こどもの歯科矯正_保険適用

―　「こどもの歯科矯正」公的医療保険の国際比較（OECD加盟国）

　我が国の歯科医療は，世界でも公的医療保障が最も高い国の一つとされているが，歯科矯正に限るとその適用範囲は先天性疾患や外科手術を要する場合に限局されており，その医療としてのあり方や学問体系，国民の公平性に関し，諸外国と比較するとたいへん異質な国家であると言える．こどもの発達段階における歯や歯列，顎顔面の位置・大きさの異常という疾病（WHO国際疾病分類 K07.0～K07.6, p.69-71）に対する歯科矯正医療の必要性は，学校歯科検診において評価され通知はされているが，何らかのステークホルダーによって議論が進んでおらず，健やかな成長へと誘導する歯科矯正医療をすべての子ども（国際的には18才以下を子どもとするが，我が国では児童・生徒）が公平に享受できる公的医療保険の適用には至っていない．こうした社会経済的負担の障壁から生じる歯科矯正医療へのアクセスの不平等は，結果として歯科医療全体，すなわち国民の口腔環境意識へも波及しており，口腔の健康増進を阻む社会的決定要因となっていないだろうか？

　我が国における子ども（児童・生徒）の口腔の健康を害する伝統的な慣行は喫緊に廃止し，基礎的で必要な医療および保健をすべての児童に提供するという「子どもの権利条約（24条～27条）の条項に沿うように，立ち遅れている歯科矯正のあり方について，諸外国と同等な健康概念へと是正・整備を確保すべきではないか？

下表 TableA.16 は，2016年の文献1）に　2022年の文献2）の記載を追加改変．

OECD加盟国以外は 2010年の3) からこちらへ記載した．☛　ヨーロッパ諸国の歯科矯正医療：公的医療保険の現状（2010）

医療制度は国民の要望によって変わりうるものである．詳細は各自で確認されたい．

　2) Oral health care in Europe: Financing, access and provision, Health Systems in Transition vol.24 No.2 2022

　3) European Orthodontic Health Insurances, June, 2010. European Federation of Orthodontic Specialists Associations Committee of European Health Insurances（日本語訳）

矯正歯科専門医の役割は誰のためにあるのか？　その目的と意義は何か？　国民への平等な医療提供体制，口腔の健康格差の是正はいかにあるべきか？

社会全体でなすべき規範：

・健康は人権であるという視点．生存権　健康権　生命権　幸福追求権　子ども権利条約

・すべての国民に負担可能な費用で医療サービスを提供すること

・過大な医療費負担によって経済的破綻に陥ることがないように国民を保護することは国家の義務であること

・常に視点は低・中所得の人々におくことで，国家としての健康指標の改善が初めてなされること

→　歯列不正・不正咬合と健康： well-being 上の健康格差のある医療領域

　　　　健康：肉体的，精神的，社会的，すべてが満たされた状態 well-being

Table A.16. Coverage of interventions which are at the frontier between health and cosmeics: Orthodontics

表 A.16. 健康と美容の境界領域^※におけるOECD加盟国の医療保険：歯科矯正

☛　※ 腫瘍摘出後の乳房再建，不妊治療，禁煙補助，眼科屈折障害，肥満手術は別表参照のこと．我が国の状況は下部記載．

Countries	Are orthodontic treatments in children covered by basic health insurance? 子どもの歯科矯正治療には基本的な健康保険が適用されていますか？	Is supplementary health insurance available? 補足的な健康保険はありますか	Was orthodontics treatment in children subject to HTA? 子どもの歯科矯正治療は医療技術評価の対象となったか？
Australia	No. 口唇口蓋裂，顎変形症など外科的治療を要するものは保障される	Not available	Not available
Belgium	Yes, maximum age of 9, only covered for correction of: frontal and lateral cross bite, frontal and lateral duress bite, position of incisor as prevention of anterior traumata, lack of space during the changing of teeth.	Not available	Not available
Canada	Yes, covered in some cases in some provinces and territories and coverage conditions vary by region.	PHIs are available but the coverage varies by plan.	Not available
Chile	No	Yes, by some private health insurers	No
Czech Republic	Yes, limited or partial coverage depending on a specific model of the aid based on a recommendation by physician	Not available	No
Finland	Yes, covered for children under 18 years	Not available	Not available
France	Yes, covered for children up to 16 and up to 6 semesters.	Not available	Not available
Greece	Yes	Not available	Not available
Hungary	Yes, prescription of physician, depending on the medical condition (for example: facial malformation, cancer, trauma)	Not available	Not available
Iceland	Yes, covered by low fixed sum for each case	Not available	No
Israel	Yes	Limited coverage by supplementary private health insurance schemes.	Yes, for congenital facial/dental defect treatments
Japan	Yes, only limited to care before and after occlusal abnormality or jaw deformity (only restricted to those which require surgeries such as jaw disarticulation) which are designated by the Minister of Health, Labour and Welfare. 咬合異常、顎変形症（顎骨切断等の手術を要するもの）のうち厚生労働大臣が指定するものの前後の診療に限る。	Not available	No

