Global economic impact of dental diseases

Journal of Dental Research
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DOI: 10.1177/0022034515602879
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Introduction
Identifying the economic burden of a disease is useful to
understand the maximum amount of resources that could be
saved or gained if that disease were to be partially or fully
eradicated (Rice 1967). Describing and highlighting the mag-
nitude of the economic impact of dental diseases on society or
on different population groups would provide relevant infor-
mation for decision makers in public health policy to evaluate
the importance of addressing oral diseases. In the context of
oral health and care, however, information about the economic
impacts of disease has been very limited so far. To our knowl-
edge, there is not a comprehensive worldwide estimation of the
economic burden of oral diseases, including direct and indirect
cost, to the extent that this is possible today given the currently
available primary data recently reported.
Although the World Health Organization (WHO) estimates
that oral diseases are the fourth-most expensive diseases to
treat in most industrialized countries (Petersen 2003), its anal-
ysis was done only for direct cost and included only a subset of
countries. Few sound studies reported estimates for individual
countries (Beaglehole et al. 2009; Patel 2012; Wall et al.
2014). Across Organisation for Economic Co-operation and
Development (OECD; 2013) countries, on average 5% of total
health expenditures have been reported to originate from treat-
ment of oral diseases. While treatment is a costly consequence
of oral diseases, reductions in morbidity may also imply other
economic benefits. Importantly, there are indirect costs to
consider in terms of productivity losses due to absenteeism
from school and work, yet relatively little evidence exists in
this regard. Recent findings from Canada suggest that oral dis-
eases accounted for productivity losses >$1 billion yearly for
Canada alone (Hayes et al. 2013). A recent US study estimated
the labor market value of the marginal tooth to be nearly $720
per year for an urban-residing woman earning $11/h and work-
ing full time (Glied and Neidell 2010).
Different economic approaches exist to estimate the eco-
nomic burden of a disease. The cost-of-illness approach views
the cost of disease as the sum of several categories of direct
(treatment) costs and indirect costs (Byford et al. 2000). This
typically includes personal medical care costs (diagnosis, treat-
ment, drugs), nonmedical costs for travel associated with
602879JDRXXX10.1177/0022034515602879Journal of Dental ResearchGlobal Economic Impact of Dental Diseases
research-article2015
1
Heidelberg University, Translational Health Economics Group,
Department of Conservative Dentistry, Heidelberg, Germany
2
Max Planck Institute for Social Law and Social Policy, Munich Center for
the Economics of Aging, Munich, Germany
3
University of Dundee Dental School, Dundee, UK
4
Queen Mary University of London, UK
A supplemental appendix to this article is published electronically only at
http://jdr.sagepub.com/supplemental.
Corresponding Author:
S. Listl, Heidelberg University, Translational Health Economics Group,
Department of Conservative Dentistry; Im Neuenheimer Feld 400,
69120 Heidelberg, Germany.
Email: stefan.listl@med.uni-heidelberg.de
Global Economic Impact
of Dental Diseases
S. Listl1,2
, J. Galloway3
, P.A. Mossey3
, and W. Marcenes4
Abstract
Reporting the economic burden of oral diseases is important to evaluate the societal relevance of preventing and addressing oral
diseases. In addition to treatment costs, there are indirect costs to consider, mainly in terms of productivity losses due to absenteeism
from work. The purpose of the present study was to estimate the direct and indirect costs of dental diseases worldwide to approximate
the global economic impact. Estimation of direct treatment costs was based on a systematic approach. For estimation of indirect
costs, an approach suggested by the World Health Organization’s Commission on Macroeconomics and Health was employed, which
factored in 2010 values of gross domestic product per capita as provided by the International Monetary Fund and oral burden of disease
estimates from the 2010 Global Burden of Disease Study. Direct treatment costs due to dental diseases worldwide were estimated at
US$298 billion yearly, corresponding to an average of 4.6% of global health expenditure. Indirect costs due to dental diseases worldwide
amounted to US$144 billion yearly, corresponding to economic losses within the range of the 10 most frequent global causes of death.
