Schedule for the European Dental Market

SCHEDULE FOR THE EUROPEAN DENTAL MARKET

www.gfDi.DE | A STUDY FROM REBMANN RESEARCH WITH STRATEGY IDEAS FOR THE EUROPEAN DENTAL INDUSTRY.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | IntroductIon

CONTENTS Introduction 4

STRATEgiES gOVERNED BY STRUCTURAL TRENDS 6

Dental care past and present 8

Development of dental expenditure in the primary health market 8

Dental health and demand 8

Trend towards greater cooperation and joint practices 9

STRATEgiES gOVERNED BY SOCiAL TRENDS 10

Demographic development and demand for dental services 12

Does the demand for dental care fall with increasing age? 12

Growing demand and prosperity – the significance of the secondary health market 13

STRATEgiES gOVERNED BY PRODUCT TEChNOLOgY 14

Digitalisation transforms structures and processes 16

Digital technologies alter the interaction between dental professional groups 16

Strategic collaborations are necessary 16

New production techniques influence quality and price 16

Europe: Quality dominates 17

Categorising of dental market segments 18

Product trends in individual segments 19

Consumables and supplies 19

Implants 19

Digital technologies also transform products 21

Opportunities inherent in other selected product groups 21

STRATEgiES fOR ThE MiCROENViRONMENT 22

Sales success depends on clear regional knowledge 24

Care structure and access differ greatly on a regional level 25

Dentists 25

Regional fluctuations 25

Supply-induced demand 25

STRATEgiES fOR ThE MACROENViRONMENT 26

Dental markets and the economic situation 28

NATiONAL STRATEgiES, BY AND LARgE 30

The market environment becomes more difficult 32

Health systems and dental care 32

Dental care in the private sector 33

Public health systems financed through taxes 33

SOCiAL iNSURANCE SYSTEMS iN DETAiL 34

Belgium 36

Germany 38

France 40

Netherlands 42

Austria 44

Switzerland 46

PUBLiC/STATE hEALTh SYSTEMS iN DETAiL 48

Denmark 50

Italy 52

Spain 54

United Kingdom 56

List of references 58

S1

S 2

S 3

S 4

S 5

S 6

S 7

S 8

2 | 3

STRATEgiES fOR ThE MACROENViRONMENT 26

Dental markets and the economic situation 28

NATiONAL STRATEgiES, BY AND LARgE 30

The market environment becomes more difficult 32

Health systems and dental care 32

Dental care in the private sector 33

Public health systems financed through taxes 33

SOCiAL iNSURANCE SYSTEMS iN DETAiL 34

Belgium 36

Germany 38

France 40

Netherlands 42

Austria 44

Switzerland 46

PUBLiC/STATE hEALTh SYSTEMS iN DETAiL 48

Denmark 50

Italy 52

Spain 54

United Kingdom 56

List of references 58

Legal notice

Publisher

GFDI Gesellschaft zur Förderung der Dental-Industrie mbH

Dr. Markus Heibach, CEO

Burkhard Sticklies, Press and Communications

Authors

Dr. med. Heidrun Sturm MPH, Dr. Bernd Rebmann

REBMANN RESEARCH GmbH & Co. KG

Mommsenstrasse 46

10629 Berlin

Design

Thomas Brecht, REBMANN RESEARCH GmbH & Co. KG

images and graphics

REBMANN RESEARCH GmbH & Co. KG

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© 2013 REBMANN RESEARCH GmbH & Co. KG, Berlin

All rights reserved.

This work and all its component parts are protected by copyright. Any use outside the narrow limits laid down in copyright law (Urheberrechtsgesetz) without the permission of the publisher is prohibited and liable to prosecution. This applies especially to duplications, translations, microfilming and storing and processing in electronic systems.

Copy deadline

20th November 2012

Schedule 1: Strategies governed by structural trends

S1

Growing prosperity

Greater demand for cosmetic products and prevention

Changing job profile

Schedule 2: Strategies governed by social trends

S 2

Double ageing

Non-vital dental servicesQuality requirements

Complementary dentistry

Economic situation

Schedule 3: Strategies governed by product technology

S 3

Digital technology transforms the value-added chain

High-quality and basic services

Expand cross-selling

Identification of regional market penetration

Digitalisation demands product adaptations

Monitoring of micro/macroenvironment

Schedule 4: Strategies for the microenvironment

S 4

Identification of high coverage densities

Secondary health market

Main target group: wealthy older people

under-mobilized target groups

Identification of affluent regions

Microenvironmental analysis

Schedule 5: Strategies for the macroenvironment

S 5

Prosperity in the countries

Growth in the countries

Consideration of cultural preferences

Public financing

Private funding share

Schedule 6: National strategies, by and large

S 6

Health policy vs. economic power

Special care programs Payment, contracts, approval

Schedule 7: Social insurance systems in detail

S 7

Germany Switzerland

France AustriaBelgium

Netherlands

S 8

Italy

Denmark Spain

United Kingdom

Schedule 8: Public/State health systems in detail


Expenditure for dental health is considerable, ac-counting for 6 – 10 % of total health spending or between 100 and 300 US$1 per capita per annum. A large proportion of this has to be borne privately in many countries. Dental health is often not re-garded as part of general health and, analogously, dental care is not considered a component part of basic medical care. For this reason, dental care is only covered in part by insurance systems in many European countries. Even in the case of people with insurance, additional out-of-pocket payments ac-count for between 11 % and 42 % of their overall health expenditure. Many people have no insurance whatsoever to cover dental care.

The range of services provided by the German den-tal industry alone encompasses over 60,000 prod-ucts. This study focuses on the member countries of the FIDE2 (with the exception of Russia), thus en-compassing a group of about 250,000 dentists and approximately 150,000 dental technicians who con-tribute to the demand for these products. Dentistry in this context embraces a spectrum encompassing everything from diagnosis and prevention to resto-ration and covering a variety of specialised areas: orthodontics, dental prosthetics, preservation and surgical treatment, individual prophylaxis, peri-odontitis therapy, endodontics, implantology and aesthetics.

In terms of overall economic development, the dental sector is, in common with the health mar-ket, also an important economic and growth factor in Germany. The oral health economy acts as an important engine for job creation. A recently pub-lished study3 has predicted that the number em-ployed in dental practices, dental laboratories and trade in oral hygiene products up until the year 2030 will grow considerably by approx. 76,000 (+18.6 %) new jobs, and that at a time when the trend in the economy as a whole is negative. Statistically speak-ing, this indicates that around nine jobs currently depend on a single panel dental practice – even in rural or structurally weak regions.

Although dental expenditure in the area of public health insurance in Germany only grew by 1.5 % in 2011, this meant an overall increase in fees for German dentists from 700 million € to 21.9 billion €.4 This is equivalent to a rise in overall market volume in 2011 of around 3.3 %. It also indicates a slight reduction in growth in dental markets when compared to the previous year (+3.8 %). Howev-er, the growth area of services offered by private dental providers in particular, which is supported by numerous innovations, remains on course and promises the professional community a very posi-tive future.

INTRODUCTION Overview of health market in fiDE countries5

2011 _______________________________________________________________________________________________________________________ fiDE (Ø) fiDE (ACCUMULATED) ___

VOLUME Of ThE MARKET

Population _______________________________________________________________________________________________________________________________________________ 364,260,000 ___

Gross domestic product __________________________________________________________________________________________________________ 11,879,250,000,000 € ___

Changes in GDP rel. to last year ________________________________________________________________________________ 1.58 % ___________________________________________

Total health expenditure of GDP _____________________________________________________________________________ 10.83 % ___________________________________________

Total health expenditure ___________________________________________________________________________________________________________ 1,266,000,000,000 € ___

VOLUME Of ThE DENTAL MARKET

Percentage of total health expenditure for dental treatment ____________________________________ 5.12 % ___________________________________________

Proportion of total health expenditure for dental treatment (calculated) ______________________________________ 72,270,000,000 € ___

Total sales value of dental market, minus software __________________________________________________________________________ 6,110,000,000 € ___

Total number of dental dealers ___________________________________________________________________________________________________________________________ 1,231 ___

Dental practices using intra-oral cameras _______________________________________________________________ 38.13 % ___________________________________________

Total sales value of sundries _____________________________________________________________________________________________________________ 3,140,000,000 € ___

Total sales value of metal implants ___________________________________________________________________________________________________ 1,020,000,000 € ___

Total sales value of metal implants per 1,000 inhabitants _______________________________________ 2,635 € ___________________________________________

Number of new dental X-ray units installed _____________________________________________________________________________________________________ 25,545 ___

Number of new dental X-ray units installed per 1,000 inhabitants _______________________________ 0.07 ___________________________________________

fUNDiNg

Percentage private expenditure of total expenditure for dental services ______________ 55.46 % ___________________________________________

Proportion private expenditure of total expenditure for dental services _______________________________________ 37,260,000,000 € ___

DENTAL hEALTh

Dental health of 12-year-olds (2010, in DMFT) ______________________________________________________________ 0.96 ___________________________________________

DENSiTY Of MARKET

Number of practicing physicians/doctors ___________________________________________________________________________________________________ 1,261,347 ___

Density of physicians (practicing physicians per 1,000 inhabitants) ____________________________ 3.54 ___________________________________________

Number of practising dentists ________________________________________________________________________________________________________________________ 250,212 ___

Density of dentists (practicing dentists per 1,000 inhabitants) ____________________________________ 0.65 ___________________________________________

Number of dental practices ____________________________________________________________________________________________________________________________ 163,546 ___

Density of dental practices (dental practices per 1,000 inhabitants) ___________________________ 0.46 ___________________________________________

Number of dental technicians __________________________________________________________________________________________________________________________ 147,121 ___

Dental technician – density (dentists per 1,000 inhabitants) ________________________________________ 0.33 ___________________________________________

Total number of dental laboratories (dentists and commercial laboratories) __________________________________________________ 46,372 ___

Dental laboratory – density (dental laboratories per 1,000 inhabitants) ______________________ 0.11 ___________________________________________

Dentists per dental laboratory ______________________________________________________________________________________ 7.45 ___________________________________________

Citizens per dental laboratory __________________________________________________________________________________ 12,490 ___________________________________________

Dental graduates per 100,000 inhabitants ___________________________________________________________________ 1.88 ___________________________________________

Main sources: OECD Health Data 2012. WHO (National Health Accounts), ADDE 2012 and others (see index in appendix).

Illustration, calculation and supplementary estimates: REBMANN RESEARCH.

DENTAL hEALTh AND hEALTh ARE NOT ThE SAME ThiNg

4 | 5

Adjusted to take the share of dental technology of 6.5 billion € as of 2011 into consideration, German den-tists earned fees of 15.4 billion € for treatment alone, equivalent to a slight reduction of 2 %. For this reason, more than a few dentists are considering an expansion of the value-added chain through integration of a practice laboratory. The German dental industry is traditionally both the pace and trendsetter in Europe. German production is so significant in this respect that European developments frequently take their cue from those in Germany (e.g. growth in drills in Germany in 2007 was around 14 % and 15 % in the EU, while the fall in Germany related to instruments of 8 % was mirrored exactly in the EU).6

Normally speaking, the dental market is divided between services rendered directly on the patient and services which are realised at a distance from the patient. Services rendered directly on the patient, the “consumer”, are essentially realised by dentists, orthodontists, oral and maxillofacial surgeries and other facilities and dental technicians. These represent the main target group in the dental industry.

Fig. 1 – Division of dental services on the patient (example Germany)

Source: cf. CBI, 2009.

The entire value-added chain begins with the dental industry and extends right up to the patient who, as a purchaser of dental services and dental care products, primarily in the so-called secondary health market, plays an increasingly important role (see Fig. 2).

The dental market and the entire health market differ from other markets: The service provider, foremost dentists as customers of the industry, is not identical to the actual consum-er, the patient. As a result, rather than depending on the usual considerations, demand is governed by further factors such as the insurance structure, approval modalities and local demographics.

The user (patient) does not pay in every case: in-surance policies cover costs to varying degrees.

The economic situation of the purchaser (doctor) is heavily dependent on political regulations (re-muneration).

Manufacturers themselves are confronted by different national regulations governing product approval and registration in remuneration cata-logues.

This means that access to and the costs associated with dental care are strongly influenced by health systems, policy and the local economic situation. Consequently, these vary considerably between Eu-ropean countries. All these factors shape the health market in a particularly complex manner and make it difficult to forecast clear trends.

Fig. 2 – Value-added chain in the dental market

Source: cf. CBI, 2009.

Most correlations encountered in conventional medicine appear to be completely inverted in the case of dental medicine.7

Fig. 3 – Dental health is subject to different rules

Doctors Dentists

The sicker a pa-tient is, the more frequently medical consultations occur.

The sicker people are, the less likely they are to visit a dentist. People generally visit dentists when they are healthy.

The lower the level of education, the more frequently medical consulta-tions occur.

The higher the level of education, the more frequently visits are made to the dentist.

Medical consulta-tions increase in old age.

Dentist visits decrease in old age.

Source: cf. Widstrom, 2005.

Expanding on these hypotheses, this study primarily aims to examine the structures of customers of the dental trade and development correlations relevant to the dental industry as an initial link in the chain. On the basis of sound data, concrete recommenda-tions for action will be derived from this and com-mon assumptions critically examined.

1 OECD Health Data (US$ calculated OECD data basis 2011), cf. also Widstrom, 2005.

2 Note: FIDE – Federation of the European Dental Industry. FIDE represents 550 dental manufacturers in Belgium, Denmark, Germany, France, Italy, the Netherlands, Austria, Russia, Spain, Switzerland and the United Kingdom. Due to the poor situation relating to the provision of data, no statements are made in this study relating to the situation in Russia. The FIDE average and overall FIDE values thus relate to all FIDE member countries with the exception of Russia.

3 cf. WifOR, 2012.

4 cf. REBMANN RESEARCH, 2012.

5 see footnote 2.

6 cf. CBI, 2009.

7 cf. Kossioni, 2012.

1 % other

3 % prophylaxis

4 % periodontitis treatment

9 % orthodontics

33 % prostheses

50 % conservative and operative treatment

Upstream Equipment, devices, products, etc.

Dental industry

Also dental industry direct salesDental trade

Manufacture of dental productsLabora- tories

Dentists Dental hygienists Orthodontists Oral and maxillofacial surgery

Providers

Secondary dental health marketPatients/Consumers

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE ONE

SCHEDULE ONE STRATEgiES gOVERNED BY STRUCTURAL TRENDSS1

Important stationsS1

Growing prosperity

Greater demand for cosmetic products and prevention

Changing job profile

6 | 7

» Improved dental health transforms the product environment«

» Multimorbidity demands an adaptation of care structures«

Increasing importance of prevention will strengthen the role of dental hygiene further

Demand has increased for dental hygiene products

Combination dentist/dental hygiene products should be promoted

Elective treatments grow in importance

Homecare is increasingly important

Give greater consideration to collaborations with conventional medical disciplines

Exploit differentiation opportunities within the product range in the area of other disciplines

» Greater cooperation and networking leads to a change in purchasing behaviour« Identify purchasing groups

Strengthen customer loyalty through additional services (added value services)

Be prepared for pricing pressure

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE ONE

DENTAL CARE PAST AND PRESENT

Development of dental expenditure in the primary health marketThe proportion of health expenditure dedicated to dental services fell in recent years. Simultaneously, dental health has improved considerably. This is primarily due to improved prevention. In addition, the framework conditions of health policy have changed. In Germany, which previously had by far the highest per capita expenditure, but was still not-ed for poor dental health, the role played by dental prosthetic therapy was reduced through a combina-tion of an altered patient deductible and intensified

prevention. Since these changes, Germans now en-joy one of the best levels of dental health, although expenditure is considerably lower. Dental care in countries such as Sweden and Australia are also regarded as good. A high level of dental health has been attained in these countries at a relatively low cost.