Korea	No	Not available	Not available
Luxembourg	Yes, a prior authorisation except for two services from the CMSS is mandatory. Dental impressions are only reimbursed three times in five years, not exceeding once a year. The treatment has to be performed before the age of 18.	Not available	Not available
Netherlands	我が国と同様．他科と連携が必要な重篤な症例にのみ適用される． No, it is normally not covered. Orthodontic treatments in children are only remunerated if the parents are insured for dental care and a child has very severe developmental/growth disturbances of the tooth/jaw/mouth, for which treatment of other disciplines than dental care is necessary.	重度の発育不全以外，18歳以下の患者の治療費は自己負担となるが，両親または両親の追加保険で保障される Some health insurers do offer osteopathy remuneration in supplementary private health insurance schemes. The amount of services remunerated and the changes in premium differs between insurers.	No
Norway	Yes, covered mainly for patients up to 20 years, based on specific criteria, financed by a combination of State remuneration system and patient payment.	Not available	Not available
Poland	Yes, covered for children up to 12 years old, orthodontic treatment with removable appliances	Not available	Not available
Slovenia	Yes	No	Defined in Regulation of CHI
Spain	No 国民医療制度は国と地域で構成され，管轄による大きなばらつきがある．顎変形症といった先天性疾患や癌の手術や審美的再建のためのインプラントや補綴治療は保障されている．子どものう蝕予防などは妊婦の健診とともにヘルスケアの一部に含まれる．	No 公的保険と民間保険によって，6-15才の永久歯列の基本的保障が確立している自治体もある．	Not available
Switzerland	No	Yes, covered by invalidity insurance for children and adolescents up to 20 years.	No
Turkey	Yes, SSI pays 1/3 of the cost of orthodontic treatments for those under 18 years of age.	Not available	Not available
United Kingdom	Yes, when clinical decision is made by physician	Not available	Not available
United States	Medicaid: 21才まで．州により適用基準には若干の違いあり．アメリカ矯正歯科学会の推奨する「医学的に必要な矯正歯科治療」基準は以下参照．　　詳細はこちらを参照されたい．　AAO推奨の基準（2019）： 1. Overjet: 9 mm or more. 2. Reverse overjet: 3.5 mm or more. 3. Anterior and/or posterior crossbite of 3 or more teeth per arch. 4. Lateral or anterior open bite: 2 mm or more; of 4 or more teeth per arch. 5. Impinging overbite with evidence of occlusal contact into the opposing soft tissue. 6. Impactions where eruption is impeded but extraction is not indicated (excluding third molars). 7. Jaws and/or dentition which are profoundly affected by a congenital or developmental disorder (craniofacial anomalies), trauma or pathology. 8. Congenitally missing teeth (excluding third molars) of at least one tooth per quadrant. 9. Crowding or spacing of 10 mm or more, in either the maxillary or mandibular arch (excluding 3rd molars). ノースカロライナ州の場合： 3.2.2 Medicaid Additional Criteria Covered The following criteria for functionally impairing occlusal conditions apply when cases are reviewed for Medicaid orthodontic approval. The probability for approval is increased when two or more of the following criteria exist: a. Severe skeletal condition that may require a combination of orthodontic treatment and orthognathic surgery to correct (beneficiary’s age and the direction of growth are also considered); b. Severe anterior-posterior occlusal discrepancy (severe Class II or Class III dental malocclusion); c. Posterior crossbite of three or more teeth per arch; d. Anterior crossbite of three or more teeth per arch; e. True anterior open bite: 2 mm or more; of four or more teeth per arch; f. Significant posterior open bite: 2 mm or more; of four or more teeth per arch (not involving primary teeth, partially erupted teeth, or one or two teeth slightly out of occlusion); g. Impinging overbite with evidence of occlusal contact into the opposing soft tissue (lower incisors must be causing tissue trauma); h. Overjet (excessive protrusion 6 mm or greater); i. Crowding greater than 6 mm in either arch that must be moderate to severe and functionally intolerable over a long period of time (such as occlusal disharmony or gingival recession secondary to severe crowding); j. Impactions where eruption is impeded with a good prognosis of being brought into the arch; k. Excessive spacing of 10 mm or more, in either the maxillary or mandibular arch (excluding third molars), or 8 mm or greater from mesial of cuspid to mesial of cuspid. Any space that will remain for prosthodontic or implant replacement cannot be included in the measurements for meeting spacing criteria; l. Two or more congenitally missing teeth (excluding third molars) of at least one tooth per quadrant; m. Occlusal condition that exhibits a profound impact from a congenital or developmental disorder (craniofacial anomaly), severe trauma, or pathology; n. Psychological and emotional factors causing psychosocial inhibition to the normal pursuits of life (requires supporting documentation of pre-existing condition from a licensed mental health professional specializing in child psychology or child psychiatry); or o. Potential that all problems will worsen.	Not available 民間保険あり	Not available