Within the limitations of currently available data sources and methodologies, these findings suggest that the global economic impact of
dental diseases amounted to US$442 billion in 2010. Improvements in population oral health may imply substantial economic benefits
not only in terms of reduced treatment costs but also because of fewer productivity losses in the labor market.
Keywords: treatment costs, indirect expenditures, health expenditures, costs and cost analysis, oral health, teeth
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© International & American Associations for Dental Research 2015

2 Journal of Dental Research
health care, and nonpersonal costs (e.g., costs for research,
income losses, and sometimes pain and suffering). Another
approach relates to measuring the value of lost output (i.e., the
economic growth approach), which estimates the expected
impact of disease on aggregate economic output (gross domes-
tic product [GDP]) due to depletion in labor, capital, and other
production factors (Bloom et al. 2012). The value-of-statisti-
cal-life approach seeks to identify a population’s willingness to
pay to reduce the risk of disability or death due to disease,
hence factoring in other factors than GDP alone (Bloom et al.
2012). While such methods to estimate the economic impact of
diseases are, in principle, well founded, limited availability of
comprehensive data sources and nonharmonized international
reporting standards make estimating the full economic impact
of oral diseases difficult.
New data from the Global Burden of Disease Study 2010
(GBD 2010) provided comparable worldwide information on
disability-adjusted life years (DALYs) by country. The data
also showed that oral conditions remained highly prevalent in
2010 and collectively affected 3.9 billion people in the globe.
Untreated caries in permanent teeth was the most prevalent
condition evaluated for all of the GBD 2010 (global prevalence
of 35% for all ages combined; Kassebaum et al. 2015), whereas
severe periodontitis and untreated caries in deciduous teeth
were the 6th- and 10th-most prevalent conditions affecting,
respectively, 11% and 9% of the global population. On the con-
trary, the prevalence and burden measured by DALYs associ-
ated with tooth loss have decreased in the past 20 y; specifically,
tooth loss was the 36th-most prevalent condition, with a global
estimate of 2.3% in 2010 (Marcenes et al. 2013; Kassebaum
et al. 2014).
Following publication of the Budapest Declaration under
the auspices of the Global Oral Health Inequalities Research
Agenda of the International Association for Dental Research
(IADR-GOHIRA®
), 1 objective for future research was to esti-
mate the global costs (direct and indirect) of oral disease
(Mossey and Petersen 2014). The purpose of the present study
was to systematically produce comparable estimates of the
economic burden of the 3 most prevalent oral conditions as
specified above in 2010. We aimed to consolidate all economic
data about the direct and indirect costs of these conditions and,
subsequently, to generate internally consistent estimates for all
countries where data are available and to provide estimates for
all 21 world regions.
Methods
A systematic approach was used to generate information to
estimate the current direct and indirect costs of dental diseases
worldwide. Direct costs were defined as overall expenditures
for dental health care (including public and private expendi-
tures). Indirect costs were intended to capture productivity
losses due to the 3 most common oral conditions—namely,
untreated caries in permanent and deciduous teeth, severe peri-
odontitis, and severe tooth loss. Identification of appropriate
methods was informed by current best practice in evidence
synthesis and heuristic piloting to test the feasibility of various
approaches. The most suitable approach to estimate worldwide
direct and indirect costs of oral diseases was determined by
consensus among all authors. To facilitate alignment with the
GBD 2010, the year 2010 was defined as the primary target
period for estimation of global economic impacts of dental
diseases.
