A woman holds a placard reading "Toothless but not voiceless" during a protest in Lyon, France on May 9, 2016. Her mask reads "give us our smiles back, indebted toothless" | Courtesy Collectif contre Dentexia France’s revolt of the toothless Dental care may be the dark side of French health care.

LYON, France — Christine Teilhol can still hear the dentist drilling 10 implants into her gums in one hellish four-hour session.

Two years later the work is half done and she’s one of more than 2,400 French victims of a defunct dental chain pleading for help from the French government. They call themselves the sans dents (“the toothless”), a phrase meant to conjure infamous claims by an ex-lover of President François Hollande that he referred to the poor that way.

Call it the dark side of French health care: Although the Socialist-ruled country tops international rankings for health care quality and patient satisfaction, and many are proud of their generous social security system, dental care is a glaring exception.

Barely a third of dental care is now covered by social security, compared to more than half in the 1980s. Patients can buy private health insurance to cover more of the cost, but a quarter still comes straight out of patients’ pockets. Critics say a disjointed payment system has led to a crisis for many who can’t afford to get their teeth fixed.

“The rates of private dentists are just way too high. You either give up on seeing one, you go abroad — to Hungary, Romania, Croatia — or you turn to low-cost centers here,” said Abdel Aouacheria, a patient himself, who leads a group of victims of the low-cost dental provider Dentexia. “People didn’t imagine one second they could get ripped off by the health care system here in France.”

'Dental bubble'

The French are more likely than their peers to put off dental care because of cost, according to a 2013 study by CSA/Europ Assistance, and recent national surveys suggest the number is rising. That report found one in four French patients delayed a procedure, the highest among 10 countries studied. That compared to just 10 percent on average in the EU, and just 2 percent who put off dental work in Britain.

Low-cost companies arrived to fill the gap. In both France and Spain they promised dental implants at half the rates of traditional private dentists. But their offer came with a dangerous catch: Patients had to pay for the whole deal upfront, typically by taking out a loan offered by a partner company.

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Dentexia patients told POLITICO the dental work they paid for was like a mirage, perpetually postponed or fraught with complications. Over the years, complaints piled up on the desks of the French college of dentists, a self-governing body that upholds ethics and standards in the profession.

In March, a court ordered the liquidation of Dentexia, saying it had accumulated a €22 million debt in just four years of existence. The health ministry this week said it would compensate some of the patients.

“At home, all day long I’m toothless,” said Teilhol, who is 60. She paid Dentexia €12,000 for implants and crowns to replace teeth lost to gum disease. After the center went bust this spring, she’s stuck with only black screws protruding from her gums — the stems for the white ceramic crowns she never got. “Trust me, even after many years of marriage it’s very tough on your personal life.”

A similar story played out in Spain, where media talk of a “dental bubble” fueled by cheap credit that’s now bursting into a public health crisis. There, Funnydent centers reportedly made €1.5 million in revenue each month, and employees posed on social media waving wads of cash. But earlier this year, they all shut down. Their flamboyant boss, Cristóbal López Vivar, a former nightclub manager, was arrested on charges of swindling close to 2,500 patients for a total €8.8 million.

Dentexia’s founder, Pascal Steichen, declined to comment for this story but he complained to a French television program that self-employed dentists waged a vendetta against him. He said Dentexia aimed to make dental care more affordable but was stopped in its tracks by their campaign.

Dentexia employees were given quotas of implants to install in patients, as that’s the most profitable segment of dentistry, according to Gilbert Bouteille, the president of the standards setting medical college for dentists.

He said the chain did not fill its public health mission of providing basic — and less lucrative — routine care: In particular, the centers were closed on Wednesdays, when children are off school and more likely to come get cavities checked.

The French general inspectorate for social affairs, known as IGAS, is looking into ways to better control dental centers. A report is due by this fall, a health ministry spokesman said.

Dentexia clients paid €7,500 on average for their care, according to data compiled by Aouacheria, the patient who leads the victims' group.

Nine in 10 never completed their treatment plan. They would need to pay another dentist to finish the work, but many have not dared touch them due to liability and insurance concerns, according to the dentist union and college officials. Now that the government has announced measures to help the victims and encourage dentists to care for them, the hope is that might change.

Loopholes in system

The union of dentists known as CNSD, which negotiates rates with the French government, has called the low-cost centers potentially dangerous for years. It says now is the time for authorities to better control them.

It blames loopholes in a 2009 law known as the loi Bachelot, which allows associations to set up health centers and networks without certification — only a paper application laying out what the project is. Since the law kicked in, an estimated 100 centers like Dentexia have mushroomed across the country claiming to make dental care more affordable.

But the origin of the problem goes back to the 1980s, union president Catherine Mojaïsky said. French officials initially wanted social security to control and cover all dental care, but quickly realized it couldn’t afford that, so they found a compromise. While preventive and routine care was regulated and covered by social security, the more sophisticated and costly dental work, such as implants and orthodontics, was not. Dentists say the system leaves them behind and they are underpaid for routine care that takes up most of their time.

Dentists and the French government are set to negotiate new rates in September.

French dentists are paid among the lowest rates in Europe for routine care, according to data from their union. They complain the rates set by the state for dental scaling and filling are among the lowest in Europe and don’t cover their costs. So they catch up by charging higher rates for implants and orthodontics.

“The system today is completely insane,” Mojaïsky said. “The rates set for basic care should at least double, so that we can take in children without feeling like we’re losing money.”

Meanwhile, a dental implant costs around €1,500 to €2,000, and it’s not at all covered by public health insurance. A ceramic crown alone costs at least €500, and the amount reimbursed by social security — €75 — has not changed since 1988. This leaves patients and their private health insurers to make up the difference.

Dentists and the French government are set to negotiate new rates in September. According to a letter laying out her roadmap, Health Minister Marisol Touraine wants to balance the system by giving dentists a better deal on routine care but at the same time limit their rates on pricier operations.

Foreign care

The collapse of parts of the system is pushing more patients outside France. According to the latest available data from the public health insurance fund, the number of people who sought reimbursement for crowns and other dental care abroad rose 16 percent in 2014 from a year earlier. The top destinations were Hungary, Spain, Portugal and Italy.

The victims of Dentexia are also getting impatient. They want an emergency fund to help those who already paid for care they never got to be able to finish their treatment.

Once a cheerful beautician, 41-year-old Séloie R’Bili lives holed up at home biting on a plastic denture. She went to Dentexia two years ago to get a loose tooth checked and said the dentist there took out nine teeth, instead of the three she signed up for. She says she is unable to work because of the pain in her mouth and sinuses. She has lost her appetite, weighs just 42 kg and is being treated for depression.

“It’s not me anymore. I don’t recognize my mouth, my face, my smile. I love crispy bread but I can’t eat it. They ruined my life,” she said.

News that Hollande’s hairdresser earns over €9,000 a month has not helped.

“And we can’t even afford to get teeth. It’s sickening,” she said.