Dental health and demandDental health all over Europe has improved con-siderably and continuously in recent years. The number of edentulous patients dropped from 30 % per annum in 1978 to 13 % a year in 1998.8 Cases of caries in children and adolescents also fell consider-ably.9 The WHO’s target of 80 % of children under 6 being free of caries by 2020 appears to be achievable in many places. For example, this rate has already been successfully raised to 50 % in Austria.10

Despite this, major differences exist between social groups and regions, and morbidity caused by dental problems is not inconsiderable. It is estimated in the United Kingdom that around 15 million working days are lost due to dental problems.11

People who have had a higher level of education typ-ically visit the dentist more often and enjoy better (dental) health. However, sections of the population are to be found in every country with poor dental health. Some studies postulate that the differences in dental health between social strata have become more pronounced in recent times. Dentistry today therefore covers a spectrum ranging from sim-ple tooth extraction on the one hand to high-end care which includes cosmetic dentistry and dental bleaching.

As the two main diseases encountered in dentist-ry, caries and periodontitis, are avoidable in most cases, public prevention programmes such as flu-oridation, dental cleaning education and healthy nutrition also play a central role when it comes to dental health. Prevention measures such as public dental care programmes are of especial relevance for children.

The public health service plays a central role here, and its importance is traditionally greater in the Scandinavian countries and countries with public health systems such as the United Kingdom. This can attenuate social differences somewhat.

In addition to this, age plays a significant role in the treatment spectrum. In industrial countries, two thirds of people over the age of 55 and 84 % of people over 75 have lost at least one tooth. In the case of those under 35, this proportion is only 33 %. Improved care also means that the younger popula-tion frequently exhibits a positive dental status (i.e. dental care may be limited to checkups and clean-ing which can also be realised by dental hygienists). Increasingly more elderly people retain their own teeth longer as a result, but periodontal condi-tions in these medium and higher age groups have increased.12

Fig. 4 – Development of health expenditure for dental health (% of total expenditure)

Source: OECD Health Data, 2012.

S1

Dental expenditure 1980 (% of total expenditure) Dental expenditure 2009 (% of total expenditure)

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

14.7 %

2.2 %

7.6 %

4.5 %6.4 %

4.1 %5.4 %

5.1 %

6.2 %8.9 %

4.3 %4.1 %

5.0 %

4.4 %4.1 %

no data

8 | 9

Almost 90 % of German senior citizens currently suffer from some form of peri-odontitis.13 This means that elderly people frequently require much greater and more complex dental treatment than in the past.

Trend towards greater cooperation and joint practicesLess than a quarter of dentists in Europe currently work in joint practices or other cooperation forms. In the medium term, the trend towards more joint practices prevails in the majority of countries. This is due in part to the fem-inisation of professions and the accompanying increase in part-time work as-sociated in most cases with this. Around 40 % of dentists in Germany are now women. The general change expressed in a desire to achieve a work-life balance is also related to this development.

Additionally, technological progress means that the level of investments re-quired for practices is rising, and sole practices find it increasingly difficult to hold their own. Nevertheless, the size of dental practices is limited in some countries. Advertising for dental practices is prohibited in Ireland, Portugal, Italy, France and Greece.

Collaborations are also increasingly desirable in terms of the prevailing policy. A more efficient and greatly enhanced level of care is anticipated as a result. According to a study, the growth in competition in all health markets, their networking and the increasing quality and cost awareness of consumers have caused two out of every three dentists to adapt or even change their strategies. Practically every second dentist has, on a personal level, also noticed the rami-fications for the service they offer.14

In addition to the growth in competition from alternative forms of care, the increase in patients suffering from comorbidities has also promoted strength-ened cooperation between dentists and other disciplines. The provision of home

care for disabled people is also increasing in importance in the context of de-mography. New structures, in part involving IT networks, need to be developed further here, and these will also facilitate the professional exchange with other service providers.

8 cf. Mathews, 2007 .

9 OECD 2011 (latest available data) and König 2010.

10 cf. ÖZZ, 2012 (1).

11 cf. Mathews, 2007 .

12 cf. Kossioni, 2012 and Widström, 2005.

13 cf. ÖZZ, 2012 (1).

14 cf. Dental Tribune, 2011.

Fig. 5 – Development of dental health status for 12-year-olds


1985

2010

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

0.7 %

3.9 %*0.9 %

6.3 %*

4.2 %*1.2 %

2.4 %0.9 %

4.3 %1.4 %

2.2 %0.8 %

2.1 %0.6 %

3.1 %

3.1 %*0.7 %

4.0 %1.1 %

1.3 %

DMFT values: average number of decayed-missing-filled teeth (DMFT)*Available data between 1983 and 1987 was used in the case of some countries.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE TwO

SCHEDULE TwO STRATEgiES gOVERNED BY SOCiAL TRENDSS2

Important stationsS2

Double ageing Economic situation

Non-vital dental servicesQuality requirements

Complementary dentistry

10 | 11

» Increased life expectancy and, simultaneously, a lower birth rate (double ageing) are changing dental treatment«

» Growth is determined by the demand for non-vital medical services«

Dental health needs should be considered in a more differentiated manner (older sick/older healthy people)

The spectrum of treatment is changing

Sales and marketing is turning its attention to the secondary health market

The dental industry is drawing closer to patients as a result

Innovative products beyond the curative market are becoming increasingly important

» Quality strategies benefit from in-creasing standards and a growing demand in many countries«

» Complementary dentistry is growing in importance in the context of holistic medicine« New cooperation partners can enhance dental care

New therapy options and training methods are an interesting area for dentistry

Quality is more important than price

The demand for high-quality products is growing in the secondary health market

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE TwO

Practically every European society is confronted with demographic change, al-though the degree of change differs. On the one hand, the relative proportion of senior citizens is strongly related to the birth rate and, on the other, to increased life expectancy. The baby boomers will exacerbate the problem further in com-ing years. Taken together with the absolute increase in people over the age of 65, this development is referred to as double ageing.

With their extremely low birth rates, Germany and Italy are among the most affected countries. Practically every third person in Germany will be over 65 in 25 years.

are usually visited when one is healthy; the sicker people are, the less likely they are to visit a dentist.

The lower the level of education, the more frequently medical consultations occur, whereas visits to the dentist increase where the level of education is greater. (73 % of university graduates visited the dentist in Europe last year, compared to only 29 % of those who have attained a lower educational qual-ification).18

Medical consultations increase in old age, whereas dental visits decrease. Whereas 63 % of 50 to 54-year-olds visited a dentist last year, the figure for those over 85 was only 25 % (see Fig. 6). According to a new study, 15 % of all those over 55 years of age polled had not been to the dentist for five or more years, while the figure for those younger was a maximum of 7 %.19

Levels of insurance expenditure in Germany also support these assumptions. This expenditure also decreases with advancing age. However, private expen-diture is not taken into consideration in this respect.20 Dental implants and ex-pensive dental prosthetics are in the main not covered by insurance (i.e. these services, which are particularly important for older people, are for the most part not recorded here).

A demographically driven expansion of services occurs as a result of intensified treatment in the case of a few primarily healthy patients and is probably also fi-nanced to a greater degree outside the framework of publicly funded services in the primary health market. This means that privately funded services increase in importance. Sales opportunities are therefore most attractive in countries with a prosperous (and frequently more healthy) elderly population sector and services and products which must for the most part be privately funded. This also means that market opportunities are less influenced by the average eco-nomic situation, and much more by the affluence of the older generation.

Patients are increasingly willing to pay for good quality. The appreciation of quality plays an important role in this context. This appreciation can, on the one hand, be influenced through their experience (durability, suitability, ap-pearance) and, on the other, not insignificantly through the media.

The demand for medical care grows with age, leading to an increase in expenditure. Taken as a whole, the expenditure of insurance providers per insured patient and year increases considerably from the age of 65 onwards. The primary causes are the increase in chronic illnesses and the associated multimorbidity.

Does the demand for dental care fall with increasing age?It is postulated that the same correlations between age and demand apply to dental medicine. But is that really the case in every respect? In addition to other considerations, the assumption that demand increases as the population ages is based on the fol-lowing observations:

Demand and health expenditure increase as a whole with advancing age.

On a personal level, teeth are preserved longer through advances in medical technology, the be-haviour of patients with regard to care and profes-sional prophylaxis.

The risk due to periodontitis and other diseases of the teeth, the periodontium and mouth increases with advancing age.

Treatment requirements increase as a whole.15

The appreciation of health grows with age, mean-ing that private expenditure for dental health in particular increases as one grows older.16

However: most correlations encountered in conven-tional medicine appear to be completely inverted in the case of dental medicine:17

The sicker a patient, the more frequently medical consultations occur. Dentists, on the other hand,

DEMOgRAPhiC DEVELOPMENT AND DEMAND fOR DENTAL SERViCES

S2

Fig. 6 – Europe is ageing: proportion of over 65-year-olds in the population

Source: European Health for All Database (DFA-DB), WHO Regional Office for Europe, as of: 2011.

2010 or latest available data

2035

30.2 %

24.2 %

20.63 %

24.4 %

25.9 %

26.1 %

25.2 %

24.1 %

21.9 %

20.08 %28.6 %

24.8 %

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

17.08 %

16.6 %

15.45 %

17.65 %

16.29 %

15.26 %

16.74 %

16.35 %

12 | 13

growing demand and prosperity – the significance of the secondary health marketThe secondary health market is a relatively ill-de-fined term. Whereas, when it comes to funding, demarcation makes it possible to differentiate to a relatively unambiguous degree between self-pay services on the one hand and services covered by public health insurance or the health system on the other, a differentiation according to services or products is infinitely more difficult.21

Colloquially speaking, the secondary health mar-ket is frequently understood to mean the “extended health economy” in the field of wellness and areas outside the core sector of curative medicine. In 2007, Roland Berger estimated the German contri-bution to private health expenditure to be 60 billion € per annum, with 20 billion of this being spent on the “extended” market in the areas of fitness, well-ness, health tourism and organic and functional

15 cf. NHS, 2008.

16 cf. Klingenberger, 2012.

17 cf. Kossioni, 2012.

18 cf. Eurobarometer, 2010.

19 cf. Eurobarometer, 2010.

20 Note: data on the distribution of private expenditure according to age is not available.

21 cf. Klingenberger, 2012, S. 44.


23 Note: noticeable here is that the private expenditure disclosed is considerably higher than that in public statistics on dental health. The share of 20 billion indicated therefore probably corresponds to that complementary to the core area of medicine in a narrower sense.


25 cf. ÖZZ, 2012.

26 cf. ÖZZ, 2012.

Fig. 7 – Proportion of respective age groups who have visited a dentist within the last 12 months

Source: Eurostat survey, 2002.

food.22 Cosmetic and aesthetic products in the den-tal sector are also subsumed under this figure.23

When one considers the privately funded segment, it is anticipated that the strongest growth effects will be encountered there as a whole in the future. These mainly arise

through prevention-oriented demand which, de-pending on the health system involved, is covered to a greater or lesser degree by publicly funded dental care. These services are primarily avail-able in the freely funded secondary health market in Germany. Accordingly, the share of the sec-ondary market in the overall oral health market would currently be 29.6 % and rise to about 40 % by 2030.24

Another trend is evident in complementary den-tistry in the context of holistic medicine.25 This includes collaborations with otolaryngologists, pulmonologists, orthopaedic surgeons or physio-therapists.

Other growth drivers are the growing interest in aesthetic dentistry, although this area strongly de-pends on the economic situation. As a consequence, these effects are also to be observed in relation to oral health products in the retail trade, strengthen-ing the confidence in a dynamic European market for dental care products. For example, toothbrush use in Austria grew from 1.2 to 2.1 brushes per an-num in the last decade.26

Belgium Germany Netherlands Austria Switzerland Spain

15 – 24 y. 25 – 34 y. 35 – 44 y. 45 – 54 y. 55 – 64 y. 65 – 74 y. 75 – 84 y. 85 y. and more

100 %

80 %

60 %

40 %

20 %

0 %

Fig. 8 – Costs for dental care relative to age in germany

Source: cf. Barmer GEK dental report, 2012.

Men 2010

0- 1- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85- 90-

150 %

125 %

100 %

75 %

50 %

25 %

0 %

Women 2010

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE ThREE

SCHEDULE ThREE STRATEgiES gOVERNED BY PRODUCT TEChNOLOgYS 3

Important stationsS 3

Digital technology transforms the value-added chain

High-quality and basic services

Expand cross-selling

Identification of regional market penetration

Digitalisation demands product adaptations

Monitoring of micro/macroenvironment

14 | 15

» Dental technology varies between high-quality and basic services«

The cultural, regional and individual demands of patients/doctors are coming to the fore during consideration of the price/quality ratio

Training of qualified up-and-coming talent in health care professions is also an issue for the industry

» The advance of digital technologies transforms the value-added chain« Dental technicians also work directly in practices

The number of individual labs is decreasing in favour of larger units

The number of dental technicians is falling, with the dentist increasingly the contact person for sales organisations

Large facilities bundle purchasing power

» Products which depend directly on demand are relatively independent of micro/macro-factors« Full prostheses, restorative treatment, prevention, CAD/CAM systems/digital technology

» »Micro and macro-factors are decisive when it comes to privately funded, but non-essential products« Implants, regenerative technologies, cosmetics, aesthetics

» Weak market penetration harbours opportunities for growth in some countries«

» Market intertwining of products and cross-selling options offer potential« e. g. implants and regenerative products


DigiTALiSATiON ChANgES STRUCTURES AND PROCESSES

Digital technologies alter the interaction between dental professional groupsNew technologies mean that many working procedures are replaced by com- puter-controlled processes. Necessary dental prosthetics are scanned by the dentist personally or in the lab and either processed further in the medical practice by dental technicians or electronically in the dental laboratory. Ful-ly-automated manufacture in centralised facilities is increasingly possible.