Estimation of Direct Costs:
Dental Health Care Costs
Selection of studies. Our search strategy was oriented to identify
country-specific yearly national expenditure for outpatient den-
tal care in 2010 or nearest year available. An electronic search
was performed focusing on the following online resources:
WHO Global Health Expenditure Database: http://www.
who.int/health-accounts/ghed/en/
OECD Data: https://data.oecd.org/
FDI Oral Health Atlas: http://issuu.com/myriadeditions/
docs/flipbook_oral_health
Platform for Better Oral Health in Europe: http://www.oral
healthplatform.eu
Council of European Chief Dental Officers: http://www.
cecdo.org/
Intergovernmental Organization Search: http://www.uia.
org/igosearch
Google (noncustomized search): http://www.google.com
Search words for dental expenditure included “expenditure,”
“expenditures,” “cost,” “costs,” or “treatment costs” combined
with “dentist,” “dental,” “dentistry,” “oral health,” “oral health
care,” “oral health services,” or “dental care.” The search was
focused on 187 countries as defined in Murray et al. (2012).
For each country, individual searches were carried out with the
respective “[country name]” as an additional search term. We
also searched MEDLINE via PubMed (keyword- and MeSH-
based searches), EMBASE via OVID, LILACS via BIREME,
the Cochrane Database of Systematic Reviews, the Database
of Abstracts of Reviews of Effects, the Health Technology
Assessment Database, and the NHS Economic Evaluation
Database for relevant information on dental expenditure (see
Appendix for details). Additional hand searches focused on
reference lists of relevant publications.
Information sources were included if they fulfilled the fol-
lowing criteria: country-specific representative reporting; over-
all expenditures for dental services reported, including public
and private source of funds, as specified in the International
Classification of Health Accounts (categories: HC.1.3.2, “out-
patient dental care”; HP.3.2, “offices of dentists”; OECD 2000);
annual expenditures reported for at least 1 y between 2000 and
2014; and expenditures reported either as absolute monetary
values or as a percentage of GDP. An information source was
excluded if it was nonrepresentative of a country’s entire popu-
lation (selective sample; e.g., only representative for a local
patient group with specific morbidity), or it reported only

Global Economic Impact of Dental Diseases 3
limited parts of overall dental expenditures (e.g., only private
out-of-pocket or only government expenditures).
Two authors (S.L., J.G.) performed all searches and selected
information fulfilling the inclusion criteria independently and
in duplicate. Those information sources found to be relevant
after initial screening were kept in the database. It was distin-
guished between countries for which there was “relevant infor-
mation identifiable” versus countries for which there was “no
relevant information identifiable.” Remaining uncertainties
were resolved by consensus among all authors. Duplication
between results was removed. All information sources meeting
the criteria for inclusion in this review were used in the estima-
tion of the direct costs of oral diseases.
Data extraction and imputation. For countries for which rele-
vant information was identifiable, yearly dental expenditure
values were extracted in terms of absolute values and as pro-
portion of GDP. Annual expenditure values were reported in or
converted to US dollars (midyear conversion rates for the
reporting year [http://www.xe.com]; purchasing power adjust-
ment based on inflation rates relative to 2010 US dollars [http://
www.usinflationcalculator.com]). If expenditure information
was originally reported as proportion of GDP, it was translated
to absolute US dollar values by using the relevant country’s
GDP in US dollars in the reporting year and applying inflation
rates relative to 2010 US dollars. Estimates of GDP per capita
and population size were extracted from the World Economic
Outlook Database (International Monetary Fund 2011). In case
of missing information, supplementary values were extracted
from UN data (United Nations 2015). As a robustness check,
worldwide dental expenditures were also computed by using
solely GDP information from UN data (United Nations 2015).
Estimation of worldwide dental expenditures involved
imputation of missing expenditure values, which leaned on
expenditure information from the nearest geographic unit for
which expenditure information was identifiable. To this end,
countries were grouped into 21 regions and 7 super-regions,
following the classification of the GBD 2010 (Fig.). When
expenditure information was not available for a particular
country, its 2010 expenditure was approximated by multiply-
ing the average expenditure (in proportion of GDP) of the near-
est geographic unit (region, super-region, world), which
included primary expenditure information with the GDP value
of the country without primary data. As an additional robust-
ness test, worldwide dental expenditures were estimated by
using the mean (95% confidence interval) expenditure level of
all GBD 2010 regions containing primary expenditure infor-
mation to impute missing expenditure values.
