IOANNINA, Greece (Reuters) - It was the first time in weeks Anthoula Papazoi had cooked meat. She had stewed the cut of beef, donated by a friend, on a low flame all morning. But now the casserole sat untouched, as Papazoi fretted about her 13-year-old daughter Nikoleta's tooth.
The teenager - long black hair, electric-blue nail polish - emerged from the bedroom in shorts and a tank top. She had slept most of the day and was late for an appointment for a long overdue root canal procedure on a bottom front tooth.
"Do we have painkillers?" she asked, rummaging through a kitchen cabinet. "I'm going crazy."
"No, we don't. Go get ready for the dentist," Papazoi said.
"Do we have milk?" Nikoleta asked.
She pulled at a piece of masking tape that held closed the refrigerator door, reached in and grabbed a carton of milk. In a tall white mug she mixed the milk with chocolate powder and five spoonfuls of sugar, and then slumped into a chair.
"Get up and go," her mother ordered.
In few places are the wounds of Greece's economic depression more evident than in the mouths of the nation's children. By most indicators of dental health, Greece is one of the unhealthiest places in Europe. The number of Greeks 16 years or older reporting unmet dental care needs was 10.6% in 2013, according to Europe's statistical agency Eurostat. That compares to a European Union average of 7.9%.
Dental problems are particularly acute among children, according to a recent survey by the Hellenic Dental Federation, a supervisory body. And the financial crisis has made things worse. In the decade up to 2014, 60% of all dental problems in 15-year-olds were left untreated for at least a year, up from 44% in the previous decade. Almost all the five-year-olds surveyed - 86.8% - suffered dental problems that had not been treated, the survey found.
"Teeth are unfortunately considered a luxury," said Niki Diamanti, a dentist who works at Hatzikosta Hospital, one of two public hospitals in the northwestern town of Ioannina. "If, five years ago, people went to the dentist once a year, now they go every five years."
In Greece's case, the situation is remarkable because the dental problems are not primarily caused by changes in daily oral hygiene, experts say. Rather, children are developing tooth diseases for reasons related to the country's six-year economic depression.
First, money woes have led to fewer dentist visits.
Disposable incomes in Greece have shrunk by about 30% since 2009. More than 1.2 million Greeks - one in four working-age people - are unemployed. Forty percent of children live in poverty, according to the U.N children's agency UNICEF, more than in places such as Chile, Turkey and Mexico.
As well, the publicly funded system of free or low-cost medical care that millions of Greeks relied on for decades has shrunk, largely because of public spending cuts demanded in exchange for the 326 billion euros ($354 billion) in financial aid Greece has received since 2010. Per capita health spending fell 9% a year between 2009 and 2012.
The result: More than 8% of Greeks skipped dentist visits in 2013 because it was too expensive, well above the 5.1% European average, according to Eurostat.
The financial crisis has also driven a surge in the consumption of cheap, high-sugar foods, dentists say. After dipping for a couple of years, sales of sugary snacks at supermarkets picked up again in 2013, according to Euromonitor, a consumer goods research group.
Greece's bad teeth may be storing up problems for the future. Studies around the world have identified links between bad oral health and chronic illnesses such as cardiovascular diseases, the world's number one killer. Severe gum disease is associated with diabetes and coronary artery disease, according to several medical studies. Scientists are still debating whether dental problems cause other health conditions, or are merely associated with them.
Doctors and scientists have long associated dental health with economic development, largely because good teeth are correlated with access to education. Pain from dental diseases keeps children in many developing countries from their studies, according to the World Health Organization.
Paula Vassallo, chair of a European lobby group that promotes oral health, said children suffering tooth pain often sleep and eat poorly, which can hurt how well they do at school. Children with tooth pain can suffer malnutrition and low levels of vitamin D, she said.
"If you're in pain like that you can't sleep, you can't eat well, you can't speak, you can't perform," says Vassallo, whose Platform for Better Oral Health in Europe receives funding from dental care firms. "The effect on Greece is going to be huge, not just in terms of the economic impact, but also the health, quality of life and employability of people."
In the Papazoi family, it's not only Nikoleta who has suffered. Anthoula Papazoi's eldest daughter, Elli, 16, was rushed to hospital last year because of pain from a pus-filled tooth, only to be turned away because there was no dentist on call. Papazoi's eldest child, Christoforos, 17, had a tooth filled recently. And Anastasis, 5, barely avoided a root canal earlier this year.
Papazoi, who runs a small business hiring out cleaners and nurses, stopped contributing to social security three years ago when she could no longer afford to. That meant the 44-year-old joined an estimated 2.5 million Greeks without access to public health care. She now owes 900 euros to four different dentists.
The family's struggles can be seen in the contents of their fridge. Five years ago, it was stocked with cheese, meat and vegetables. Today: celery, a bit of shredded pumpkin and home-churned butter Papazoi's parents send from their village. The family diet is high in carbohydrates and sugar. Most days they eat rice, pasta, or occasionally lentils.
"I always used to buy fruit but now you can't buy fruit. It's too expensive," said Papazoi. "I'd never imagine I'd reach this point: running around from day to night and not even being able to provide the basics for my children."
Diamanti, the dentist, sees similar struggles almost every day. The 42-year-old studied in Athens and in Britain, before moving to Ioannina in 2010 after she married a local.
By that time, the city of 112,000 near the border with Albania was reeling from Greece's economic downturn. The capital of a mountainous northwest region, Ioannina has a large student population and produces feta cheese and spring water. But it is poor. Per capita output in 2012 was just 12,000 euros, down from 15,000 in 2008 and a third lower than that of Greece as a whole, according to the latest data.
