
variables; ui,t are the observation-specific errors.
For the model, the dependent variable is Dental Health (DentalH), reflected by the
number of dentists per one-hundred-thousand inhabitants, starting from the presumption
of the authors [4–7,30], according to which a greater number of dentists generates more
demand and determines the greater attention of the citizens regarding dental health care.
We use, in our paper, four variables as determinants of Dental Health (see Table 1),
namely: (a) income of households (EUR/inhabitant) (Income); (b) R&D personnel and
researchers (% in labor force) (R&D); (c) gross fixed capital formation (Investment). From an
income perspective, the literature identifies its role in dental health management [2,9–14,17].
R&D personnel and research include, in addition to research, the idea of education, which
is also considered an important factor for dental care [15–17].

Table 1. The variables included in the analysis.

Variable Definition Data Source

DentalH Dentists/one-hundred-thousand inhabitants European Commission [23]
Income Income of households (EUR/inhabitant) European Commission [23]
R&D R&D personnel and researchers (% in labor force) European Commission [23]
Investment Gross fixed capital formation European Commission [23]
Source: computed by the authors, based on sources indicated inside the table.

Tables 2 and 3 provide descriptive statistics for the variables included in the model
for the eight Romanian regions regarding the relationship between dental health and the
well-being of the individual over the period 2001–2015.

Table 2. Pairwise correlations.

Variables (1) (2) (3) (4)

(1) DentalH 1.000
(2) Income 0.703 * 1.000
(3) R&D 0.842 * 0.743 * 1.000
(4) Investment 0.692 * 0.803 * 0.924 * 1.000
* shows significance at the 0.05 level.

Table 3. Descriptive Statistics.

Variables. Obs Mean Std.Dev. Min Max p1 p99 Skew. Kurt.

(1) DentalH 120 58.36 26 20.6 124.31 21.95 123.14 0.797 2.651
(2) Income 120 0.453 0.542 0.138 2.138 0.143 2.009 2.224 6.183
(3) R&D 120 2894.167 1812.343 900 9800 1000 9100 2.015 7.09
(4) Investment 120 3656.914 3821.709 542.03 22,191.5 597.22 17,171.89 2.746 10.572
Source: the authors’ calculation using Stata 15.1.

Above is the correlation matrix for all variables in the model. The numbers are the
Pearson correlation coefficients that go from −1 to 1. A value closer to 1 means a strong
Healthcare 2022, 10, 2030 9 of 13

correlation. A negative value indicates an inverse relationship (roughly, when one goes up,
the other goes down). According to our data, there are strong correlations between variables,
the values being in the interval [0.62–0.92]. All variables show significance at the 0.05 level.

4. Results
The results of the regression analysis represent empirical evidence which justifies the
purpose of the research regarding the relationship between dental health and the well-being
of the individual.
We used the OLS Model for the panel data developed for the eight Romanian Re-
gions over the period 2001–2015, as can be seen in Table 4. To estimate equation 1 and
structure the results, we first solved the problems of spurious regression. We used the
variance inflation factor (VIF) to check for multicollinearity, showing values of 6.08 for our
regressions. The adjusted R2 -square shows the amount of variance of Y (outcome variable
DentalH) explained by X (prediction variables Income, R&D and Investment). In this case, the
prediction variables explain 82% of the variance in Dental Health (DentalH). This provides
a more honest association between X (prediction variables) and Y (outcome variable). We
used robust standard errors to control for heteroskedasticity.

Table 4. The results of the regression analysis.

(1)
DentalH
0.0198 ***
Income
(0.00151)
19.68 ***
R&D
(2.450)
−0.00622 ***
Investment
(0.000685)
14.81 ***
_cons
(2.360)
N 120
R2 0.820
Standard errors in parentheses; * p < 0.05, ** p < 0.01, *** p < 0.001; Source: the authors’ calculation using
Stata 15.1.

Our results show, according to the OLS model provided in Table 4, that the coeffi-
cients of the income of households and R&D personnel and researchers are positive (+)
and statistically significant, as predicted by our hypothesis. The investment variable is
statistically significant but has a negative impact (−). Two-tail p-values test the hypothesis
that each coefficient is different from 0. In our model, all prediction variable (Income, R&D
and Investment) are statistically significant in explaining the outcome variable DentalH
(*** p < 0.001).
To complete the image of our model, we want to identify the status of each region in
the analysis, as can be seen in Figure 8.
Figure 8 plots the prediction from a quadratic regression, and it adds a confidence
interval for the eight regions in Romania. As can be seen, the North-East (Nord-Est) region
has a high number of dentists relative to the level of income per inhabitant, the explanation
being that the North-East Region has an important university and medical research center
in Iasi. The tendency of dentists is to stay in Iasi after graduation and, in general, in the
North-East region. In the case of the South-East (sud-Est), South-West Oltenia (Sud-Vest
Oltenia) and South-Muntenia (Sud-Muntenia) regions, we notice a very low level of dentists,
these also being the regions that do not have university centers in dental medicine. The
best location is the Bucharest-Ilfov Region, which has high per capita incomes and also a
significant number of dentists.
Healthcare 2022,10,
Healthcare2022, 10,2030
2030 10 of
10 of 13
14