Estimation of Indirect Costs
Indirect costs were estimated according to an approach sug-
gested by the WHO’s Commission on Macroeconomics and
Health (WHO 2001), which was recently used to estimate
global economic costs of cancer (Cancer Society 2010). This
approach is based on valuing 1 DALY at 1 y of per capita GDP
to approximate productivity losses. Following this approach,
we factored in 2010 values of GDP per capita (International
Monetary Fund 2011) and extracted DALY estimates for
untreated caries, severe periodontitis, and severe tooth loss (<9
remaining permanent teeth) in 187 countries from a recent
study (Marcenes et al. 2013). Note that untreated caries included
deciduous teeth, whereby respective productivity losses include
parents taking time off to look after their children. Country-
specific GDP values were aggregated on the level of the 21
GBD 2010 regions and weighted according to country-specific
population sizes (International Monetary Fund 2011). In case of
missing information, supplementary values were extracted
from UN data (United Nations 2015). Relevant data for estima-
tion of indirect costs (i.e., GDP per capita in US dollars and
DALYs in thousands [2010 values]) are summarized in Table 1.
All analyses were carried out with Microsoft Excel (v.
14.0.7015.1000).
Results
Direct Costs: Treatment Costs
The systematic information search started with identification
of countries relevant to estimate global expenditures.
Accordingly, 187 country-specific electronic searches were
carried out and submitted to initial screening. At this stage, 107
countries were excluded because no relevant information could
be identified. Of the remaining 80 countries, 14 more countries
were excluded because the respective information did not meet
the inclusion/exclusion criteria. For the remaining 66 coun-
tries, relevant information was found to be identifiable. Full
lists of included and excluded information sources (with rea-
sons for exclusion) are presented in Appendix Tables 1 and 2.
Worldwide expenditure estimations are presented in Table
2. Aggregate direct treatment costs due to dental diseases
worldwide were estimated at $297.67B; 82% of the estimated
expenditures ($244.40B) occurred in high-income countries
(North America: $120.08B; Western Europe: $91.05B; High-
Income Asian Pacific: $23.30B; Australasia: $7.03B; Southern
Latin America: $2.93B). Latin America and the Caribbean
accounted for $14.06B (Tropical Latin America: $6.92B;
Central Latin America: $5.79B; Andean Latin America:
$0.76B; Caribbean: $0.59B). South Asia contributed $12.84B.
Eastern Europe ($6.12B), Central Europe ($2.75B), and
Central Asia ($0.45B) together contributed $9.32B. North
Africa and the Middle East contributed $8.33B. The region
comprising East Asia ($5.02B), Southeast Asia ($0.75B), and
Oceania ($0.02B) accounted for $5.79B; $2.96B was attrib-
uted to Sub-Saharan Africa (Southern: $2.70B; East: $0.20B;
West: $0.04B; Central: $0.01B).
The results from robustness checks are shown in Appendix
Tables 3 and 4. Findings in Appendix Table 3 show somewhat
higher worldwide expenditures of $299.61B if GDP values
from UN data are compared with $297.67B when based on GDP
values from the World Economic Outlook Database. Appendix
Table 4 highlights the extent of uncertainty in the estimation of

worldwide dental expenditures. Using the mean expenditure
level (95% confidence interval) of all GBD 2010 regions with
primary expenditure information to impute missing expenditure
values, worldwide expenditures were estimated at $311.14B
(lower bound: $281.43B; upper bound: $340.85B). Uncertainty
stems mostly from areas with sparse primary information on
expenditure.