The downturn has hurt local people's teeth. The prefecture around the city has the worst rate of five-year-olds with caries, or severe tooth decay, in Greece, according to the Hellenic Dental Federation survey.
"People have surrendered, psychologically. They no longer care about their health, including oral health," said Yorgos Papazaharis, head of the regional unit's dental association.
As a result, he said, dentists are struggling to keep their practices alive. He estimates that the cost of dental care in the region has dropped 35% over the past six years. Many dentists now treat patients for free.
At the same time, Value Added Tax on medical supplies such as cotton wool or gauze has risen from 9% to 13% during the crisis. VAT on other supplies used by dentists is as high as 23% thanks to Greece's bailout commitments.
Successive governments have tried to paper over the cracks. Last year, for instance, the Greek government gave uninsured citizens free prescription drugs and free care, including dental treatment, in public hospitals. And this April, the government of leftist Prime Minister Alexis Tsipras scrapped the 5-euro fee to access public hospitals. But the country's international creditors have ordered the government to reinstate the fee or come up with another way to make up the lost revenue.
Because so many people find private care unaffordable Diamanti says she now sometimes sees as many as 20 patients in one day. At private practices it costs 30 to 50 euros for a filling, 150 euros for root canal treatment, and 200 euros for a crown. For Greeks with national health insurance, treatment in a public hospital costs much less. But only two of 199 dentists in Ioannina take such patients, meaning appointments can take months to secure. Many people join the long lines at hospital emergency rooms, or wait until a rotting tooth needs to be pulled, Diamanti said.
Sitting behind her desk, she rubs her aching hands and wrists. One of the reasons for bad teeth is cultural, she said. "People in Epirus grow up with the idea that sweet things make us feel better. They put honey on children's dummies (pacifiers)."
Now many of her patients can't afford fruit and vegetables, she said, so they turn to processed food. "It's the sugar. Sugar is the food of the poor."
ONE FAMILY'S STRUGGLE
In her kitchen, casserole on the stove, Anthoula Papazoi details her health problems. A sturdy woman with auburn hair and neatly trimmed fingernails, she has a respiratory disease that is set off by cigarette smoke, strong perfumes or the smell of food. She struggles to make it up the stairs to her two-bedroom flat in a neighborhood of low-rise buildings.
Papazoi's small business usually earns her between 30 and 60 euros a month; some months she makes nothing. The state pays her a benefit. Last year, a family with four children or more got 3,900 euros a year, though that amount has now been cut to 2,400 euros. Papazoi says she paid more than half of last year's benefit back in taxes. The rest goes towards the 200 euros monthly rent for her 70 square-metre apartment. Papazoi says her monthly expenses can reach about 1,000 euros. She has disconnected her home phone and owes hundreds of euros in unpaid water and electricity bills.
Before Papazoi divorced, her family was financially comfortable. She worked during the day, shopped in the late afternoon and cooked meals at night. There was always enough food and clothes, she said, and the children got new shoes when they needed them.
Now the hallway of her apartment doubles as an office, with overflowing bookcases, unpacked cartons and a desk stacked with columns of papers and folders. The paint has begun to chip off the mustard-coloured walls of the living room, which is dotted with vases of plastic flowers. Papazoi said her ex-husband, who could not be contacted for this article, does not help with costs.
Her two girls share a room, which is overflowing with boxes and clothes. Anastasis and his older brother Christoforos sleep on a bunk bed in their mother's room.
Papazoi bakes her own bread with flour that relatives send. Though her children crave milk, she can rarely afford it. She makes up for the lost calcium with yogurt. For breakfast, she sometimes splurges on chocolate croissants.
"ARE YOU KIDDING ME?"
Angelos Priovolos, who has worked on the teeth of three Papazoi children, said the family's problems were typical. People have stopped going for check-ups for fear their dentist will find problems they can't afford to fix.
That happened last year when Elli began complaining of pain in a back tooth that had filled with pus. At first, her mother told her to try to ignore it. She gave her daughter paracetamol and anti-inflammatory drugs. When she ran out, Papazoi told Elli to swish tsipouro, a Greek brandy, in her mouth.
The nights became unbearable. Papazoi and Elli quarreled. That woke Nikoleta. Exhausted, both girls would sleep their summer days away.
One afternoon, when Elli's pain became too much to bear, Papazoi told Christoforos to take his sister to the hospital. But the children were turned away because there was no dentist on call, she said.
"She (Elli) phoned and began screaming at me, saying, 'Are you kidding me? Why did you send me here?'" recalled Papazoi. Desperate, she sent her daughter to Priovolos, a private dentist, who provided basic treatment. Later, after the swelling had subsided, Elli had the tooth filled.
This summer it was Nikoleta's turn. One day in August, the roof of her mouth and part of her throat began swelling from her infected tooth. Papazoi didn't bother with hospital but took Nikoleta to a private specialist who opened up the tooth and drained the pus. Cost: 200 euros, plus extra to remove a cyst that had formed on another tooth. Priovolos said such cysts are usually found in people over 60.
On the evening of Nikoleta's next appointment, as the family awaited her return, Papazoi chopped pears sent by her mother and placed them on a plate on the kitchen table. Anastasis grabbed a yogurt dessert with chocolate flakes from the fridge.
"You never buy what we want," joked Elli as she walked into the kitchen, ignoring the pears.
The casserole sat, cold. Papazoi's mobile phone rang. It was the dentist. She listened and then hung up. "Another 100 euros," she said, leaving the room.