Figure 8.8.Dentists
Figure per one-hundred-thousand
Dentists inhabitants
per one-hundred-thousand and income
inhabitants of households
and income of (EUR/inhabit-
households
ant), averaged over the period 2001–2015. Source: computed by the authors based on
(EUR/inhabitant), averaged over the period 2001–2015. Source: computed by the authors thebased
Eurostat
on
database [23] using Stata 15.1.
the Eurostat database [23] using Stata 15.1.

Figure
For 8 plots
greater the prediction
accuracy in reflectingfrom
the arole
quadratic regression,
of economic and it adds
development, a confidence
we will also make
interval for the eight regions in Romania. As can be seen, the North-East
a graphical representation in terms of dentists per one-hundred-thousand inhabitants (Nord-Est) region
and
has a high number of dentists relative to
GDP per capita, averaged over the period 2001–2015. the level of income per inhabitant, the explana-
tion Figure
being that the the
9 plots North-East
predictionRegion
fromhas an important
a quadratic university
regression, and and medical
it adds research
a confidence
center in Iasi. The tendency of dentists is to stay in Iasi after graduation
interval for the eight regions in Romania based on dentists per one-hundred-thousand and, in general,
in the North-East
inhabitants and GDP region.
per In the case
capita. of the
As can beSouth-East (sud-Est),
seen, the results South-West
are similar Oltenia
to those (Sud-
obtained
Vest
in theOltenia)
previousand South-Muntenia
figure, reflecting that(Sud-Muntenia)
the North-East regions,
(Nord-Est)weregion
noticehas
a very lownumber
a high level of
dentists,
of dentiststhese alsotobeing
relative the regions
the level of GDPthat per do not have
capita. In theuniversity
case of thecenters in dental
South-East medi-
(Sud-Est),
cine. The best
South-West location
Oltenia is the Bucharest-Ilfov
(Sud-Vest Region, which (Sud-Muntenia)
Oltenia) and South-Muntenia has high per capita incomes
regions, we
and also
notice a significant
a very low levelnumber of dentists.
of dentists and a low level of GDP per capita. The best location is
Healthcare 2022, 10, 2030 For greater accuracy
the Bucharest-Ilfov Region, in reflecting
which the role
has a high GDPof pereconomic
capita anddevelopment, we will
also a significant 11 of
number 14
also
make
of a graphical representation in terms of dentists per one-hundred-thousand inhabit-
dentists.
ants and GDP per capita, averaged over the period 2001–2015.
Figure 9 plots the prediction from a quadratic regression, and it adds a confidence
interval for the eight regions in Romania based on dentists per one-hundred-thousand
inhabitants and GDP per capita. As can be seen, the results are similar to those obtained
in the previous figure, reflecting that the North-East (Nord-Est) region has a high number
of dentists relative to the level of GDP per capita. In the case of the South-East (Sud-Est),
South-West Oltenia (Sud-Vest Oltenia) and South-Muntenia (Sud-Muntenia) regions, we
notice a very low level of dentists and a low level of GDP per capita. The best location is
the Bucharest-Ilfov Region, which has a high GDP per capita and also a significant number
of dentists.

Figure9.9.Dentists
Figure Dentistsper
perone-hundred-thousand
one-hundred-thousand inhabitants
inhabitants and
and GDP
GDP per
percapita,
capita,averaged
averagedover
overthe
the
period 2001–2015.
period 2001–2015. Source:
Source:computed
computedbyby
thethe
authors based
authors on on
based the the
Eurostat database
Eurostat [23] using
database Stata
[23] using
15.1.
Stata 15.1.

5. Discussion
The obtained results are in accordance with the literature [2,9–17] emphasizing that
the economic context influences dental health, at least from the perspective of two im-
portant indicators, namely, the income of households and R&D (research and develop-
ment), which are positive and statistically significant, as predicted by our hypothesis.
Healthcare 2022, 10, 2030 11 of 13