Moreover, it is also noticeable that more dental technicians work directly in medical practices. Their field of activity is increasingly characterised by com-puter-controlled processes. Routine work is realised by machines, with delicate tasks remaining the domain of the dental technician. Various manufacturers therefore recommend the combination of scanners with a centralised milling machine capability in dental laboratories. This would also enable dental labora-tories to access the latest technology without the necessity to invest in complex and maintenance-intensive milling equipment. The quality of centralised mill-ing machinery is well defined, enabling technicians to react in a flexible manner to customer wishes.27

Strategic collaborations are necessaryMore than three of every four dental labs are still small or medium-sized fa-cilities. However, technical innovations and pricing pressure from low-wage countries means that a consolidation is currently underway among dental laboratories. Outsourcing frequently takes preference over expenditure for new investment products when it comes to mergers. Laboratories also strive to replace manual tasks with automated procedures. The consequence will be a fall in the number of dental technicians. In Germany, a considerable decline has also been evident in the employment trend in the last decade.28 Turnovers achieved by dental laboratories will grow at a considerably slower rate in future than those of dentists. An overall growth of 8.8 % is anticipated up until 2030 in Germany, approximately half as large as that of dentists. In dental technology, the area outside public services is also growing considerably quicker. Whereas

this accounted for a share of approx. 1.5 billion € in Germany in 2010, the figure for 2030 is expected to grow to 2.3 billion €.29

In implant prosthetics in particularly, cooperation between the lab and practice plays a significant role. Digitalisation and material innovation increase the importance of an early involvement of dental technology in patient-centred high-quality solu-tions. Common goals are evident here, as dentists themselves demonstrate their capability to patients through dental technology quality. Collaborations and common strategies between dentists and den-tal technicians should be developed to maintain the affordability of good quality in the actual country. The involvement of dental technicians in the clarifi-cation of patients is therefore regarded as important.

New production techniquesinfluence quality and priceDental technology is increasingly divided into two to three classes, with high-end dental technology at one end, a middle ground with a balanced price/performance ratio and then, finally, low-budget care which also migrates to low-wage countries. Qual-ified training is regarded as a central factor if the medium and high-end dental technology segments are to be retained in Europe. However, problems re-lating to the provision of qualified up-and-coming talent are encountered in some countries (France, USA …). Initiatives in this context such as are to be increasingly found in the USA are doubtlessly very promising, with manufacturers cooperating with training institutes and universities. This applies in particular to highly innovative technologies.30

S 3

16 | 17

EUROPE: QUALiTY DOMiNATES

Taken as a whole, the EU market is strong and, in terms of quality, the image of European prod-ucts bearing the CE seal is excellent. In addition, the increasing uniformity of market approval requirements and standards within the EU fa-cilitates matters even further. Most innovations in the area of medical technology (i. e. not only confined to the dental sector) are first introduced to the market in the EU, and the EU has also been a key innovation driver for some considerable time now.

Medical technology is a significant economic factor, and healthcare in itself is also increasing-ly regarded as such, in as much as it is assured political and state support. A clear goal will il-lustrate an aim to maintain the attractiveness of the market for medical products within the EU to avoid endangering the competitiveness and in-novativeness of the domestic industry. Promot-ing innovation also supports new enterprises. Medical technology is ultimately one of the few sectors in which Europe will be able to maintain an advantage with its knowledge economies and know-how in competition with China and other growing economies.

As a consequence, state support for research in-stitutions and collaborations will continue. In addition to this, an increasing number of collab-orations between the private and public sector will further support development. However, it is important to confront a few challenges in this respect. These primarily relate to innovation and national regulations:

Strong competition from low-wage countries High costs relating to new technologies and

updates High research and development outlay Increasing specialisation of accessories Approval restrictions Payment limitations and stricter conditions for

inclusion in the service catalogues of health systems

Tax restrictions The need for intermediaries in some countries

Competition from discounters is encountered re-gionally and in overseas markets such as Brazil, Korea and Israel. As a result, less well established providers are forced to fight for their market share, while quality providers frequently number es-tablished dental practices with a large number of patients among their customers which are not as greatly influenced by fluctuations in demand and, additionally, do not switch so quickly to discount-ers. Equipment and material manufacturers are particularly threatened by low-price competition. Instrument manufacturers, on the other hand, are not influenced to the same degree.

There are three principle types of discounter: 1. Asian broadliners (which, despite conducting

their own research, profit from low personnel and purchasing costs, currency advantages and lean sales and service structures)

2. Copycats (which replicate established products by circumventing patents, are mainly small firms and are distinguished by lean administra-tion and an appropriate sales organisation)

3. One stop shop distributors (which combine their own products with established products in distribution)31

Fig. 9 – Dental labs in Europe (inhabitants per dental lab)

16,210

15,895

4,172

14,283

12,904

7,967

12,333

5,126

9,599

25,956

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

Source: cf. ADDE Survey, 2012.

In addition, large providers offer established basic products at low prices or in-clude a separate low-price product line in their range.

However, the demand within the EU primarily involves high-tech, innovative products.32 Competition is also stiff in this high-end segment, a situation which is also reflected within Europe where the dental market includes a large number of medium-sized enterprises. Competition and delimitation in this segment are predominantly driven by innovations. Consequently, new production facilities invariably encompass an R&D lab. In recent years, major dental manufacturers have increased their budgets for research and development.33 Funding in the scientific field is also extremely important, as its loss would, for example, lead to market losses in the area of implants and bone substitutes.

Consumables and supplies Dental materials and products

– Materials for dental fillings – Hygiene and disinfectants

Dental products/Metal implants et al. – Crowns – Multiple unit bridges – Inlays, onlays – Partial prostheses, full prostheses

Technical service After-sales service Customer, etc.

Equipment Dental practice and laboratory equipment Appliances (dental X-ray equipment, ultrasonic

systems, digital intraoral scanners, etc.) Dental instruments

Teeth delivered Incl. digital prosthetics, implants

Miscellaneous Included here are cosmetic products for customers (aesthetic treatments, toothpaste, mouthwashes, whiteners, etc.)

Fig. 10 – Market segments in the dental industry

Source: cf. ADDE Survey, 2012.


As regards framework conditions, it is not anticipated that health funding will become so limited that the quality of care would be significantly impaired, but dental medicine is normally not considered to be part of primary care and, as such, is treated as a special category. Although the accommodation of new technologies is not immediately relevant for dental medicine, a close eye should nevertheless be kept on the international trend towards increased formal health technology assessment and cost-benefit evaluations. Adjustments which includ-ed outpatient care were last made in this area in Germany through the Health Care Structure Act (Versorgungsstrukturgesetz).

The demand among patients for unpaid products and products not offered in the so-called primary care market is growing. These products appear to depend to a particular degree on the economic situation of customers, whereas emergency treatment and, additionally, cost-effective new technologies are less sensitive ar-eas. National framework conditions relating to the payment situation and trad-ing conditions are as relevant for market assessment as national contacts and the cultural preferences predominating in individual countries, particularly with regard to the range of non essentials on offer.

Categorising of dental market segmentsProducts and market segments differ considerably in terms of their custom-er structure, growth trends, innovation and quality specifications. It is there-fore sensible to also consider different product groups separately. Services and materials for dentists and laboratories can be arranged in different categories, depending on the considerations involved. The following is an example of the categorisation which, on the whole, corresponds to that of ADDE. These seg-ments are listed independently of payment and, consequently, only partially included in internationally accessible data on dental health expenditure (e.g. OECD, WHO).

18 | 19

6 % technical service

22 % equipment

2 % teeth

55 % consumables

15 % miscellaneous

PRODUCT TRENDS iN iNDiViDUAL SEgEMENTS

Consumables and suppliesConsumables and supplies account for the majority of the so-called dental mar-ket, with European sales of these increasing by 2.9 % between 2009 and 2010.34 The market value of dental instruments, dental and oral hygiene equipment and consumables in Europe was more than 519 million € in 2011. Consumables and supplies with the strongest sales are to be found in the following product groups:35

Hygiene and disinfectants: 19 % Prostheses: 19 % Endodontics: 13 % (diseases of the pulp/dentin

complex and periapical tissue) Restoration: 13 % Impressions: 12 % Polishing and surface finish: 10 %

In the area of consumables, demands are contin-uously increasing with regard to material variety, value for money and service (i.e. innovations will play a significant role). The market for dental phar-maceutical products in particular is regarded as promising for the future.

Growth is also anticipated in the area of restorative materials, as the moulding and restorative materials business is already achieving high growth rates in local currency in the USA.36

In the area of prosthetics, precious metals are being increasingly replaced by industrial solutions con-sisting of ceramics and non-precious metals, which lead one to expect a proportional drop in sales. In general, classic materials and technologies will in-creasingly be displaced by digital solutions. This change is also a result of the fall in turnover in the analog X-ray film business.37

In terms of growth markets, a good example is the implant market, and a closer look is taken at this below.

implantsThe implant market is one of the markets governed by the economic situation. In addition to economic framework conditions, market penetration and the acceptance of implants are of major significance when it comes to national market developments.

The dental implant market is divided into the pre-mium, value and discount segments. Discount im-plants make up the smallest and most fragmented part of the market. These products mainly compete

Fig. 11 – global implant market

45 – 50 % Europe

25 – 30 % North America

15 – 20 % Asia Pacific

5 – 10 % rest of world

Source: Estimates from Straumann, 2012, based on data from the Millennium Group and iData

in terms of the price and not with regard to innovation. The European market is currently dominated by a few major manufacturers who are focusing on digital prosthetics, particularly involving high-end implants.

However, increasing market fragmentation has reduced their overall market share to just over 40 %. The increasing demand for cost-effective dental im-plants has enabled many low-price competitors to enlarge their market shares in practically every European market. In particular, low-cost players from out-side Europe are attracted by this. Similar to many aspiring/new European com-petitors, these firms also supply cost-effective products, but they combine these with training programs, a strategy which promotes brand loyalty.38

HOWEVER The premium market still demonstrates its stability. Despite the economic cri-sis, a growing number of customers still demands high-quality products that guarantee an appropriate level of service and scientific improvements and can only be provided by premium manufacturers, due to the equipment required for this purpose. This can also doubtlessly be explained by the relatively low proportion of material costs as a percentage of overall costs (15 – 20 %) which patients have to bear. Material prices between countries only differ in this re-spect by a maximum of 10 %, with the USA also leading the price spectrum when it comes to implants.

Although the European market is classified as difficult, a considerable surge in growth is anticipated in the coming years, particularly as markets in Europe are still severely “underpenetrated”.

In 2011, only 15 – 20 % of adults who allowed themselves to be treated for tooth loss in the Western world received a dental implant. Even in the USA, where as few as about 2 % of patients suffering tooth loss allow themselves to be treated, over 80 % of these still received conventional treatment in 2011. It is expected that, by 2020, treatment with implants will increase from today’s figure of about 20 % to 25 – 30 %.39


Fig. 12 – Market penetration of implants

no data

55

110

no data

115

no data

190

160

20

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

Details per 10,000 inhabitants in 2011

110

Source: Estimates from Straumann, 2012, based on data from the Millennium Group and iData.

Illustration: REBMANN RESEARCH.

The fact that many dentists are presently still less than familiar with implantol-ogy represents further grounds for growth opportunities. Simultaneously, this area is still not regarded with an adequate degree of importance on a broad level during training in professional associations and dental faculties. Although im-plantology is frequently (still) not regarded as a formal specialisation, an overall improvement appears to be occurring which will have a positive effect on de-mand. Increased competence with regard to the use of implants and finishing of restorations has been identified. Moreover, general dentists are increasingly willing to recommend implant treatment to their patients. Providers can them-selves support their dental customers with training seminars in this respect.

Although a downturn resulting from the recession is apparent in Europe, pa-tients’ confidence in this technology is also growing. For this reason, signifi-cant growth in the high single digit percentage range is anticipated up to 2015 in Europe. However, strategies need to be adapted to suit differing national

situations. Analysts consider the main risk to lie in a renewed economic crisis. The economic crisis in Spain and Italy has had a clear impact on the im-plant market:40

Italy: Currently the second largest implant mar-ket in Europe. However, the downward price spi-ral will make it difficult to achieve profits here.

Spain: The market here is expected to shrink fur-ther in the near future.

France and UK: A low penetration rate and the simultaneous growth in acceptance among both doctors and patients mean that considerable growth may be expected in both these countries. Growth rates of about 8 % or approximately dou-ble the rate in the rest of Europe are forecast.

China: Increasing prosperity offers market op-portunities.

Eastern Europe: The greatest growth rates are an-ticipated here. Labour and dental costs are low, and this strongly influences the overall price. As a consequences, these countries profit from dental tourism from Germany, the United Kingdom and France. By the end of 2015, it is anticipated that sales rates in this region will correspond to those of Benelux (or represent > 5 % of all earnings in the European dental market).

20 | 21

27 cf. Straumann, 2012.

28 cf. WifOR, 2012.

29 cf. WifOR, 2012.

30 cf. Franke, 2004.

31 cf. Eucomed, 2012.

32 cf. CBI, 2009.

33 Heraeus reported in 2011 that the dental products business division had increased its research and development activities by 6.6 % when compared to the previous year. The innovation rate in all other divisions was also 8.0 % for 2011. Straumann adopted this progressive innovation as a strategy, and 6 % of turnover was invested in R&D and a comprehensive develop-ment portfolio (and numerous clinical studies).

34 cf. businesscoot.com, 2012

35 cf. businesscoot.com, 2012

36 cf. Heraeus, 2011.


38 cf. Millennium Research Group, 2012.

39 cf. Achermann, 2012.

40 cf. Millennium Research Group, 2011 and cf. Straumann, 2012.

41 cf. www.marketresearch.com.

42 cf. Millennium Research Group, 2012.





Digital technologies also transform productsDigitalisation is also rapidly forging ahead in the dental area. Experts assume that significant shares of turnover will be generated through digital pros-thetics and other technically based services, both in the dental practice and laboratory market. The con-sequence of this is the transfer of dental technology services from the laboratory to the dental practice and can either be rendered completely directly on location or, alternatively, in centralised production facilities.

If the strategies of major manufacturers are re-garded as trend indicators, the outlook for digital technologies is positive. Major producers are in-creasingly investing in new technologies and ap-plications in the area of digital dental medicine, particularly prosthetics. Indications and produc-tion technologies are expanding, with production capacity in the CAD/CAM business increasing. In addition, the range of services is being expanded through intra-oral scanners for digital recording of oral situations, a central element in further forward integration in the prosthetic care process chain.

Admittedly, uneven developments have been ob-served between countries in the area of CAD/CAM (bridges and crowns):41 the European average in-dicates slight growth. However, the CAD/CAM market is, on the whole, frequently less profitable at present than implants.

Opportunities inherent in other selected product groups Abutments (the connecting elements between the implant and crown) can be

very expensive, depending on the material involved. Despite this, it is antic-ipated that turnover in the area of cost-intensive, individually milled abut-ments will increase by almost 7 % per annum up until 2016.42

New technologies are rapidly conquering the market. Tapered internal con-nections, for example, are among the latest innovations and currently repre-sent the connection type exhibiting the strongest growth in the dental im-plant industry.43

The challenges posed by the current economic crisis and the Euro crisis are graver in some areas than in others. For example, the area of regenerative products and barrier membranes has been severely affected by a reluctance to spend on the part of consumers, because these products are not consid-ered an urgent necessity in many cases. Similar can be said of bone substitute materials.44

Market intertwining occurs in the case of implants and regenerative prod-ucts: both are often used in combination. As a consequence, both segments are interrelated with regard to growth, and the most important customers are frequently the same (e.g. maxillofacial surgeons and paradontologists).45

By contrast, the area of industrially manufactured dental crowns and bridge frameworks developed in a positive manner recently for some manu-facturers.46

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE fOUR

SCHEDULE fOUR STRATEgiES fOR ThE MiCROENViRONMENTS 4


Identification of high coverage densities

Secondary health market

Main target group: wealthy older people

under-mobilized target groups

Identification of affluent regions

Microenvironmental analysis

22 | 23

» Demand is governed by the microenvironment (e. g. medical condition, age and social status of patients)«

» Target groups with hitherto low mobility show potential (e. g. two to six-year-old children, men, segments of the urban population)«

» The demand in regions with a high coverage density of dental professions is more marked (supply-induced demand)«

» Affluent and growth regions – insofar as these are identified – are the drivers behind aesthetic and innovative products (demand-induced supply)«

» Your product strategy should be governed by whether the product segment is dominated more by the primary or secondary health market«

» Healthy, educated, affluent older people form a significant user group«

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE fOUR

SALES SUCCESS DEPENDS ON CLEAR REgiONAL KNOwLEDgE

A successful marketing strategy begins with analy-sis of market conditions at the location: There are patients at every location who can be

mobilised. A contemporary study of the utilisa-tion of dental services47 indicates who is involved: two to six-year-old children, men, segments of the urban population.