　　　→　ドイツは下表参照

☛　日本の平均寿命，健康寿命は世界一である．しかし長寿であること＝健康なのだろうか？　世界の幸福度指数調査（2022 World Hapiness Report ）では，146カ国中54位（OECD加盟38カ国では33位）であり，長寿は幸福の指標の一つに過ぎず，日本の順位は長年変わっていないのも事実である．well-being について．

☛　2022 World Hapiness Report をOECD加盟国，EU加盟国を抜粋

☛　歯列矯正の社会的・精神的側面からの健康 well-being について，諸外国の現状と比較検討する．

☛　従来型の生物医学モデル（現在の日本）から，生物社会心理モデル（欧米諸国）としての医療（歯科矯正）．

医学モデル：病気/障害を個人の問題とする考え方．その人の持っている条件や身体的な課題に対して医療的な治療やケア、リハビリが必要だとするものです。

社会モデル：社会の中で自由に生きる条件が整っていないことが障害/病気の原因であり，社会に問題があるという考え方．生きやすい社会を作り，問題解決をする人権的観点．

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

健康とは、病気ではないとか、弱っていないということではなく、肉体的にも、精神的にも、そして社会的にも、すべてが満たされた状態 well-being にあることをいいます。

保険適用の境界線について：各国と我が国の状況（6.86～

OECD health Working Papers No. 90 (2016)

How OECD health systems define the range of good and services to be financed collectively

補完代替療法（温泉療法；関節リュウマチ，腰痛）

☛

鍼灸，漢方薬

☛

肥満手術（病的肥満）

☛　2014年　腹腔鏡下スリーブ状胃切除術の保険適用．6か月以上の内科的治療によっても十分な効果が得られないBMI35以上の患者で，糖尿病，高血圧症，脂質異常症，閉塞性睡眠時無呼吸症候群のうち1つ以上を合併している

医師以外でも対応可能な治療法（心理療法，メンタルヘルス）

☛

屈折障害（視覚製品，眼鏡，コンタクトレンズ，眼科検診，眼科医，検眼士）

☛　2006年（平成18）9才未満の小児の弱視、斜視および先天白内障術後の屈折矯正の治療用として用いる眼鏡およびコンタクトレンズ（以下「治療用眼鏡等」という）の作成費用が保険適用

禁煙補助製品（喫煙，薬物療法，禁煙プログラム）

☛　2006年　一定の基準を満たす患者の禁煙治療に関して保険適用

生殖補助医療技術（男性・女性の不妊治療，排卵誘発剤，人工授精，体外受精）

☛　2022年　不妊治療に保険適用．

腫瘍摘出後の乳房再建（Table A.14）

☛ 2013年7月　乳がんで乳房切除術（全摘術）後の乳房再建に限り保険適用
2018年　「乳腺腫瘍に対する乳房切除術」が追加．良性腫瘍にも適用．
2020年　「遺伝性乳癌卵巣癌症候群患者に対する乳房切除術」が追加．