Indirect Costs
The estimates of worldwide productivity losses are set out in
Table 3. Indirect costs due to major dental diseases amounted to
$144.25B. Thereof, $63.03B (44%) was attributable to severe
tooth loss, $53.99B (37%) to severe periodontitis, $25.14B
(17%) to untreated caries in permanent teeth, and $2.09B (1%)
to untreated caries in deciduous teeth. The highest productivity
losses are found for Western Europe ($40.98B), High-Income
North America ($30.19B), East Asia ($15.70B), High-Income
Asia Pacific ($13.82B), and Eastern Europe ($6.17B); the low-
est productivity losses are found for Oceania ($21.46 million),
Sub-Saharan Central Africa ($202.82 million), the Caribbean
($404.06 million), Sub-Saharan East Africa ($433.61 million),
and Sub-Saharan West Africa ($450.81 million).
Severe tooth loss accounted for the highest proportion of
productivity loss in High-Income Asia Pacific, Western
Europe, High-Income North America, Central Europe, and
Eastern Europe. Severe periodontitis accounted for the highest
proportion of productivity loss in Australasia, Southern Latin
America, Tropical Latin America, Central Latin America,
Southeast Asia, Central Asia, and Sub-Saharan East Africa. In
Andean Latin America, severe tooth loss and severe periodon-
titis had the largest share in productivity loss. Untreated caries
in permanent teeth accounted for the highest proportion of pro-
ductivity loss in North Africa and Middle East, South Asia,
Oceania, Sub-Saharan Southern Africa, Sub-Saharan Central
Africa, and Sub-Saharan West Africa.
Discussion
The findings of the present study suggest that direct treatment
costs due to dental diseases worldwide were $298B in the year
2010, corresponding to 4.6% of global health expenditure
Figure. Map of GBD 2010 regions and super-regions. Reprinted from: Murray CJ et al. (2012). GBD 2010: design, definitions, and metrics. Lancet.
380(9859):2063-2066. Copyright 2012, with permission from Elsevier.

($6.5 trillion in 2010; WHO 2012). In addition, the annual
global indirect costs due to dental diseases (i.e., productivity
losses) were estimated at $144B. Direct and indirect costs
together amounted to an annual economic impact of $442B for
2010 alone; 83% of direct treatment costs were attributable to
high-income countries. The global region with the next-largest
amount of dental expenditures was Latin America and the
Caribbean (5%), followed by South Asia (4%), Central/Eastern
Europe and Central Asia (3%), North Africa and the Middle
East (2%), Southeast Asia, East Asia and Oceania (2% of
global expenditures), and Sub-Saharan Africa (1%). Forty-four
percent of productivity losses were attributable to severe tooth
loss, 38% to severe periodontitis, and 17% to untreated caries
in permanent teeth. Economic losses of the top 10 global
causes of death were recently estimated through a similar
approach as the present study, to range between $895B (can-
cer) and $126B (lower respiratory infections; Cancer Society
2010). Therefore, the present study’s estimate for productivity
loss due to dental diseases ($144B) may be interpreted in the
sense that indirect costs due to dental diseases worldwide cor-
respond to economic losses within the range of the 10 most
frequent global causes of death.
Due to limitations in the underlying data sources, the find-
ings of the present study should be interpreted with caution.
For estimation of direct costs, relevant information was identi-
fiable for only 66 of 187 countries (35%). Expectedly, our
results emphasize considerable uncertainty in estimating
global costs of dental diseases. Routine health expenditure
information was found to be primarily published by depart-
ments of health or international organizations. Although
information availability tended to be better for high-income
countries, there is ample room for improvement in the quality,
Table 1. GDP per Capita and DALYs: 2010.