The dental environment is very often extremely heterogeneous.

Extensive medical and economic reserves are to be found in multidisciplinary cooperation with other specialised medical groups.

Supplementary dental insurance from health in-surance providers offers opportunities.

Opportunities in the dental sector are to be found in addressing patients correctly, the targeted offering of the service spectrum and regular mobilisation (e.g. through recall marketing measures). Accord-ing to the Barmer GEK dental report,48 two out of every three children in Germany between the ages of two and six years miss individual screening ex-aminations, with commensurate consequences for milk teeth which, after all, account for 5 % of all dental fillings. Experts recommend the extension of group prophylaxis in this case to encompass kinder-

S 4gartens to reach children otherwise who do not come to screening examinations at the dentist. The study indicates that, on the whole, only 31 % of children under the age of 6 participate in oral prophylaxis at the dentist. By contrast, the par-ticipation rate in paediatric check-ups U5 to U7 in Germany (or between month 6-7 and 21-24) is around 95 %, and 90 % for U8 and U9 (between month 46-48 and 60-64). This means that, in the case of countries with systems similar to that in Germany, dental care exhibits a considerable potential for mobilisation un-der certain circumstances (in comparison to paediatricians). In countries with strongly public healthcare systems (DK, UK), programs of this nature have ex-isted for a long time and are organised in a different manner.

Prophylactic measures are without question an important topic for all age groups. Although the German study indicates that the annual prophylaxis at the dentist has become established and about half the population has cal-culus removed annually through professional dental cleaning, the other half can still be addressed and mobilised in a targeted manner. The frequency of prophylactic measures is as much a topic for the practical profile as expansion to include corresponding products or services, known as cross-selling. Dentists and dental hygienists should themselves be active at this point. A further item involves the regional differences where the entire dental service package is tak-en advantage of.

Another issue is the increasing importance of aesthetic aspects in dental care and the so-called secondary health market which is not directly connected to the health system

The German study particularly examines factors in this respect which influence treatment frequency. It determined that an average of 70.3 % of the population had contact at least once with the dentist during 2010. The question arises here as to why the treatment rate is so different on a regional level, being around 78.9 % in Saxony. The lowest value, 63.7 %, was recorded in Saarland (see “Re-gional fluctuations”). On the other hand, the study provides indications of a range of further reasons which correlate with frequent dental visits, including a high proportion of persons with public insurance cover or old age. Sex also plays a significant role. The male population (66 % consulted a doctor) represents an even higher mobilisation potential for the dental profession than women (74 %).

Fig. 13 – Density of dentists (inhabitants per dentist)

Source: cf. ADDE, 2012.

2,334

1,531

1,206

1,509

2,021

1,670

1,212

1,061

1,707

2,077

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

24 | 25

Fig. 14 – Density of dental technology (inhabitants per dental technician)

Source: cf. ADDE, 2012.

4,053

3,578

1,231

6,695

2,943

3,650

3,265

2,160

2,935

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK 8,712

Even considering the addressing of females and males in a different manner in dental practices may prove decisive. The specifically German situation also indicates that the frequency of dental visits made by children can be traced back to the long-term effects of socialisation in early childhood in day-care centres and nurseries in the former German Democratic Republic.

CARE STRUCTURE AND ACCESS DiffER gREATLY ON A REgiONAL LEVEL

DentistsAround 83 % of all practicing dentists in the EU work in private practices. This reaches almost 100 % in some countries (e.g. Portugal)49, while including around 80 % of a total of 46,000 medical practices in Germany. The largest de-mand for dental products currently comes from this group. The number of both dentists and auxiliary personnel has increased continually almost everywhere in the EU, with a growth of 13 % being recorded between 1997 and 2007.50 The greatest level of growth in this period was recorded in Portugal (+200 %). Con-siderable growth also occurred in Spain (+56 %), Luxemburg (+51 %), Austria and Switzerland (+44 %) and Ireland (+30 %).51 The WHO recommends a dentist density of one dentist for max. 2000 of the population. Most Western Europe-an countries were already far below this figure in 2007, with Switzerland and Austria still registering a slightly lower dentist density. The increase is put down to the then positive economic situation and the fall in the edentulous popula-tion and their increasing demands. In Sweden, Denmark and Finland, on the other hand, the number of dentist fell slightly, a trend which can be traced back to the policy-driven reduction of training capacity for dentists in favour of den-tal hygienists.52

Regional fluctuationsThe density of dentists fluctuates considerably on a regional level. In addition to fluctuations between countries, clear differences are also evident within coun-tries. Despite an increase in the density of dentists, a relative care deficit can be detected in rural and structurally weak regions, due to the long distances patients need to travel. For example, a clear north/south disparity is evident in Italy: the provision of dental care in the north is considerably better. As a consequence, requirements planning exists in some countries. However, the majority of Europeans (88 %) indicated that they could get to a dentist with-

in 30 minutes,53 including in rural areas. Access was poorest in the United Kingdom (82 %), Poland (83 %), the Czech Republic (80 %) and Italy (79 %).

Supply-induced demandA current study forecasts that the dental market will experience a constant growth rate for the fore-seeable future, due to the increase in the number of dentists and dental hygienists and the growing use of cosmetic dentistry products.54 This implies that the number of service providers correlates to the demand. We would like to take a closer look at this hypothesis. The phenomenon of supply-induced de-mand is familiar from the health market. This im-plies that, relatively independent of the actual treat-ment requirement, the more services are offered, the more frequently health services will be availed of. The indirect relationship between the customer (pa-tient) and provider (doctor) in particular is the caus-al factor here, as the insurance pays, not the patient him or herself. In Germany at least, improved dental health does not appear to correlate negatively with the number of fillings, extractions or prosthetic ser-vices.55 This can be a consequence of supply-induced demand. However, the growing demands of insured customers relating to dental health doubtlessly rep-resent a further factor.

That dental health demand is not necessarily a consequence of supply and, consequently, a sup-ply-induced demand phenomenon is illustrated by a further perspective of the study. A comparison be-tween dental services demanded by urban and rural patients surprisingly indicated a higher level of de-mand among the rural population, even though the density of dentists in rural areas is about 24 % low-er. Overall, rural utilisation is 3 % greater than the urban level. When viewed conversely, considerable

Fig. 15 – Number of dental visits (dental visits per dentist)


3,837

2,533

1,825

2,581

2,222

2,305

1,142

1,495

2,837

1,662

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

mobilisation potential still appears to exist as a consequence in conurbations in a generally multicultural patient pool. Dentists who can adapt to suit the spe-cial needs of these target groups should have a good chance of attracting more patients into their own practices.

47 cf. Barmer GEK dental report, 2012.

48 cf. Barmer GEK dental report, 2012.

49 cf. CBI, 2009.

50 cf. Widström, 2010.



53 Note: This applies to Belgium, Cyprus, Finland, Ireland, France, the Netherlands, Germany, Malta and Slovenia, where > 90 % of those polled indicated this. The figure was lower in Sweden, Spain and Greece. (cf. Eurobarometer 2010, (p. 40)).

54 cf. Global Information Inc., 2012.

55 cf. Saekel, 2010.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE fiVE

SCHEDULE fiVE STRATEgiES fOR ThE MACROENViRONMENTS 5


Prosperity in the countries

Growth in the countries

Consideration of cultural preferences

Public financing

Private funding share

26 | 27

» Countries in which dental services are for the most part covered promise a stable market«

» Price strategies are primarily appreciated in countries with a shrinking GDP«

» Countries in which there is a high level of private funding are more receptive to growth, but also harbour risks«

» Consideration should be given to cultural preferences, particularly with regard to non-essential services«

» Countries with unchanging/growing prosperity (measured relative to GDP) offer a suitable environment for rather more quality-oriented strategies«

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE fiVE

S 5DENTAL MARKETS AND ThE ECONOMiC SiTUATiON

How does the economic situation of a country and the liquidity of patients (and, possibly, the econom-ic situation of dental service providers) influence the demand for dental treatment?

Firstly, there are indications that the economic sit-uation of patients (their income) generally influ-ences the demand for dental treatment. Due to the costs involved, people with lower incomes evidently avoid having necessary or desirable treatment real-ised with greater frequency, and this is largely un-

connected to the country and the proportion of costs which must be privately funded there. In addition to the overall economic situation of a country, the distribution of resources within a society also influences demand. In countries where, for example, numerous older people have lower incomes, the demand for den-tal care can be relatively lower than is demographically expected.

What is the relationship between dental services which must be privately funded and demand?56 This ques-tion is relevant, both from the point of view of individual countries and with regard to product groups and services. Different correlations are conceivable here: 1. The market is more stable where dental services are covered, as services can still be obtained if the pri-

vate economic situation deteriorates. 2. The market is more promising where a higher private funding share exists, as the demand here is

governed directly by the need/price /quality requirement and more resources can be made available for care.

In principle, it can be said that, the less essential they are considered by a society, the less services tend to be covered. Emergency care and dental maintenance in particular are covered in most cases as a result. Pre-vention is only gradually being recognised as a cost-effective strategy for long-term cost avoidance. Care for children and adolescents in particular is, as a consequence, covered in most countries. On the other hand, services such as dental prosthetics are available which are classified as being more of a cosmetic nature.

It was observed during the economic crisis in 2009 that, in general, the level of treatment for tooth loss fell. More patients postponed treatment or did without it.57 Dental implants and bone substitute materials were also affected by the economic crisis, these mainly involving self-pay services. The implant market recovered slowly following the crisis, only to be negatively affected once again by the debt crisis in 2011, primarily in the USA and Europe. Other non-essential therapies or materials such as regenerative products were also particularly affected by the savings behaviour of customers.58

This all suggests that chiefly uninsured indication areas and those which are not absolutely necessary de-pend on the economic situation of patients. A further indication of the dependence of demand on payment is the fall in demand in indication areas affected by savings measures in healthcare. Examples of this are the successful move away from dental prosthetic therapy following its exclusion from payment cover in Germany or the restriction of payments for precious metal alloys in recent times.59

Fig. 17 – Non-fulfilled treatment demand relative to income

Source: Eurostat, 2009/2010.

Lowest income quintile (%)

Total population (%)

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

2.1

3.91.4

5.7

8.94.4

2.00.8

2.81.5

8.84.2

2.4

6.5

0.80.6

11.76.7

4.6

28 | 29

no data

Fig. 18 – Private expenditure vs. rate of change of economic development

Source: OECD Health Data 2012; illustration and calculation: REBMANN RESEARCH.

56 Note: dental services funded privately vary considerably bet-ween different countries, but are difficult to quantify uniformly. The proportion of private expenditure for dental medicine is therefore drawn upon as an approximate value.




0 % 2 %–2 %

0 %

20 %

40 %

60 %

80 %

100 %

4 % 6 %

X-axis: rate of change GDP 2008 – 2011

Y-axis: proportion of private expenditure

relative to total outlay for dental

services 2011

Circle size: per capita dental expenditure

NetherlandsX: 1.30 %

Y: 25.00 %0: 191.80 €

franceX: 3.30 %Y: 25.30 %

0: 184.60 €

DenmarkX: 2.20 %Y: 70.50 %

0: 230.64 €

germanyX: 4.80 %Y: 25.90 %

0: 287.34 €

BelgiumX: 6.80 %Y: 28.10 %0: 88.32 €

AustriaX: 6.40 %Y: 39.60 %

0: 215.66 €

SpainX: -2.20 %Y: 97.20 %

0: 118.31 €

italyX: 0.30 %Y: 97.00 %0: 211.10 €

SwitzerlandX: 3.3 %

Y: 91.00 %0: 463.30 €

UKX: 5.20 %Y: 69.30 %0: 127.98 €

X-axis: rate of change gDP 2008 – 2011

Y-ax

is: p

rop

ort

ion

of p

riva

te e

xpen

dit

ure

rel

ativ

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tal o

utl

ay f

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den

tal s

ervi

ces

20

11

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE SiX

SCHEDULE SiX NATiONAL STRATEgiES, BY AND LARgES 6


Health policy vs. economic power

Special care programs Payment, contracts, approval

30 | 31

» Each health system also offers special health programs for dental health care«

» Knowledge of specific national regulations relating to approval, panel doctor legislation and payment increasingly represents a decisive success factor for the sale of dental products«

» The success of many dental products is significantly influenced by the economic power of a country«

S 6ThE MARKET ENViRONMENT BECOMES MORE DiffiCULT

Europe accounts for about 30 % of the global den-tal market, with Germany for its part representing the largest market.60 From the point of view of the VDDI, the German market was worth 1.67 billion € in 2011.61

In Europe, Germany also leads in terms of the num-ber of manufacturers of dental products, occupying first place ahead of France, Italy and Great Britain. Alone the 200 member companies of the Associa-

tion of German Dental Manufacturers (Verband der Deutschen Dental-Industrie VDDI) employed about 18,100 personnel in 2011 at home and abroad. Customers of these manufacturers are the around 264,000 European dentists and, additionally, dental laboratories.

Slight single-digit market growth is forecast for the next few years, but this may differ greatly from sector to sector and country to country. A complete recovery to the double-digit growth levels which typified the sector prior to 2008 is at present not anticipated.62

Consolidation is also currently taking place in some segments. Merger and takeover activities in 2011 relating to, for example, implantology and digital dental medicine confirm this.

Clear regional differences are also evident: whereas the market in Europe has become increasingly more difficult, the US market appeared to be more or less unaffected by economic fluctuations in terms of the im-plant market.63 The European market is covered 60 – 80 % from the EU itself. The other significant supplier countries are Switzerland, the USA and Japan. Markets within Europe also developed differently. While sales figures in Germany barely changed (+1.1 %), France recorded significant growth (+10.7 %). On the other hand, Great Britain (-1.9 %) and, most significantly, Italy (-2.6 %) suffered losses.64

health systems and dental careIt is becoming increasingly advisable for the manufacturers of dental products to adapt with greater in-tensity to the distinctive peculiarities of specific countries. These are addressed below in strategic recom-mendations for individual countries, a collection of relevant market data and the depiction of key systemic relationships relating to dental medicine.

Overall, however, opinion leaders in the dental market regard the influence of health policy to be consid-erably lower in the area of dentists/orthodontics than in other health markets (less than 70 %) and, in con-trast, estimate the significance of general economic development to be considerably greater.65

Relative to economic development, health expenditure in a majority of Western countries has risen slightly in recent years, if only moderately in most countries like Germany, France and Austria. After the USA, the highest expenditure is registered by Germany, the Netherlands, France and Switzerland. Health expen-diture was consciously increased in England in recent years and has since drawn closer to the European average. However, considerable cost-saving measures are currently being implemented again in the UK.