歯列矯正

☛　1982年　唇顎口蓋裂の保険導入

　　1990年　顎変形症の保険導入

　　1995年　学校歯科健診に歯並びの項目が追加．

　　1996年　顎口腔機能診断施設基準の追加

　　2018年　前歯3歯以上の永久歯萠出不全に起因した咬合異常（埋伏歯開窓術を必要とするものに限る。）

　　XXXX　　☛　「子どもの歯科矯正」への保険適用は？　OECD加盟国の状況は上記参照．

各国における適用が相違する理由（6.139～）

　社会規範，民間保険の有無

公的医療保険の優先順位を設定する最善の方法を見つけるため，各国は苦心し，さまざまな手法が検討されているが，国民の好みを評価し考慮する最善の方法にはコンセンサスもなく，実際の科学的根拠もないのが実情である．国民や患者にとって公平とされる決定プロセスを実施し、国民全体が納得することが必要である．とOECD報告書では考察．

わが国の国民は，子どもの歯科矯正は，わが国以外ほぼすべての国々においては公的医療保険により保護されていることを知るべきであろう．日本の国民は，政府のみならず歯科界自体からも「歯科矯正は美容医療である」と洗脳され限られた情報の中にいる．半世紀前の英国の状況に大変類似しており，不必要あるいは過剰な歯科矯正治療をおこなう歯科医による健康被害も数多報告されている状況である．

HTA: Health technology Assessment 医療技術評価とは．ウィキペディアより

・政策分析に関する学際的領域であり、医療技術の向上や普及、実用に関する医学的・社会的・倫理的、そして経済的な意義について研究するもの

・医療技術の、直接的で予想される効果はもちろんのこと、間接的で予想されなかった効果についても扱い、医療技術に関する患者に知らせたうえでの意思決定を主に目的とした、医療技術の価値や効果に関する体系的評価

・医療技術を実用する際の医学的社会的経済的そして倫理的な問題を体系的で、透明で、公平でしっかりとしたやり方でまとめていく学際的な過程

・医療技術評価の目的は、「患者中心で最大限の価値への到達を模索した安全で効果的な健康政策についての定式方法を知らせること

・医療技術は「健康を増進し、疾病を予防・診断・治療し、あるいはリハビリテーションのため、長期にわたるケアのために用いられうるいかなる介入」として広く定義されている

　　欧州医療技術評価ネットワーク: EUnetHTA

　　英国国立医療技術評価機構 NICE: National Institute for Health and Care Excellence

　　ドイツ医療品質効率性研究機構 IQWiG: Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen

　　中央社会保険医療協議会診療報酬調査専門組織（医療技術評価分科会）

　　中央社会保険医療協議会費用対効果評価専門部会

Table A.17. Coverage of dental care and prosthesis

Countries	Is dental care and/or dental prosthesis covered by basic health insurance?
Australia	Not covered and no Medicare subsidies for private dental services but covered by some PHIs.
Austria	Covered.
Belgium	Covered.
Canada	Dental care and prostheses are not typically covered unless deemed medically necessary but for certain groups (e.g., low-income residents and seniors), most provincial and territorial governments cover a range of supplementary benefits related to dental care, that are not covered under the Canada Health Act. Individuals and families who do not qualify for publicly funded coverage may be covered for dental care under an employment-based group insurance plan, or buy private insurance.
Chile	Patients insured under FONASA are covered for dental care and prosthesis while publicly insured patients with free choice of provider are not. People insured with one of the private insurance companies of the ISAPOREs, also generally do not have coverage for dental care or prostheses, but insurers often offer preferential prices following certain agreements. In addition, the GES Programme (Explicit Health Guarantees) includes the coverage of dental care to some populations, such as children below age 6, pregnant women and older people age 60 and over.
Czech Republic	Covered but a range of covered dental services is limited. For some types of dental procedures, patients must obtain permission from a review doctor working for their health insurance fund in order to qualify for coverage.
Denmark	Prostheses are covered for children. Dental surgery and treatment and prostheses are covered for patients carrying certain diseases or in particular need of treatment (nursing home and long term hospital patients). Prosthesis is generally not covered although there is some coverage for persons not developing teeth as they grow up and for persons having lost their teeth traumatically as a consequence of certain diseases.
Estonia	Dental care is covered for the insured over 63 years of age and persons eligible for an old-age pension. Dental care is also covered for persons with a greater need for dental treatment because of a particular condition, persons eligible for a work incapacity pension, pregnant women and mothers of children up to 1 year of age.
Finland	Covered.
France	Covered.
Germany	Covered and include a wide range of services such as conservative dental treatment, surgical treatment, x-rays, crowns, bridges and prostheses. Orthodontic is also covered.
Greece	Covered.
Hungary	Covered.
Iceland	Dental care and prostheses are covered for children, seniors and those with vulnerable medical conditions.