DALYs, ×1,000
Untreated Caries Teeth Severe
Region GDP per Capita, US$ Deciduous Permanent Periodontitis Tooth Loss
Asia Pacific, High Income 36,848.52 3 35 149 188
Europe, Western 38,771.20 6 114 391 546
Australasia 51,809.58 0 4 35 34
North America, High Income 46,805.05 8 57 224 356
Europe, Central 10,951.79 4 116 133 140
Latin America, Southern 10,047.62 1 20 95 60
Europe, Eastern 8,427.02 7 183 265 277
Asia, East 5,180.64 71 1,023 1,265 672
Latin America, Tropical 10,561.95 13 97 250 212
Latin America, Central 7,819.41 13 135 210 167
Asia, Southeast 2,732.69 50 432 544 281
Asia, Central 3,609.36 5 61 69 54
Latin America, Andean 4,228.81 4 32 46 46
North Africa/Middle East 6,919.93 33 297 257 287
Caribbean 4,753.69 2 23 21 39
Asia, South 1,227.88 129 1,413 943 1,015
Oceania 1,788.10 1 6 2 3
Sub-Saharan, Africa Southern 5,747.58 4 52 34 38
Sub-Saharan, Africa East 658.98 32 206 292 128
Sub-Saharan, Africa Central 1,361.21 9 60 48 32
Sub-Saharan, Africa West 1,053.29 29 187 129 83
DALY, disability-adjusted life year; GDP, gross domestic product.
Table 2. Estimated Worldwide Dental Expenditures: 2010.
Super-region: Region US$ Billion
Southeast Asia, East Asia, and Oceania 5.79
Asia, East 5.02
Asia, Southeast 0.75
Oceania 0.02
Central Europe, Eastern Europe, and Central Asia 9.32
Asia, Central 0.45
Europe, Central 2.75
Europe, Eastern 6.12
High Income 244.40
Asia Pacific, High Income 23.30
Australasia 7.03
Europe, Western 91.05
Latin America, Southern 2.93
North America, High Income 120.08
Latin America and Caribbean 14.06
Caribbean 0.59
Latin America, Andean 0.76
Latin America, Central 5.79
Latin America, Tropical 6.92
North Africa/Middle East 8.33
Asia, South 12.84
Sub-Saharan Africa 2.96
Sub-Saharan, Africa Central 0.01
Sub-Saharan, Africa East 0.20
Sub-Saharan, Africa Southern 2.70
Sub-Saharan, Africa West 0.04
Global 297.67

standardization, and reporting of dental expenditures. In the
absence of more comprehensive information, estimates of
global expenditure are at risk of substantial upward or down-
ward bias. Moreover, it is important to appreciate that without
appropriate detail on coding the direct costs, figures cannot
distinguish between the percentage of the economic burden
aimed toward different treatment categories (e.g., disease
avoidance [checkup, diagnosis, prevention]) and interventive
treatment of dental disease (restorative, periodontal, and
optional cosmetic care [tooth whitening]). For estimation of
indirect costs, it was assumed that each DALY can be valued at
1 y of per capita GDP. In addition to limitations implied by the
concept of DALYs themselves (Anand and Hanson 1997), the
economic value of DALYs is affected by the size of per capita
GDP of the various regions examined. Prioritization of health
policies to improve oral health according to regions with high
estimated economic impacts may impose risks of neglecting
regions and countries with comparably small GDPs.
Nevertheless, the results of the present study may serve as
informative approximation of global economic impacts of oral
diseases.
The present study emphasizes the urgent need to increase
the availability of internationally comparable data on dental
treatment costs, disease-specific absenteeism from work and
school, as well as intangible costs of oral diseases in terms of
quality of life. While in principle there are a number of suitable
approaches available to estimate the economic burden of a spe-
cific disease, these have been rarely applied (Cancer Society
2010). In this regard, oral health is no exception. Data relevant
to comprehensively assess the full magnitude of direct and
indirect costs of dental and oral diseases still seem very sparse.