Fig. 19 – Development of health expenditure in an international comparison: 1996 – 2009; share in gDP in %

Source: WHO Global Health Expenditure Database, National Health Accounts. Retrieved on 23.08.2012

20 %

15 %

10 %

5 %

0 %

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

USA UK Germany Switzerland France

32 | 33SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE SiX

Fig. 20 – Public health expenditure and expenditure for social insurance (2009)

Source: OECD Health data, 2012.

60 cf. CBI, 2009.

61 cf. VDDI, 2012.


63 cf. Finanz und Wirtschaft, 18.08.2012.

64 cf. ADDE, 2012.


66 Note: e. g. Denmark, Finland, Iceland, Ireland, Lithuania, Malta, Norway, Sweden and the UK.

Scientifically speaking, countries are frequently grouped together according to the insurance sys-tem involved but, from the point of view of the den-tal industry, other factors appear to be of particular relevance, including strict payment regulations and the level of the deductible paid by patients. Division into categories cannot be achieved in a practical and stringent manner for this purpose. For example, there are certain services which are offered inde-pendently of the system in different countries, such as subsidised care for the elderly, which is available in Denmark, Hungary, Portugal and Norway. In the interest of cooperation and customer relations, it is therefore important to understand the individual structures of respective countries.

Dental care in the private sectorNo purely market-oriented health systems exist in Europe comparable to the situation in the USA. General health care in Europe is predominantly financed through public funding or from social in-surance. However, in the case of dental care, this is mainly paid for privately in Southern Europe and Switzerland, as is the case in the USA. Only care for children and adolescents is frequently financed by the public sector.

Public health systems financed through taxesSystems of this nature are primarily encountered in the Nordic Countries and Great Britain (N, S, DK, UK). Dental care is typically based on a large public sector with salaried dentists and doctors und strong prevention programs. Care for children and adolescents is in most cases free, with home care for the elderly also being offered by the public health sector.66 The private sector is frequently supported

by public insurance providers, but dental expenditure tends to be paid privately.

In social insurance systems (Germany, France, the Netherlands, Belgium, Austria …), the involvement of the public care sector is much less pronounced (i. e. fewer public prevention programs). Dental treatment is covered to varying degrees, with care for children and adolescents being in the main free of charge. Doctors mainly work in private practices whose representatives conduct price negotiations with the insurance pro-viders. Dental expenditure is for the greater part covered by the insurance.

8.53 %

3.85 %

22.73 %

24.42 %

32.34 %

18.95 %

84.56 %

79 %

no data

83.20 %

Belgium

Germany

France

Netherlands

Austria

Switzerland

Denmark

Italy

Spain

UK

Public expenditure (except social insurance) Social insurance Private expenditure

6.74 % 70.52 %

10.93 % 64.65 %

14.32 %

22.87 %

34.78 %

15.44 %

21 %

7.9 %

77.15 %

73.72 % 22.43 %

44.79 %

46.27 %

8.9 %

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE SEVEN

SCHEDULE SEVEN SOCiAL iNSURANCE SYSTEMS iN DETAiLS 7


Germany Switzerland

France AustriaBelgium

Netherlands

34 | 35

» Dental care is covered to varying degrees in these countries. Nevertheless, the demand for quality and aesthetic products is strong«

» Prevention and dental hygiene will also tend to grow in importance here«

» These countries are attractive for products in the secondary health market or for the affluent self-payer target group, frequently also for well-insured pensioners«

» The dental infrastructure is in the main good, the density of dentists and dental labs is high«

» Relative to the state systems of the UK and Denmark, average dental health is poorer«


BELGIUM» Dentists work primarily in sole practices.«

» Only basic services are remunerated in a fee-for-service system, 28 % is funded privately.«

» Many dentists only treat private patients/self-payers.«

» The trend towards aesthetic dental treatment is expressed in above-average growth in, for example, ceramic inlays.«*

Belgium without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _____________________________ Belgium ___________ Deviation ____


Population ____________________________________________________________________________________________________________________________________________________________________ 10,700,000 __________________________________

Gross domestic product ___________________________________________________________________________________________________________________________________ 401,100,000,000 € __________________________________

Changes in GDP rel. to last year ____________________________________________________________________________________________ 1.5 8 % ________________________________ 1.90 % ________________________ ____

Total health expenditure of GDP __________________________________________________________________________________________ 10.83 % ________________________________ 10.7 % ________________________ ____

Total health expenditure ____________________________________________________________________________________________________________________________________ 43,000,000,000 € __________________________________


Percentage of total health expenditure for dental treatment ________________________________________________ 5.12 % _______________________________ 2.20 % ________________________ ____

Proportion of total health expenditure for dental treatment (calculated) ______________________________________________________________ 900,000,000 € __________________________________

Total sales value of dental market, minus software ________________________________________________________________________________________________ 128,000,000 € __________________________________

Total number of dental dealers __________________________________________________________________________________________________________________________________________________ 60 __________________________________

Dental practices using intra-oral cameras ___________________________________________________________________________ 38.13 % _____________________________ 25.00 % ________________________ ____

Total sales value of sundries _____________________________________________________________________________________________________________________________________ 78,000,000 € __________________________________

Total sales value of metal implants ___________________________________________________________________________________________________________________________ 12,000,000 € __________________________________

Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € _______________________________ 1,121 € ________________________ ____

Number of new dental X-ray units installed ___________________________________________________________________________________________________________________________ 1,165 __________________________________

Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0,07 _________________________________ 0,109 ________________________ ____

fUNDiNg

Percentage private expenditure of total expenditure for dental services ___________________________ 55.46 % ________________________________ 28.1 % ________________________ ____

Proportion private expenditure of total expenditure for dental services _______________________________________________________________ 270,000,000 € __________________________________

DENTAL hEALTh

Dental health of 12-year-olds (2010, in DMFT) ___________________________________________________________________________ 0.96 ___________________________________ 0.90 ________________________ ____

DENSiTY Of MARKET

Number of practicing physicians/doctors ___________________________________________________________________________________________________________________________ 31,030 __________________________________

Density of physicians (practicing physicians per 1,000 inhabitants) ________________________________________ 3.54 ___________________________________ 2.90 ________________________ ____

Number of practising dentists _______________________________________________________________________________________________________________________________________________ 7,100 __________________________________

Density of dentists (practicing dentists per 1,000 inhabitants) ________________________________________________ 0.65 _________________________________ 0.664 ________________________ ____

Number of dental practices ___________________________________________________________________________________________________________________________________________________ 6,100 __________________________________

Density of dental practices (dental practices per 1,000 inhabitants) _______________________________________ 0.46 _________________________________ 0.570 ________________________ ____

Number of dental technicians _______________________________________________________________________________________________________________________________________________ 1,600 __________________________________

Dental technician – density (dentists per 1,000 inhabitants) ____________________________________________________ 0.33 __________________________________ 0.150 ________________________ ____

Total number of dental laboratories (dentists and commercial laboratories) __________________________________________________________________________ 750 __________________________________

Dental laboratory – density (dental laboratories per 1,000 inhabitants) ___________________________________ 0.11 _________________________________ 0.070 ________________________ ____

Dentists per dental laboratory ___________________________________________________________________________________________________ 7.45 ___________________________________ 9.47 ________________________ ____

Citizens per dental laboratory ______________________________________________________________________________________________ 12,490 _______________________________ 14,267 ________________________ ____

Dental graduates per 100,000 inhabitants _______________________________________________________________________________ 1.88 ___________________________________ 1.33 ________________________ ____



36 | 37

* cf. Simer A., 2010.

The system

Political background Federal democracy and constitutional monarchy. Capital: Brussels. Approx. 65 % of a population of about 10.7 million live in towns or cities.

Belgium is one of the most densely populated countries in the EU (349 inhabitants/km²).

The birth rate has being increasing slightly again since the mid-2000s.

The insurance system Obligatory social insurance system (Bismarck model) with predominantly

private providers. 99 % of the population is insured. Social health insurance consists of six private health insurance providers

(not-for-profit, but privately managed) and a public insurer. Insurance contributions are income related, not risk related.

Two insurance schemes exist: – Major risks: hospital care, obstetrics, elective surgery, dialysis,

rehabilitation, implantations and consultant care. – Minor risks encompass medical consultations, dentist, minor surgery,

home care, medication in the outpatient sector. Self-employed persons previously only insured for major risks are obliged to pay insurance for both schemes since 2008.

Private insurance providers account for a small market share.

Organisation A national health insurance institute administers the overall health system

and distributes funds to health insurance providers. The national health insurance provider negotiates tariffs for two years at a

national level with representatives of doctors (and dentists). This “conven-tion” must be signed by the health minister. All individual doctors must then agree.

Physicians are free to practice as “convention doctors” or to apply their own tariffs (lower remuneration). Individual contracts between insurance firms and providers are not possible.

Patients are free to choose their doctor, hospital and insurance.

Funding National social insurance covers approx. 67 % of expenditure (2008). Patients pay an additional amount of approx. 28 % from private funds (ad-

ditional payments and private insurance policies). 17 % is covered by direct payments, 9 % through supplementary insurance and consumer taxes.

Fixed budgets for the health insurers were introduced in 1995 to attenuate costs. Since then, health insurance firms endeavour to acquire cost-effective care services.

Medical technology/Dental technology The market volume for medical technology is approx. 3.6 billion € (2009). The demand for medical technology grows by around 3 to 4 % per annum. Around 300 medical engineering companies are registered in the Unamec

association, 250 of which are involved in sales and only 40 producing them-selves.

Imports from Germany grew in 2009 by 21 % to 400 million €, and growth rates of 12 % were also recorded each year in 2010 and 2011.

About one quarter of all dental instruments and X-ray appliances originates in Germany (Eurostat).

Recognisable trend towards aesthetic aspects of dental treatment: above-average growth in, for example, ceramic inlays.

Dental care

Dentists The majority of dentists work in private sole practices and are remunerat-

ed through a fee-for-service system. Numerous dentists restrict treatment exclusively to private patients

Payroll expenditure for doctors is 27.8 % of the budget and 2.8 % for dentists.

Remuneration Practically every service involves a deductible or additional payments with a

salary-based upper limit. Dental services involving prevention and tooth extraction are remunerated

in full. Orthodontics, prosthetics and further treatment are remunerated in line

with an agreed service catalogue.

Distinctive features There is no fluoridation programme in Belgium

(as of 2008).

Sources cf. EU Manual of Dental Practice, 2008, Belgium cf. HiT Profile Belgium 2007 and 2010

Further information Unamec professional association Union Francophone des Laboratoires Dentaires

de Belgique; www.ufldb.be; (French-language dental laboratories)

Unie van Dentaaltechnische Bedrijven; www.udb.be; (Flemish dental laboratories)

Dentex; www.dentex.be; dental technology fair held every two years in Brussels


GERMANY» The majority of dentists work in private practic-es, with remuneration of basic care and part of dental prosthetics.«

» The level of dental health is now one of the best in Europe and, simultaneously, Germany leads both in terms of expenditure and infrastructure.«

» The density of dentists and, in particular, the density of dental technicians is above average.«

»Annual care is remunerated.«

»The demand for quality products is growing.«

germany without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) ___________________________ germany ___________ Deviation ____


Population _____________________________________________________________________________________________________________________________________________________________________ 81,310,000 __________________________________

Gross domestic product _______________________________________________________________________________________________________________________________ 2,794,500,000,000 € __________________________________

Changes in GDP rel. to last year _____________________________________________________________________________________________ 1.58 % ________________________________ 3.00 % ________________________ ____

Total health expenditure of GDP __________________________________________________________________________________________ 10.83 % ______________________________ 11.00 % ________________________ ____

Total health expenditure __________________________________________________________________________________________________________________________________ 307,400,000,000 € __________________________________


Percentage of total health expenditure for dental treatment ________________________________________________ 5.12 % ________________________________ 7.60 % ________________________ ____

Proportion of total health expenditure for dental treatment (calculated) _________________________________________________________ 23,400,000,000 € __________________________________

Total sales value of dental market, minus software _____________________________________________________________________________________________ 2,308,000,000 € __________________________________

Total number of dental dealers _________________________________________________________________________________________________________________________________________________ 160 __________________________________


Total sales value of sundries _________________________________________________________________________________________________________________________________ 1,178,000,000 € __________________________________

Total sales value of metal implants _________________________________________________________________________________________________________________________ 355,000,000 € __________________________________

Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € ______________________________ 4,366 € ________________________ ____


Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 _________________________________ 0.050 ________________________ ____

fUNDiNg

Percentage private expenditure of total expenditure for dental services ___________________________ 55.46 % ______________________________ 25.90 % ________________________ ____

Proportion private expenditure of total expenditure for dental services ____________________________________________________________ 6,050,000,000 € __________________________________

DENTAL hEALTh


DENSiTY Of MARKET

Number of practicing physicians/doctors ________________________________________________________________________________________________________________________ 300,829 __________________________________


Number of practising dentists _____________________________________________________________________________________________________________________________________________ 67,808 __________________________________


Number of dental practices _________________________________________________________________________________________________________________________________________________ 46,670 __________________________________


Number of dental technicians _____________________________________________________________________________________________________________________________________________ 66,400 __________________________________

Dental technician – density (dentists per 1,000 inhabitants) ____________________________________________________ 0.33 _________________________________ 0.817 ________________________ ____

Total number of dental laboratories (dentists and commercial laboratories) _____________________________________________________________________ 19,595 __________________________________



Citizens per dental laboratory ______________________________________________________________________________________________ 12,490 __________________________________ 4,149 ________________________ ____




38 | 39

The system

Political background Germany is a federal republic consisting of 16 federal states with a parlia-

mentary democracy. The population density of a total of approximately 82 million inhabitants fluctuates strongly on a regional level. Falling birth figures and growing life expectancy have led to a demographic change with a strong increase in the share of the elderly population.

The insurance system Public social insurance with insurance obligation up to an upper salary limit

(Bismarck model). Public health insurance currently consists of approx. 120 individual insurance providers (primary insurers (including local, company, agricultural and trade association health insurance funds such as the BKK, LKK or IKK open today to all) or substitute insurers). The state specifies the framework conditions, while local self-administration (everybody involved in care) is responsible for care.

Approx. 10 % of the population is privately insured.

Organisation Insured people can freely select doctors. Contributions (practically split in half between the employee and employer)

are paid into the health fund. Insurers are allocated their funds from this via a risk structure compensation scheme which is adjusted to take morbidity into consideration.

The associations for panel doctors (and dentists) are responsible for ensuring outpatient care.

Funding Private expenditure arises as a result of supplementary insurance, private

health insurers, individual healthcare services and fees (e. g. prescription fees). Contributions for private insurance policies cover approx. 8.8 % of overall expenditure for health.

Approx. 7.6 % of all health care expenditure is for dental health.

Medical technology/Dental technology Following a boom in the 1970s resulting from comprehensive reimburse-

ment, the volume grew at the expense of quality. Limiting reimbursement caused competition and quality to come to the fore.

Approval/remuneration of medical technology Medical technology in the inpatient area is governed by the prohibition

reservation (which permits all innovations which have not been explicitly banned), and the permission reservation (where a permit is required) in the outpatient sector.