Ireland	Oral examination and emergency dental treatment including extractions and complex treatments are covered and denture repairs are covered where justified as an emergency treatment. Oral examination is limited to once every calendar year and fillings up to 2 fillings per year. Wider range of dental treatment is covered for high risk patients i.e. those with special needs and those with greater clinical needs and for instance, dentures are covered subject to approval based on clinical necessity or emergency circumstances. Some PHIs offer plans that include emergency and non-emergency dental care.
Israel	Dental care and prostheses are covered for children under 12 and people with vulnerable medical conditions. PHIs are also available
Italy	Emergency care for dental infections is covered and so as dental care and prostheses for children up to 16. Dental care and prostheses are also covered for designated groups of people with particularly vulnerable conditions (e.g. serious cardiovascular diseases, drug addiction, disabilities and rare diseases) and the low income. Some regions and local health authorities cover extra dental and prostheses services.
Japan	Covered and include a wide range of services such as conservative dental treatment, surgical treatment, x-rays, crowns, bridges and prostheses.
Korea	Dental care is covered and prosthesis is covered for the elderly
Luxembourg	Covered.
Mexico	The public health insurance fund Seguro Popular with the coverage of about half of the population cover certain dental treatments but not prostheses. Social Security does not cover dental care.
Netherlands	Basic dental care is covered but the coverage is restricted to specialist dental care in hospitals which include prostheses. Dental care is covered up to age 22 and specialist dental care and prostheses are covered for older people. PHIs are also available.
New Zealand	Dental care is covered for children under 18. Emergency dental treatment at hospitals or with approved dental contractors is covered for low to middle income population who are entitled to Community Services Card. PHIs are also available.
Norway	Surgical interventions and cleansing in the case of gum disease/periodontitis are covered. Dental care and prostheses are covered for children up to age 20, patients in nursing homes, persons who receive health care at home and those with certain medical conditions. Orthodontic treatment can be also covered based on the condition. But prosthesis is generally not covered although there is some coverage for persons not developing teeth as they grow up and for persons having lost their teeth traumatically as a consequence of certain diseases or accidents.
Poland	Covered but a range of covered dental services is limited. For example, one lower and one upper acrylic prosthesis is covered every five years. But orthodontic is also covered for children up to 18. Prosthesis is generally not covered although there is some coverage for persons not developing teeth as they grow up and for persons having lost their teeth traumatically as a consequence of certain diseases.

Portugal

Dental care is covered for children up to 16, pregnant women and people living with HIV/AIDS. Dental care and prostheses are also covered for low income elderly but they are covered for dental prosthetic every three years. Each occupation- or profession-based health insurance schemes called subsystems defines its own list of eligible dental treatments.

Slovenia

Covered.

Spain

The following treatments are covered:

Treatment of acute odontologic processes
Preventive examination of oral cavity in pregnant women
Preventive and assistance measures for children (application of topical fluoride, obturations, sealing of cracks)
Dental implants for patients undergoing oncological processes that

imply loss of teeth or congenital malformations

Sweden

Covered.

Switzerland

Dental care is covered only in very exceptional cases, e.g. if dental treatment is pat of another treatment, or if dental problems are caused

by another disease).

Turkey

Covered and services include inpatient and outpatient oral health care, such as oral and dental examinations, diagnostic tests and procedures, medical interventions and treatments after diagnosis, tooth extraction, conservative dental treatment and endodontic treatment, follow-up services, oral prosthesis and emergency services. Orthodontic is also

covered for children up to 18 years old.

United Kingdom

Dental care and prostheses are covered for children, seniors, the low income and pregnant women in England but in Scotland, dental examinations and treatment are covered.

United States

Most Medicare and Medicaid programmes include dental care and prostheses and dental care are also covered depending on health

insurance funds.

Note: The table only includes information from responding countries. Source: 2012 OECD Health System Characteristics Survey