Conclusion
Within the limitations of currently available data sources and
thus still restricted methodologies to estimate the full costs of
oral diseases, the findings of the present study suggest that the
global economic burden of dental diseases amounted to $442B
in 2010, of which $298B was attributable to direct treatment
costs and $144B to indirect costs in terms of productivity
losses due to caries, periodontitis, and tooth loss. The actual
burden and cost of oral conditions are likely to be much higher
as dental conditions such as oral cancer dysplasias of the oral
mucosa, oral infections, oral developmental disorders (e.g.,
clefts of the lip and palate) and noma could not pertinently be
included in this study. Further research on the cost of oral con-
ditions should include all oral conditions, rather than be
restricted to the most common dental conditions. Improvements
in population oral health may imply substantial economic ben-
efits not only in terms of reduced treatment costs but also
because of fewer productivity losses in the labor market.
Table 3. Estimated Productivity Losses due to Untreated Caries, Severe Periodontitis, and Severe Tooth Loss (US$ Million): 2010.
Untreated Caries Teeth Severe
Super-region: Region Deciduous Permanent Periodontitis Tooth Loss Total
Southeast Asia, East Asia, and Oceania
Asia, East 367.83 5,299.79 6,553.51 3,481.39 15,702.51
Asia, Southeast 136.63 1,180.52 1,486.59 767.89 3,571.63
Oceania 1.78 10.73 3.58 5.36 21.46
Central and Eastern Europe and Central Asia
Asia, Central 18.05 220.17 249.05 194.91 682.17
Europe, Central 43.81 1,270.41 1,456.59 1,533.25 4,304.05
Europe, Eastern 58.99 1,542.14 2,233.16 2,334.28 6,168.58
High Income
Asia Pacific, High Income 110.55 1,289.70 5,490.43 6,927.52 13,818.20
Australasia 0 207.24 1,813.34 1,761.53 3,782.10
Europe, Western 232.63 4,419.92 15,159.54 21,169.07 40,981.16
Latin America, Southern 10.05 200.95 954.52 602.86 1,768.38
North America, High Income 374.44 2,667.89 10,484.33 16,662.60 30,189.25
Latin America and Caribbean
Caribbean 9.51 109.33 99.83 185.39 404.06
Latin America, Andean 16.92 135.32 194.53 194.53 541.29
Latin America, Central 101.65 1,055.62 1,642.08 1,305.84 4,105.19
Latin America, Tropical 137.31 1,024.51 2,640.49 2,239.13 6,041.43
North Africa/Middle East 228.36 2,055.22 1,778.42 1,986.02 6,048.02
Asia, South 158.40 1,734.99 1,157.89 1,246.30 4,297.58
Sub-Saharan Africa
Sub-Saharan, Africa Central 12.25 81.67 65.34 43.56 202.82
Sub-Saharan, Africa East 21.09 135.75 192.42 84.35 433.61
Sub-Saharan, Africa Southern 22.99 298.87 195.42 218.41 735.69
Sub-Saharan, Africa West 30.55 196.97 135.88 87.42 450.81
Global 2,093.76 25,137.72 53,986.91 63,031.61 144,249.97

Author Contributions
S. Listl, W. Marcenes, contributed to conception, design, data
acquisition, analysis, and interpretation, drafted the manuscript; J.
Galloway, contributed to conception, design, data acquisition, and
analysis, critically revised the manuscript; P.A. Mossey, contrib-
uted to conception, design, data acquisition, analysis, and interpre-
tation, critically revised the manuscript. All authors gave final
approval and agree to be accountable for all aspects of the work.
Acknowledgments
This study was performed under the auspices of the Global Oral
Health Inequalities Research Agenda of the International
Association for Dental Research (IADR-GOHIRA®
). Early results
of this work were presented at the Satellite Workshop “Oral Health
Inequalities: Translating Research into Public Health Strategies
and Action” during the IADR Pan European Region Conference
2014. The authors thank David Williams, Richard Watt, Georgios
Tsakos, Helen Whelton, Lone Schou, Jimmy Steele, and
Christopher Fox for helpful comments. All authors were funded
by their own institutions to perform all work relating to the present
study. The authors declare no potential conflicts of interest with
respect to the authorship and/or publication of this article.
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