The Health Care Structure Act (Versorgungsstrukturgesetz) permits the temporary inclusion of innovative products in the service catalogue until evidence of cost-benefit is produced (§ 137 SGB V).

Dental care

Dentists Around 85 % of dentists work in sole practices, and this figure is as high as

95 % in the new federal states. Oral and maxillofacial surgery exists as sub-specialities (2007: 2048, Medi-

cal Association (Ärztekammer)), orthodontics (3309), periodontology (40), dentist for public healthcare system (480).

Accreditation Dentists are remunerated via panel dentist associations or private health

insurers according to regulations governing fees for dentists. Accreditation restrictions for panel dentists have been lifted since 2007

(German competition reinforcement act in public health insurance (GKV-Wettbewerbsstärkungsgesetz)). Requirements planning was adapted in 2007 in the case of orthodontists to reflect the falling demand for treat-ment, this being primarily a consequence of the continuous decline in the patient group up to the age of 18 and a drop in caseloads as a whole.

Remuneration Preventative checkups and dental treatment

for children and adolescents are covered in Germany. Treatment by dentists is also covered. Additional payments are necessary in particular for dental prosthetics (generally 50 %).

Dental services accounted for 5 % (2.29 billion €) in the first quarter of 2012, with dental prosthet-ics accounting for 2 % (0.79 billion €) of all public health insurance services.

Distinctive features 69.2 % of table salt is fluoridated.

Sources cf. EU Manual of Dental Practice,

2008, Germany cf. Rebmann B., 2012 cf. Saekel R., 2010 cf. Klingenberger, 2012 cf. Barmer GEK dental report, 2012 cf. ADDE, 2012


FRANCE» The French generally consider teeth to be relatively unimportant.«

» After all, the quality of life is defined through other things.«

» High additional payments to health insurance funds also mean that the quality of dental care plays a rather subordinate role.«

» Accordingly, dental health is also ahead of Spain the second worst in Europe, despite a level of expenditure and density of dentists comparable to that in Denmark.«

france without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _______________________________ france ___________ Deviation ____


Population ____________________________________________________________________________________________________________________________________________________________________ 62,810,000 __________________________________

Gross domestic product ________________________________________________________________________________________________________________________________ 2,169,000,000,000 € __________________________________



Total health expenditure ___________________________________________________________________________________________________________________________________ 257,700,000,000 € __________________________________



Proportion of total health expenditure for dental treatment (calculated) __________________________________________________________ 11,600,000,000 € __________________________________

Total sales value of dental market, minus software ______________________________________________________________________________________________ 1,013,000,000 € __________________________________

Total number of dental dealers _________________________________________________________________________________________________________________________________________________ 113 __________________________________

Dental practices using intra-oral cameras ___________________________________________________________________________ 38.13 % ________________________________________________________________________________

Total sales value of sundries ____________________________________________________________________________________________________________________________________ 551,000,000 € __________________________________



Number of new dental X-ray units installed __________________________________________________________________________________________________________________________ 5.000 __________________________________


fUNDiNg

Percentage private expenditure of total expenditure for dental services ___________________________ 55.46 % _______________________________ 25.3 % ________________________ ____


DENTAL hEALTh


DENSiTY Of MARKET

Number of practicing physicians/doctors _________________________________________________________________________________________________________________________ 194,723 __________________________________

Density of physicians (practicing physicians per 1,000 inhabitants) ________________________________________ 3.54 ____________________________________ 3.10 ________________________ ____





Number of dental technicians ______________________________________________________________________________________________________________________________________________ 17,550 __________________________________


Total number of dental laboratories (dentists and commercial laboratories) _______________________________________________________________________ 3,950 __________________________________


Dentists per dental laboratory ___________________________________________________________________________________________________ 7.45 _________________________________ 10.38 ________________________ ____





40 | 41

The system

Political background Independent republic with a bicameral parliament. A region consists of

commune and department levels with arrondissments. Of 63 million inhabi-tants, 1.7 million live overseas, with about 80 % being urban dwellers. Demographic ageing is less serious in France than in Germany, and the birth rate is one of the highest in Europe.

The insurance system Social health insurance system with centralised statutory health insurance,

increasingly tax-based revenues and a mixture of public and private care. The national health insurance (Régime général d‘assurance maladie) is occupation-related, families are also insured and there is no exemption from the insurance obligation.

Approx. 92 % of the population have additional private insurance, as the statutory insurance demands high additional payments. The “Couverture maladie universelle”, through which those with a low income are now also additionally insured, has been in existence since 2000.

Organisation The National Assembly stipulates an annual (virtual) upper limit for health

insurance expenditure. Four expenditure types are divided into sectors: pri-vate practices, public clinics, private clinics, social health care.

Numbers of doctors, hospital beds and major equipment items are centrally planned.

The decision-making autonomy of communes is increasing. The regional health agencies (agence régionale de santé) are responsible for the care and budget of their populations beyond sector limits.

Funding Health insurance covers approx. 3/4 of health expenditure. Private funding consists of 12.5 % for voluntary supplementary insurance

for additional payments and min. 11 % copayment (e.g. contact lenses, aids and appliances, dental treatment, medication). Private additional payments exist for practically every service.

Medical technology/Dental technology Medical technology in France generated a volume of 7.7 billion € in 2010,

making it the second-largest MT consumer in Europe after Germany. The sector is strongly characterised by foreign companies, generating around two-thirds of turnover and almost 80 % of exports. A study from 2007 indi-cated that dental technology accounted for a volume of 2.3 billion €.

Of the 7.6 billion € of medical technology imports, German products were responsible for almost 1 billion €. In the case of dental medical equipment, Germany is responsible for the highest share of imports at 50 %.

Approval/remuneration of medical technology Snitem (an association of medical technology manufacturers) deplores

the long market launch process for new products which can take up to five years. G-MED is responsible for certification in the area of health and med-ical technology.

Dental care

Dentists Practically every dentist works in a private practice. Some dentists work

in dental centres in clinics. In addition to dentists, stomatologists exist who realise orthodontic opera-

tions. Stomatologists also mainly work in private practices (approx. 84 %). The number of dentists has risen less than other doctors. 20 % of all outpatient expenditure is for dental services.

Remuneration (Dental) physicians are bound by the tariffs negotiated between represen-

tatives of the medical profession and insurance funds, unless they join the “second sector” where higher prices can be charged. Almost all oral surgeons work within the insurance fund convention.

Dental service Patients pay, and their expenditure for dental treatment is reimbursed

by up to 70 %. Care for children and people with low income is covered.

Additional payments of 30 % in the case of dental treatment are covered by supplementary insurance where necessary. Only 33 % of dental prosthetics and 10 % of orthodontic care costs are covered.

Annual statutory care is provided in schools since 2007.

Private supplementary insurance covers min. 30 % of orthodontic or prosthetic services.

High private additional payments generate social disparities in care.

Distinctive features Fluoridated salt has existed for over 20 years,

while fluoridated toothpaste is in part distrib-uted to schoolchildren in the context of dental health education.

The dental health of children has improved con-siderably. The DMFT figure fell from 4.2 (1987) to 1.2 (2006), comparable with the development in Spanish dental health, but far behind that of Germany or the United Kingdom. Social inequalities continue to pose a problem. Preven-tion programmes have only existed since 2004.

The pharmaceutical industry is obliged to pay 1 % of its turnover and additional taxes on adver-tising expenditure towards health insurance (the figure was 662 billion € in 2007). Other major companies pay 0.03 % of their turnover, and there are also levies for environmental pollution.

Sources HiT: France Hit Profile 2010 cf. EU Manual of Dental Practice (2008): France cf. Duscha 2008 and 2011


NETHER-LANDS» Slightly below-average dental expenditure,

dental health of adolescents is of average quality.«

» The density of dentists is considerably lower than the European average, the level of up-and-coming talent is low. Apart from this, there are considerably fewer dental technicians than, for example, in Germany.«

» Around 80 % of dental care has to be paid privately.«

» The medical technology market is innovative and agile.«

Netherlands without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) ______________________ Netherlands ___________ Deviation ____


Population ____________________________________________________________________________________________________________________________________________________________________ 16,730,000 __________________________________

Gross domestic product __________________________________________________________________________________________________________________________________ 656,600,000,000 € __________________________________





Percentage of total health expenditure for dental treatment __________________________________________________ .12 % ________________________________ 4.10 % ________________________ ____

Proportion of total health expenditure for dental treatment (calculated) ___________________________________________________________ 3,200,000,000 € __________________________________


Total number of dental dealers ___________________________________________________________________________________________________________________________________________________ 27 __________________________________

Dental practices using intra-oral cameras ___________________________________________________________________________ 38.13 % ________________________________________________________________________________

Total sales value of sundries ___________________________________________________________________________________________________________________________________ 155,000,000 € __________________________________

Total sales value of metal implants ______________________________________________________________________________________________________________________________________________________________________________________

Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € ________________________________________________________________________________

Number of new dental X-ray units installed _____________________________________________________________________________________________________________________________ 950 __________________________________


fUNDiNg

Percentage private expenditure of total expenditure for dental services ___________________________ 55.46 % _____________________________ 25.00 % ________________________ ____


DENTAL hEALTh


DENSiTY Of MARKET

Number of practicing physicians/doctors __________________________________________________________________________________________________________________________ 50,525 __________________________________


Number of practising dentists ________________________________________________________________________________________________________________________________________________ 7,119 __________________________________


Number of dental practices __________________________________________________________________________________________________________________________________________________ 5,800 __________________________________


Number of dental technicians ________________________________________________________________________________________________________________________________________________ 4,100 __________________________________


Total number of dental laboratories (dentists and commercial laboratories) _______________________________________________________________________ 1,025 __________________________________







42 | 43

The system

Political background The Netherlands has been a constitutional monarchy since 1815 with a

bicameral parliament. It is traditionally governed by coalition governments. The Queen does not have any executive power.

The 16.7 million Dutch inhabit a confined country (population density: 450 people/km²). About 20 % of the population are from a migrant background; 40 % are not members of any religion. Life expectancy is one of the highest in the EU.

The insurance system Private insurance has been brought into line with public health insurance

since 2006. The reform means that they no longer differ in terms of basic coverage. All insurances can generate profits.

Since then, every inhabitant is insured for a “basic package” in a public/pri-vate health insurance, and nobody is entitled to refuse this.

A large proportion of the population has voluntary supplementary insur-ance (e. g. for dental treatment).

Organisation Traditionally, the healthcare system was heavily regulated by the state. A

health fund exists since 2006. Funds are distributed to insurers through a risk structure compensation scheme.

The Ministry of Health, Welfare and Sport is responsible for health policy framework conditions.

Funding Public health insurance revenues are evenly divided between income related

contributions from insured persons and a fixed basic premium which in-sured persons pay directly to their insurance.

Private funding covers about 30 % of health expenditure (fees and private supplementary insurance).

Medical technology/Dental technology The market for medical technology in the Netherlands is far larger than

would be expected for a population of 16.7 million, and also extremely lucrative for German suppliers.

Numerous clusters contribute to the networking of the economy and re-search. The FHI sector association supports numerous clusters, including on a cross-border level. Specialised German SME’s can find good locations for subsidiaries and collaborations in this structure. Products from highly inno-vative manufacturers are mainly channelled into a growing export trade.

Dental technology sector turnover: around ¼ of companies generated great-er turnover in 2010 than in 2009, with the majority realising less. More than 80 % anticipate that turnover will remain unchanged for 2011.

The number of companies involved in dental technology rose in recent years to approx. 1000 with somewhat more than 4000 employees.

Dental care

Dentists Dentists work in private practices or clinics. There are approx. 1/3 fewer

dentists when compared to other EU countries.

Accreditation Insurance funds no longer have to foster contacts to all service providers,

They can conclude individual contracts and, consequently, can influence the type and quality of the service. They can influence cost categories 2 and 3 in negotiations.

Dental service Fundamentally speaking, dental treatment for adolescents up to the age of

22 is free. This also encompasses the sealing of teeth. It is currently being considered whether this service should be cut.

Basic insurance only covers special dental interventions (e.g. artificial dentures).

Further dental treatment for adults is covered by voluntary supplementary insurance. As a result, around 80 % of expenditure for dental care is private.

Sources Hit Country profile: 2004,

at a glance summary 2005 cf. Okma K. 2008 cf. Diewitz, M. 2011 cf. SVGB-rapport 2011

Further information Dutch Journal of Dentistry http://english.ntvt.nl German-Dutch Chamber of Commerce (AHK

Niederlande); http://Netherlands.ahk.de Federatie van Technologiebranches (FHI);

www.fhi.nl Federatie van Medische Technologie;

www.medischetechnologie.fhi.nl


AUSTRIA» Austrian dentists mainly work in sole practices. A few group practices exist.«

» Dentists were for a long time medical physicians with a specialisation, and a 6-year long course of studies purely dedicated to dentistry only exists since the 2000s.«

» The dental health of 12-year-olds is the worst in the FIDE countries, even though the structure and expenditure for dental health are average.«

» Only basic dental care and some prophylaxis services are covered by social insurance. About half of treatment is paid for privately.«

» Despite this, people are greatly interested in high-quality dental prosthetics.«

Austria without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _______________________________ Austria ___________ Deviation ____


Population ______________________________________________________________________________________________________________________________________________________________________ 8,430,000 __________________________________










Dental practices using intra-oral cameras ___________________________________________________________________________ 38.13 % ______________________________ 15.00 % ________________________ ____






fUNDiNg



DENTAL hEALTh


DENSiTY Of MARKET

Number of practicing physicians/doctors __________________________________________________________________________________________________________________________ 40,464 __________________________________


Number of practising dentists _______________________________________________________________________________________________________________________________________________ 4,150 __________________________________



Density of dental practices (dental practices per 1,000 inhabitants) _______________________________________ 0.46 ___________________________________ 0.45 ________________________ ____

Number of dental technicians _______________________________________________________________________________________________________________________________________________ 2,850 __________________________________


Total number of dental laboratories (dentists and commercial laboratories) _________________________________________________________________________ 650 __________________________________







44 | 45

The system

Political background A democracy, Austria is a federal republic consisting of nine federal states.

Of a population of 8.4 million, approx. 68 % lives in towns and cities. Pop-ulation growth is 5 %, and the proportion over 65 years of age is increasing (2010: 17.7 %). Per capita health expenditure is around 1,100 US$ above the OECD average, with life expectancy 1.3 years below.

The insurance system Statutory accident and health insurance exists, as is the case in Germany.

Around 98 % of the population has occupational health insurance. Conse-quently, there is no competition between insurance providers. The 21 pro-viders of the public health insurance scheme are organised in the federation of Austrian social insurers (Hauptverband der österreichischen Sozialversi-cherungsträger).

About a third of the population has additional private insurance, mainly for inpatient care (82 %), private outpatient treatment (10 %) and dental pros-thetics. Approx. 5 % of patients have supplementary dental insurance. The seven private health insurers are organised in the association of insurance companies (Verband der Versicherungsunternehmen Österreichs).

Health insurance contributions are income-related, with 50 % being covered by the employer.

Organisation Organisation and funding of the healthcare system is generally determined

in financial compensation negotiations between the federal government and the governments of the federal states, with negotiations held once in each legislative period (a binding agreement).