5. Discussion
The obtained results are in accordance with the literature [2,9–17] emphasizing that the
economic context influences dental health, at least from the perspective of two important
indicators, namely, the income of households and R&D (research and development), which
are positive and statistically significant, as predicted by our hypothesis. Therefore, educa-
tion and personal income will determine the health awareness of the human individual in
general. Of course, an educated and wealthy human individual will place a lot of emphasis
on dental hygiene, which leads to medical check-ups at the dental office. In this context,
the higher concentration of dentists will be identified at the level of a community that is
aware of its role at the level of an educated and developed community.
The role of investments is significantly negative according to our model, and the
explanation may be that it consists of resident producers’ acquisitions used in processes of
production and justifies the technical-professional dimension of the economic individual,
which is strictly professional-oriented and determines a negligent behavior in terms of
dental health. Too much focus on investment processes, without a correct correlation with
the variables of sustainable development, can lead to a negative relationship with health,
as evidenced by our model.
Complete answers on the impact of economic policies are not likely to be certain, but,
overall, we think the evidence supports the idea that well-defined and -targeted economic
policies may help in promoting dental health development. However, there are still a few
more steps that need to be taken to define the best legal framework for Romania. Political
considerations associated with providing equal access to services and placing a greater
priority on the health improvements of specific population groups may be important goals.
These findings are understandable given that certain economic variables can become
real levers of influence for dental health care and considering the current stage of the
Romanian economy and the stage of each Romanian region. Thus, noting that the income of
households is a relevant economic variable that influences dental health care in a region, it is
important, from the perspective of this indicator, to insist on the elimination of discrepancies
and inequalities between citizens’ incomes. Of course, we are not campaigning for a social
vision specific to the socialist ideology, but these inequalities must be reduced precisely
through the European vision of eliminating very strong economic inequalities between
regions and, in general, inside a country. A healthy economy will generate sufficient
income for each family and, thus, guaranteed access to high-quality dental health services.
Currently, to mitigate these inequalities and for access to dental medical services, the Health
Insurance System is used, which does not consider the effective contribution of the citizen,
but it is important to be registered in the Health Insurance System as a citizen. We consider
that this form of social contribution is beneficial, but if we consider that dental medicine is
carried out mainly through Individual Medicine Cabinets and that not all of them apply
for funds from the Health Insurance System, then we can realize the importance of each
family having sustainable incomes.
A sustainable economy is also justified by the level of Research and Development
(R&D), which, according to our analysis, is positive and statistically significant with dental
health care. In this sense, the states are driven to raise the level of R&D from the perspective
of the objectives established by the Europe 2030 Strategy because of the status of the current
society as a knowledge society. Romania has assumed this objective through the Europe
2030 Strategy and is taking significant steps in this direction.
The strength of our study is the novelty of the study regarding the relationship between
dental health and the well-being of the individual for the eight Romanian Regions over the
period 2001–2015 using a linear regression model. From this point of view, our analysis is
an original one and is absolutely novel for Romania, where, as far as we know, there has
been no previous study.
The limitation of this study is the lack of variables (oral health and economic) at the
Romanian regional level that could better justify the influences, as well as the lack of recent
data as close as possible to the present.
Healthcare 2022, 10, 2030 12 of 13

Our future research directions are to extend the analysis by evaluating the relationship
between oral health policies and the level of socio-economic development of different
developed and developing countries in Europe and all over the world, including even more
variables in the econometric model.

6. Conclusions
This study has successfully answered the research paper’s questions, and these find-
ings are in accord with our hypothesis that dental health care is influenced by the economic
variables in a country. More precisely, our paper highlights the status of the relationship
between dental health and the well-being of the individual for eight Romanian Regions
over the period 2001–2015 using a linear regression model. From the path analysis results,
it was found that the coefficients of the income of households and R&D (research and devel-
opment) variables are positive and statistically significant, as predicted by our hypothesis.
These two variables, which directly impact dental health, are explicable because education
and personal income will determine the health awareness of the human individual in
general. An educated individual will always be aware of his oral health status and invest
in it, based on sustainable income, given that a job with a higher education, according to
the law, is on a higher salary scale. A developed state that emphasizes innovation will
build its GDP from areas of activity based on innovation, which are also the strongest
revenue generators.
From the investment perspective, the relationship is negative if it is not accompanied
by innovation. In this context, the development of entrepreneurship in its forms, but
which does not involve innovation, can lead to a consumption of human and material
resources, which determines a guaranteed neglect of oral health. These situations appear
in developing or transitioning states, as is the case with Romania. The regions with smart
cities will invest intelligently, but in Romania, the regions are not characterized by such a
level of development.

Author Contributions: Conceptualization, E.C. and A.T.C.; methodology, E.C. and A.T.C.; soft-
ware, E.C. and A.T.C.; validation, E.C. and A.T.C.; formal analysis, E.C. and A.T.C.; investigation,
E.C. and A.T.C.; resources, E.C. and A.T.C.; data curation, E.C. and A.T.C.; writing—original draft
preparation, E.C. and A.T.C.; writing—review and editing, E.C. and A.T.C.; visualization, E.C. and
A.T.C.; supervision, E.C. and A.T.C.; project administration, E.C. and A.T.C.; funding acquisition, E.C.
and A.T.C. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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