Detail planning and implementation of the Austrian structural plan for health (ÖSG) is realised at federal state level through health platforms.

Insured people can freely select doctors.

Funding Social health insurance and taxes cover approx. 70 % of overall health

expenditure, with private households covering approx. 30 %. Almost all services involve additional payments.

Medical technology/Dental technology In 2009, the Austrian healthcare market exceeded a limit of 35 billion € for

the first time, and a doubling of this figure is expected by 2020. Germany supplied goods in 2010 to a value of 527 billion €, almost 14 % more

than 2009. The German delivery volume is equivalent to an import share of about 45 %.

Dental care

Outpatient sector (GPs, consultants, dentists) Social insurance concludes contracts with individual doctors. Only approx.

43 % of physicians and about 70 % of dentists are bound by a contractual relationship with one or more health insurers. Treatment by non-panel doctors (doctors of one’s choice) is remunerated at 80 % of the normal tariff.

57 % have no contract (they are non-panel doctors), while 28 % of dentists are non-panel practitioners.

Dentists Up until 2004, a six-year course of general medical studies and at least three

years of practical experience as a dentist were required to set oneself up in practice. Following the Bologna Process, it is now possible to complete a sepa-rate course of dental studies.

No further specialisations exist, apart from oral and maxillofacial surgery (human medicine).

Well over 90 % of dental medical care is provided in doctor’s surgeries (practices) and only a low percentage in health insurer outpatient clinics (2008: 396 dentists).

Around 82 % work in sole practices. They are not permitted to employ further doctors, but cooperation is in no way restricted.

Group practices (which can be freely configured) can only work in a private ca-pacity (i.e. without an insurance contract). Only dentists can become partners.

Dentists are represented by the Austrian Dental Chamber (Österreichische Zahnärztekammer) or its representatives at federal state level.

Payment is realised in a fee-for-service system.

Dental professions Dental technicians undergo 4 years of training. There are no separately trained dental hygienists, but some dental assistants

undergo further training.

Dentists mainly work in practices.

Dental service Basic dental treatment is insured (encompassing

dental conservation, surgery and orthodontic treatment.) It is granted according to the stipula-tions of the articles governing health insurers.

Subsidies are available for periodontal treatment up to a maximum of 55.12 € twice a year.

As of the 1st October 2012, the Federal Insur-ance Authority (BVA) grants insured persons a subsidy for oral hygiene of 35 €, at the most twice in a given calendar year.

Fixed dental prostheses (such as crowns, bridges and implants) are not covered by health insurers.

Distinctive features Dental health: the Austrian DMFT index in

2002 was still 1.0. The deterioration of the dental status to a value of 1.4 in 2006 can in part be explained by a survey focus on children with a migrant background in 2007. Children from so-cially disadvantaged families tend to have poorer dental health.

Sources cf. Hit-Country Profile: Austria, 2006,

HiT summary Austria, 2006 cf. Simer, A., 2011 cf. ÖZZ cf. Bodenwinkler et al., 2007

Further information Österreichische Zahnärztekammer;

www.zahnaerztekammer.at Österreichische Gesellschaft für Zahn-, Mund-

und Kieferheilkunde, Verein Austriaischer Dentists; www.oegzmk.at


SWITZER-LAND» Dental care is almost completely funded through private means, prices are relatively high, as is the proportion of dental expenditure as a share of overall expenditure.«

» Nevertheless, the demand for quality products is strong and the dental health of adolescents above average.«

» Switzerland is also a location for major dental technology companies.«

Switzerland without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _______________________ Switzerland ___________ Deviation ____


Population _______________________________________________________________________________________________________________________________________________________________________ 7,660,000 __________________________________











Total sales value of sundries ______________________________________________________________________________________________________________________________________ 71,000,000 € __________________________________

Total sales value of metal implants _____________________________________________________________________________________________________________________________ 9,000,000 € __________________________________

Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € _______________________________ 1,176 € ____________________________ ____

Number of new dental X-ray units installed _________________________________________________________________________________________________________________________________________________________________________

Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 ________________________________________________________________________________

fUNDiNg



DENTAL hEALTh


DENSiTY Of MARKET



Number of practising dentists ______________________________________________________________________________________________________________________________________________ 4,590 __________________________________

Density of dentists (practicing dentists per 1,000 inhabitants) ________________________________________________ 0.65 ___________________________________ 0.60 ________________________ ____





Total number of dental laboratories (dentists and commercial laboratories) __________________________________________________________________________ 962 __________________________________

Dental laboratory – density (dental laboratories per 1,000 inhabitants) ___________________________________ 0.11 __________________________________ 0.126 ________________________ ____






46 | 47

The system

Political background Since 1848, Switzerland has been a democratic federal state with 26 cantons

and semi-direct consociational democracy. About 7.7 million people live in Switzerland. 188 inhabitants per km² make Switzerland one of the more densely populated countries in Europe. Birth figures fell between the 1970s and 2001 and the population shrank. The life expectancy of women/men is 84.5/80.1 and, consequently, one of the highest in the world.

The insurance system The Swiss healthcare system is a social insurance system with market

economic elements. Obligatory basic insurance for every Swiss citizen (Obligatorische Krankenpflegeversicherung, OKP) covers nationally defined services for acute care and nursing.

Alternative insurance models (AVM/managed care) can also be selected since 1996, these being offered jointly by service providers and insurers and involving a limited selection of doctors. About half of the Swiss opted in favour of this system.

Organisation It is one of the world’s most expensive health systems.

Funding The Swiss health system is funded to approx. 40.8 % from social insurance

contributions and around 20 % through public subsidies (in part from taxes). Private cost sharing (franchise and deductible) and cash expenditure for

services account for approx. 30.5 %. Contributions from private health insurance and supplementary insurance are approx. 9.8 %.

Medical technology/Dental technology The dental market is crisis resistant. Straumann and Nobel Biocare Holding

are two of the world’s leading companies in dental prosthetics. In Switzerland, increased pricing and cost pressure and the growth in

competition on an international level has also led to a change in focus from product innovations to profitability.

After-sales service is of considerable importance. Implants are among the most important production goods.

German products achieved an import quota of around 27 %. Important im-ports from Germany include in particular medical furniture (import market share: 62 %), X-ray equipment (44 %) and dental instruments (44 %).

The import value of dental prosthetic goods reaches 60 million € per annum, with the figure being about 100 million € for dental equipment.

Dental care

Dentists Dentists mainly work in private practices. They have an average of

2000 – 3000 “registered” patients. Although the number of dentists rose, considerably fewer dentists were working in independent practices in 2010 than in Germany.

Prices are high: a Swiss dentist charges around 85 € for a brief examination. In comparison, this costs German publicly insured patients about 17 € and private patients around 30 € (as of 2005).

The quality of dentist and dental laboratory services is high, just as their pric-es are. Inlays, crowns and implants are generally provided by local labs.

Remuneration Public health insurance does not cover any normal dental treatment in

Switzerland. According to Art. 31 of the Health Insurance Act, dental treatment is always

paid from social health insurance if the patient was unable to avoid the disease which caused dental damage (i.e. if a serious disease of the mastica-tory system occurs), in relation to a serious general illness (e. g. in the case of leukaemia, cardiac valve replacement)), if dental treatment is necessary to support and ensure medical treatment or if, following accidents, no other insurance is willing to cover treatment costs.

Over 90 % of dental treatment is funded through private means, either directly or through private supplementary insurance. Dental care therefore also accounts for a large proportion of all private health expenditure.

Only approx. 10 % of the Swiss have private supplementary insurance which primarily covers orthodontics. Supplementary insurance to cover dental care costs is expensive.

Distinctive features Swiss purchasers of dental and other medi-

cal technology particularly value innovative technologies and products which are durable in terms of quality and offer a long service life. Patients rely greatly on the advice of the doctor (or dentist) treating them in this respect.

People are acutely aware of the value of high-quality care.

Similar to in Germany, an annual appointment for dental hygiene treatment is usual in Switzer-land in order to try to retain one’s own teeth for as long as possible.

Where an inlay or crown is necessary, the major-ity of Swiss opt for ceramic.

Customs clearance is necessary when shipping dental technology products from Germany to customers in Switzerland, but this is normal-ly realised without any difficulties. Added to the net value of goods (the invoice should not contain any German value added tax) is Swiss (import) value added tax which is 8 % for medi-cal technology products.

Fluoridation is only realised in salt, not in drinking water or milk

Sources cf. EU Manual of Dental Practice: Version 4,

2008, Switzerland cf. Gerlinger T., 2003 cf. Implantat Stiftung Switzerland, 2009 Forum Managed Care, www.FMC.ch

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SChEDULE EighT

SCHEDULE EighT PUBLiC/STATE hEALTh SYSTEMS iN DETAiLS 8


Italy

Denmark Spain

United Kingdom

48 | 49

» Dental care in these countries is paid for privately in most cases and, in part, also provided outside the healthcare system«

» These countries represent a growth market with positive economic development. Ancillary dental professions (dental hygienists in particular) play an important role as customers of the dental industry, particularly in the UK and Denmark«

» The dental medical infrastructure is in the main good, with state organisations in part also playing a role in purchasing«

» Nevertheless, the demand for quality and aesthetic products is great, but depends heavily on the economic situation«

» Where care and, in particular, prevention are regarded as very important (UK and Denmark), dental health is above average«


DeNmark» Expenditure for dental medicine is slightly lower than the FIDE mean, the density of dentists is relatively high and the dental health of 12-year-olds is the best in Europe.«

» Training of dental hygienists was already expanded years ago in preference to dentists.«

» The public health system plays a central role, including in purchasing.«

» Approx. 80 % of dental care is provided through private funding, and some patients have private supplementary insurance.«

Denmark without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) ___________________________ Denmark ___________ Deviation ____


Population ______________________________________________________________________________________________________________________________________________________________________ 5,540,000 __________________________________




Total health expenditure _____________________________________________________________________________________________________________________________________ 29,700,000,000 € __________________________________




Total sales value of dental market, minus software ___________________________________________________________________________________________________ 51,000,000 € __________________________________



Total sales value of sundries ________________________________________________________________________________________________________________________________________________________________________________________________

Total sales value of metal implants ______________________________________________________________________________________________________________________________________________________________________________________

Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € ________________________________________________________________________________

Number of new dental X-ray units installed ______________________________________________________________________________________________________________________________ 130 __________________________________


fUNDiNg



DENTAL hEALTh


DENSiTY Of MARKET



Number of practising dentists ______________________________________________________________________________________________________________________________________________ 4,580 __________________________________


Number of dental practices __________________________________________________________________________________________________________________________________________________ 3,080 __________________________________




Total number of dental laboratories (dentists and commercial laboratories) _________________________________________________________________________ 450 __________________________________


Dentists per dental laboratory ___________________________________________________________________________________________________ 7.45 __________________________________ 10.18 ________________________ ____





50 | 51

The system

Political background Denmark is a constitutional monarchy and EU member state since 1973.

Approx. 85 % of the 5.5 million inhabitants are urban dwellers, with 30 % of these living in the greater Copenhagen area. The average life expectancy at the end of the last century was lower than the EU average, but then improved rapidly to exceed the average.

The insurance system The social insurance system was replaced in 1973 through a system with a

national health insurance funded through taxation. The entire population is compulsorily insured. Two insurance service options are available: access to general practitioner

care and hospital treatment is free for Group 1 , while insured persons in Group 2 have a free choice of doctors. A fee is charged for this. The majority of the population opts for Group 1.

Approx. 36 % have voluntary supplementary insurance for additional payments. This is a non-profit system and has been subsidised by the state since 2002.

With free access available to everybody, the system has wide support among the population.

Organisation Local authorities and county councils have been responsible for the health

system since 1970. These have to present a plan for coordination of all preven-tive and curative activities every four years. In addition, budget negotiations are held every year at different administrative levels.

Local authorities are responsible for inpatient care and fund outpatient care. They provide nursing homes and local authority dentists who also visit disabled patients at home. 2 % of public expenditure is utilised for local authority dentists.

Funding There has been a health tax since 2007 which covers around 80 % of the entire

budget. Of the approx. 9.9 % of gross domestic product (2008) for health expenditure,

– 7.8 % (84 %) is public expenditure,

– 2.1 % (15.5 %) is private (additional payments, fees and voluntary supple-mentary insurance). Cost increases occur primarily in the inpatient sector.

Approx. 9 % of all public health expenditure and 4.3 % of all health expenditure is for dental health.

Medical technology/Dental technology There are, in total, around 1,000 Danish companies in the medical technol-

ogy sector. Dental technology accounts for approx. 1 % of a total turnover of around 7 billion €.

The main buyers of medical technology are the purchasing centres in the five regions of Denmark. These operate a common tendering portal. The procurement of aids is the responsibility of the 98 communes and their purchasing companies.

Accreditation of medical technology The Danish Medicines Agency increased its fees for the registration of

medical products by approx. 1.5 % in 2010. The fees cover the registration of medical products, the evaluation of applications for clinical studies and the testing and monitoring of accredited bodies in Denmark, and two addition-al new fees were introduced.

Dental care

Dentists Dentists are remunerated on a fee-for-service basis. Prices are negotiated ev-

ery second year in negotiations between the Danish Dental Society (Dansk Tandlægeforening) and the Health Remuneration Negotiation Committee (Sygesikringens Forhandlingsudvalg).

Dentists are not subject to any practice restrictions.

Dental services Dental services are mainly privately remunerated, or about fifty per cent is

paid through supplementary insurance. – Dental treatment for children up to the age of 18 is provided free of

charge through the local community-based dental service (or by private practices remunerated by it). There is also a school-based prevention programme. Around 253 million € is expended for this purpose.

– Basic dental care such as examinations, fillings and periodontology is

subsidised. Nevertheless, adults must pay for on average around 80 % of services them-selves. These can avail of voluntary sup-plementary insurance. Approx. 30 % of the population has supplementary insurance.

Distinctive features Dental health is prescribed by law and recorded

annually by local authorities. The role of the dental hygienist was strengthened

in the 1990s. As a consequence, more dental hy-gienists were trained at the expense of dentists.

As is the case in Sweden, almost all Danes visit a dentist or dental hygienist once a year. Patients are automatically called for dental care once to twice a year.

Only fluoridated toothpaste is available on the Danish market, but there is no public fluorida-tion programme.

In addition to taxes on tobacco and alcohol, a controversial tax was introduced a few years ago on unhealthy food (the fat content in foodstuffs), but the influence this has had on health is still unclear.

Sources cf. Hit-Country Profile: Denmark 2007 und 2012 cf. EU Manual of Dental Practice: version 4,

2008, Denmark

Further information Medicoindustrien industry association Professional association for the dental sector:

Dansk Dentalbrancheforening, www.dentalbranchen.dk;

Danmarks Statistik, www.dst.dk/da/ International Profiles of Health Care Systems,

The Commonwealth Fund, June 2010


ITALY» The majority of dental care is provided outside the national health system.«

» This means Italy is relative sensitive to general economic developments.«

» Despite this, Italy is one of the largest dental markets in Europe and has a conspicuously above-average density of dentists and dental laboratories.«

iTALY without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) ___________________________________ italy ___________ Deviation ____


Population _____________________________________________________________________________________________________________________________________________________________________ 61,260,000 __________________________________


Changes in GDP rel. to last year _____________________________________________________________________________________________ 1.58 % _______________________________ 0.40 % ________________________ ____


Total health expenditure __________________________________________________________________________________________________________________________________ 163,700,000,000 € __________________________________



Proportion of total health expenditure for dental treatment (calculated) _________________________________________________________ 10,736,000,000 € __________________________________

Total sales value of dental market, minus software ______________________________________________________________________________________________ 1,127,000,000 € __________________________________

Total number of dental dealers ________________________________________________________________________________________________________________________________________________ 355 __________________________________






Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.121 ________________________ ____

fUNDiNg


Proportion private expenditure of total expenditure for dental services __________________________________________________________ 12,540,000,000 € __________________________________

DENTAL hEALTh

Dental health of 12-year-olds (2010, in DMFT) ___________________________________________________________________________ 0.96 ____________________________________ 1.10 ________________________ ____

DENSiTY Of MARKET

Number of practicing physicians/doctors ________________________________________________________________________________________________________________________ 226,666 __________________________________



Density of dentists (practicing dentists per 1,000 inhabitants) ________________________________________________ 0.65 ___________________________________ 0.93 ________________________ ____

Number of dental practices ________________________________________________________________________________________________________________________________________________ 36,400 __________________________________


Number of dental technicians _____________________________________________________________________________________________________________________________________________ 28,000 __________________________________


Total number of dental laboratories (dentists and commercial laboratories) _____________________________________________________________________ 11,800 __________________________________







52 | 53

The system

Political background Italy has been a parliamentary republic since 1948 with a bicameral parlia-

ment (House of Representatives and Senate). Since the mid-90s, Italy may be considered to be a federal state consisting of 20 regions and 94 provinces with broad financial autonomy.

Italy has the lowest birth rate in the world (1.2) and a steadily increasing life expectancy. The proportion of the population over 65 years of age is growing.

The insurance system The National Health System (NHS) has existed since 1978, is accessible to

every citizen and aims to guarantee the same services for all. It has since been reformed and restructured on several occasions (1992 pro-competition reform, complete reorganisation in 1998).

The system is predominantly funded through taxes. National health insur-ance has been replaced at a national level through a taxed-based national solidarity fund which offsets regional differences.

Providers of care are either employees of the NHS or work in private practices/clinics.

Organisation Central government is responsible for the passage of the national health plan

(every three years), allocation of funding and the definition of guidelines (clinical and for accreditation).

The regions are responsible for implementing the plan and quality control. Planning and management of local health centres and public

and private clinics.

Funding Funding of the National Health Service has been almost completely covered

since the beginning of the millennium through regional (value added) taxes. Public funding covers approx. 3/4 of overall expenditure. Private funding

(about one quarter of total expenditure) consists of additional payments for medication, diagnostics and consultant visits, direct payments for services from private providers and private insurance contributions.

Expenditure for dental services were estimated to be around 13 billion € in 2008, approximately half of all private expenditure for health.

Medical technology/Dental technology The global financial and economic crisis has barely affected the market for

medical technology in Italy. The government’s austerity programme has left the health sector broadly untouched.

Dental technology and optics in particular exhibited stable growth rates. The scope of services of the Italian industry also includes dentist equipment

such as X-ray appliances, cardiological equipment, equipment for operating theatres, anaesthesia equipment and dialysis machines.

Dental technology in 2007 consisted of approximately 125 dental technolo-gy firms with about 5,000 staff and around 75 dental technology importers with about 2,200 employees.

Dental technology sales and marketing consists of a further 250 firms with 2,100 employees.

Around 82 % of the market volume is covered by imports. The demand for technology is of the highest level. Italy is currently the

second-largest European market for dental implants. However, pricing pressure is making further growth difficult.

Dental care

Dentists Dentists work in about 34,200 private practices, 58 % of which consist of

small sole practices. Additionally, there are specialised practices for surgical services, periodontitis and implantology (12.5 %). However, the trend is towards larger practices.

Between 2000 and 2006, the number of dentists grew by 31 % to 51,975. Even if preventive services are increasingly offered in some regions, the

minimum dental care within the NHS means that trust in the state dental service is poor. There are also waiting lists to contend with.

As patients therefore have to pay for practically every service, economic difficulties saw the number of patients fall in recent years. Only about 1/3 of all Italian families visit a dentist every year.

Dental service In general, dental services are not covered by the

NHS and also rarely provided through the public health service.

A maximum of 8 % of services is provided through the NHS. These principally involve emergency treatment.

Sources cf. HiT -Country Profile Italy 2009,

at a glance summary 2001 cf. Breuer, S., 2011 cf. CERGAS, 2008 cf. EU Manual of Dental Practice: version 4,

2008, Italy

Further information Italian Dental Yearbook,

www.dentaldirectory.it


SPAIN» With average dental health expenditure and den-sity of dentists, the dental health of adolescents is among the worst in Europe.«

» In Spain, dental care is also mainly provided outside the national health system, and private supplementary insurance usually does not cover dental prosthetics.«

» The majority of dentists practice exclusively or additionally in private practices.«

» Despite this, the majority of public health centres also have dentists, but these are only responsible for emergency care (tooth extraction, etc.) and prevention.«

SPAiN without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _________________________________ Spain ___________ Deviation ____


Population _____________________________________________________________________________________________________________________________________________________________________ 47,040,000 __________________________________









Total number of dental dealers ________________________________________________________________________________________________________________________________________________ 350 __________________________________





Number of new dental X-ray units installed __________________________________________________________________________________________________________________________ 3,600 __________________________________


fUNDiNg


Proportion private expenditure of total expenditure for dental services _____________________________________________________________ 5,410,000,000 € __________________________________

DENTAL hEALTh


DENSiTY Of MARKET


Density of physicians (practicing physicians per 1,000 inhabitants) ________________________________________ 3.54 ____________________________________ 4.10 ________________________ ____



Number of dental practices ________________________________________________________________________________________________________________________________________________ 18,500 __________________________________


Number of dental technicians ______________________________________________________________________________________________________________________________________________ 15,700 __________________________________


Total number of dental laboratories (dentists and commercial laboratories) ______________________________________________________________________ 4,800 __________________________________



Citizens per dental laboratory ______________________________________________________________________________________________ 12,490 _________________________________ 9,800 ________________________ ____




54 | 55

The system

Political background Spain is a constitutional hereditary monarchy with a bicameral parliament

(the Cortes). With a population of about 47 million, the country is divided into 17 autonomous regions which each have their own directly elected gov-ernments. Regional tongues in Catalonia, the Basque Country and Galicia have the status of official languages – in addition to the state language of Spanish, which is also known as Castilian. Linguistic and cultural variety has been anchored in the Spanish constitution since 1978.

The insurance system A state health system in which almost the entire population (approx. 95 %)

is insured. All employees, the unemployed, pensioners, the disabled and destitute persons are insured. Families are co-insured.

Approx. 15 % have private supplementary insurance (in particular the self-employed and public servants and for dental care).

Organisation 17 autonomous regions are responsible for health care and compile a health

plan. The government defines regional budgets and determines prices for the services provided. The service catalogue is defined by the Ministry of Employment and Social Security.

There are around 2900 regional health centres and over 10,000 medical practices for primary care where patients must register themselves.

INSALUD, the national health institute, administers a large proportion of healthcare services.

Funding About 75 % of health expenditure comes from public funding, meaning tax-

es (the majority of which are levied centrally). The universal contribution for social security (employee 23.6 %, employer 4.7 %) includes health insurance, old age pensions and invalidity pensions.

Around 25 % of health expenditure involves private spending which primarily arises in the form of tax contributions (for the national health service) and, to a lesser degree, contributions for voluntary supplementary insurance.

Medical technology/Dental technology Spain’s medical technology market generates a turnover of approx. 7.4

billion € and employs around 32,000 people in 725 firms (as of 2008). Some SME’s have managed to conquer international markets through investment in R&D (electro-medicine and surgical instruments).

Spain is in 9th position on a global scale when it comes to the consumption of health products.

70 % of the Spanish market involves orthopaedic and disposable products. These are followed by electro-medical products and dental fillings.

The ten largest product groups of Spanish medical technology exports include dentists’ chairs and other furniture and drills and other dental instruments.

Dental care

Dentists The majority of health centres (ambulatorios or centros de salud) have

dentists who provide emergency care, extractions and prevention. There are about 0.5 dentists per 1000 inhabitants.

Emergency care is also provided in clinics. Waiting times are a problem here.

There are numerous private practices where remuneration is on a fee-for-service basis. Prices are considerably lower than in the UK. A checkup costs around 10 €, a filling about 40 – 50 €.

Remuneration Dental treatment is only covered in the context

of emergency treatment (tooth extraction). State supplementary insurance exists for public

servants and comparable private insurance pol-icies which cover examinations, extractions and prophylaxis services. Only 18 % of the popula-tion chooses comprehensive private supplemen-tary insurance.

Distinctive features According to the WHO World Health Report

2000, Spain had the 7th best health system in the world.

Sources cf. Infodent, 2010 cf. ICEX 2009 cf. International Health Systems,

www.Kaiseredu.org cf. Hit Country profile Spain, 2008


UNITEDKINGDOM» Despite below-average expenditure and density of dentists, dental health has improved consider-ably due to national prevention programmes and, together with Denmark and Germany, is currently the best in Europe.«

» Dentists mainly work in private practices, and basic care is covered by the NHS.«

» In addition to dentists, there are also various other professional groups (e.g. dental hygienists) who also work on the patient.«

» The dental industry has proven to be crisis resistant.«

UNiTED KiNgDOM without assessment neutral deviation positive deviation negative deviation

2011 ____________________________________________________________________________________________________________________________________ fiDE (Ø) _______________ United Kingdom ___________ Deviation ____


Population ____________________________________________________________________________________________________________________________________________________________________ 62,060,000 __________________________________

Gross domestic product _______________________________________________________________________________________________________________________________ 1,888,800,000,000 € __________________________________












Total sales value of metal implants per 1,000 inhabitants ___________________________________________________ 2,635 € _________________________________ 671 € ________________________ ____



fUNDiNg


Proportion private expenditure of total expenditure for dental services _____________________________________________________________ 4,410,000,000 € __________________________________

DENTAL hEALTh


DENSiTY Of MARKET






Density of dental practices (dental practices per 1,000 inhabitants) _______________________________________ 0.46 __________________________________ 0.187 ________________________ ____


Dental technician – density (dentists per 1,000 inhabitants) ____________________________________________________ 0.33 __________________________________ 0.114 ________________________ ____

Total number of dental laboratories (dentists and commercial laboratories) ______________________________________________________________________ 2,390 __________________________________


Dentists per dental laboratory ___________________________________________________________________________________________________ 7.45 _________________________________ 12.50 ________________________ ____


Dental graduates per 100,000 inhabitants _______________________________________________________________________________ 1.88 ________________________________________________________________________________



56 | 57

UNITEDKINGDOM» Despite below-average expenditure and density of dentists, dental health has improved consider-ably due to national prevention programmes and, together with Denmark and Germany, is currently the best in Europe.«

» Dentists mainly work in private practices, and basic care is covered by the NHS.«

» In addition to dentists, there are also various other professional groups (e.g. dental hygienists) who also work on the patient.«

» The dental industry has proven to be crisis resistant.«

The system

Political background The United Kingdom of Great Britain and Northern Ireland (UK) consists of

four countries: England, Scotland, Wales (together known as Great Britain) and Northern Ireland. Approximately 90 % of the around 62 million inhabi-tants are urban dwellers.

The insurance system The National Health Service (NHS) was introduced in 1948 as a classic tax-

based healthcare system. The state thus assumed simultaneous responsibility for the comprehensive health care of the entire population and, consequent-ly, free and fair access to services for all.

The majority of services are free of charge to patients. NICE (National In-stitute for Clinical Excellence) is responsible for the approval and inclusion of new medicaments and technologies in the service catalogue. Patients can also choose private service providers.

The private sector still exists parallel to the NHS, and this has been used increasingly in recent years to remedy bottlenecks in the NHS. It is funded through private insurance, direct payment by patients or through the pay-ments of trusts/funds.

Private supplementary insurance is growing, particularly to cover dental care.

Organisation The Department of Health is responsible for strategic and policy planning

in the NHS. The system has a regional hierarchy: regional organisations (Health Authorities) are responsible in constantly changing forms for local health care. Financial restrictions and inefficiencies (waiting lists) have resulted in the NHS being repeatedly reformed.

The latest reform, the Health and Social Care Bill 2011, aims to achieve the most comprehensive restructuring of the NHS ever. The main targets are the strengthening of general practitioners through direct financial responsibil-ity for regional care and increased competition between private and public providers.

Around 80 % of the entire budget of all public hospitals and doctors’ practic-es will be administered in future through a few hundred Clinical Commis-sioning Boards. GP consortiums will be obliged to personally purchase the services required by their patients through these.

The overall budget is determined for three years in each case (spending review). It was doubled in recent years (1997: 55.1 billion £ 2009/10: approx. 100 billion £), but now massive savings are to be made.

Funding The NHS is primarily funded through taxes (> 80 %). Private health insurance policies are concluded with increasing frequency. In 2009, 3.2 % (3.1 billion £) of all NHS expenditure was spent on dental

care. The private market is estimated to be around another 3 billion £.

Medical technology/Dental technology At about 4 %, medical technology devices and equipment only account for

a relatively small proportion of overall health expenditure. The demand for medical technology in 2011 was around 6.73 billion €.

The medical technology market shrank in this context by a total of 0.7 % between 2006 and 2010.

Despite this, the demand for dental equipment has grown and represents an important sales segment (2011: 445 billion €). Above-average growth is also anticipated in the coming years in this area.

Dental care

Dentists The majority of dentists are self-employed and treat patients within and

outside the NHS, with increasingly more services being provided in the private sector (about 60 % of dental earnings). This creates regional supply bottlenecks.

Dentists, like GP’s, are primary care professionals whose services are pro-vided through local trusts, although private care is also possible.

Of around 30,000 dentists, approx. 22,000 in basic care worked in private practices in 2010, with ¾ of these being paid through the general dental services contract.

In addition to this, specialised care is provided in clinics. Community dentists are employees and responsible for care.

A dentist in private practice earned a net income of around 131,500 £ in 2009.

In addition to dentists, there are 21,700 regis-tered dental professionals (e.g. assistants, hygien-ists and dental technicians).

Dental service Patients must make additional payments for

dental treatment and medication. Remuneration is realised in three categories. Dental treatment involves a 20 per cent deductible for treatment and checkup examinations. 80 % of dental pros-thetics are covered to an upper limit of around 575 €.

Distinctive features Oral health has improved significantly. 1/3 of the

population was edentulous in 1968, whereas the figure in 1998 was only 11 %. The dental health of adolescents is now among the best in Europe, but there are significant social disparities.

Fluoridated toothpaste and drinking water fluoridation were introduced in the 1970s. A strong emphasis is placed on national prevention programmes.

Up until 2009, the NHS Purchasing and Supply Agency (PASA) was an executive agency which realised approx. 50 % of purchases of goods cen-trally. Purchasing has since been privatised.

Sources cf. Klein, R., 2006 cf. Oliver, A., 2006 cf. Darcy, 2008 cf. AHK-Großbritannien

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Documents

Schedule for the European Dental Market