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A STUDY FROM REBMANN RESEARCH WITH STRATEGY IDEAS FOR THE EUROPEAN DENTAL INDUSTRY.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | Introduction

2 | 3

CONTENTS
Introduction

S1

STRATEGIES GOVERNED BY STRUCTURAL TRENDS 6

S 5

STRATEGIES FOR THE MACROENVIRONMENT 26

Dental care past and present

Dental markets and the economic situation

Development of dental expenditure in the primary health market

Dental health and demand

S 6

NATIONAL STRATEGIES, BY AND LARGE 30

Trend towards greater cooperation and joint practices

The market environment becomes more difficult

Health systems and dental care

32

28

32

S 2

STRATEGIES GOVERNED BY SOCIAL TRENDS 10

Dental care in the private sector

33

Demographic development and demand for dental services

12

Public health systems financed through taxes

33

Does the demand for dental care fall with increasing age?

12

Growing demand and prosperity the significance of the secondary health market

13

S 7

SOCIAL INSUR ANCE SYSTEMS IN DETAIL 34

S 3

Belgium

36

STRATEGIES GOVERNED BY PRODUCT technologY 14

Germany

38
40

Digitalisation transforms structures and processes

16

France

Digital technologies alter the interaction between dental professional groups

16

Netherlands

42

Strategic collaborations are necessary

16

Austria

44

New production techniques influence quality and price

16

Switzerland

46

Europe: Quality dominates

17

Categorising of dental market segments

18

S 8

Product trends in individual segments

19

Denmark

50

Consumables and supplies

19

Italy

52

PUBLIC/STATE HEALTH SYSTEMS IN DETAIL 48

Implants

19

Spain

54

Digital technologies also transform products

21

United Kingdom

56

Opportunities inherent in other selected product groups

21

List of references

58

S 4 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

Greater demand for cosmetic


products and prevention

Schedule 1: Strategies governed by structural trends

S1
Changing
job profile

Growing prosperity

Non-vital
dental services

Quality requirements

Schedule 2: Strategies governed by social trends

S2
Double ageing

Complementary
dentistry

Economic situation

Legal notice
Publisher

Identification of regional
market penetration

Schedule 3: Strategies governed by product technology

High-quality and
basic services

Expand
cross-selling

GFDI Gesellschaft zur Frderung der Dental-Industrie mbH


Dr. Markus Heibach, CEO

S3

Burkhard Sticklies, Press and Communications


Monitoring of micro/
macroenvironment
Main target group:
wealthy older people

Schedule 4: Strategies for the microenvironment

Digitalisation demands
product adaptations

Digital technology transforms


the value-added chain
Identification of high
coverage densities

Authors
Dr. med. Heidrun Sturm MPH, Dr. Bernd Rebmann
Secondary
health market

REBMANN RESEARCH GmbH & Co. KG


Mommsenstrasse 46
10629 Berlin

S4
Microenvironmental
analysis

under-mobilized
target groups

Design

Identification of
affluent regions

Thomas Brecht, REBMANN RESEARCH GmbH & Co. KG

Prosperity in
the countries

Private funding share

Schedule 5: Strategies for the macroenvironment

Images and graphics


REBMANN RESEARCH GmbH & Co. KG

S5

Cover, Page 6, 10, 14, 22, 30, 48: fotolia.com,


Page 26: prodente.de;
Public
financing

Growth in
the countries

Consideration of cultural
preferences

Health policy vs.


economic power

Schedule 6: National strategies, by and large

S6
2013 REBMANN RESEARCH GmbH & Co. KG, Berlin

Special
care programs

Payment, contracts, approval

Belgium

All rights reserved.

Austria

France

Schedule 7: Social insurance systems in detail

S7
Germany

Netherlands

Switzerland

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

Denmark

Spain

20th November 2012

Schedule 8: Public/State health systems in detail

S8
Italy

United Kingdom

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | Introduction

INTRODUCTION

4 | 5

Overview of health market in FIDE countries5


2011 ________________________________________________________________________________________________________________________ FIDE () _FIDE (ACCUMULATED) ____
Volume of the market
Population ________________________________________________________________________________________________________________________________________________364,260,000 ____
Gross domestic product ___________________________________________________________________________________________________________ 11,879,250,000,000 ____

DENTAL HEALTH AND HEALTH ARE NOT THE SAME THING

Changes in GDP rel. to last year _________________________________________________________________________________ 1.58 % ____________________________________________


Total health expenditure of GDP _____________________________________________________________________________ 10.83% ____________________________________________

Expenditure for dental health is considerable, accounting for 610% 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 regarded 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 account for between 11% and 42% of their overall
health expenditure. Many people have no insurance
whatsoever to cover dental care.

In terms of overall economic development, the


dental sector is, in common with the health market, also an important economic and growth factor
in Germany. The oral health economy acts as an
important engine for job creation. A recently published study3 has predicted that the number employed 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 speaking, this indicates that around nine jobs currently
depend on a single panel dental practice even in
rural or structurally weak regions.

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

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%). However, 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 positive future.

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.

Adjusted to take the share of dental technology of 6.5 billion as of 2011 into consideration, German dentists 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)

1% other

The

user (patient) does not pay in every case: insurance policies cover costs to varying degrees.
The economic situation of the purchaser (doctor)
is heavily dependent on political regulations (remuneration).
Manufacturers themselves are confronted by
different national regulations governing product
approval and registration in remuneration catalogues.
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 European countries. All these factors shape the health
market in a particularly complex manner and make
it difficult to forecast clear trends.

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 patient 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 consultations occur.

The higher the level of education,


the more frequently visits are
made to the dentist.

Medical consultations increase in


old age.

Dentist visits decrease


in old age.
Source: cf. Widstrom, 2005.

3% prophylaxis
Fig. 2 Value-added chain in the dental market

4% periodontitis treatment
9% orthodontics

Dental
industry

Upstream
Equipment, devices, products, etc.

33% prostheses
50% conservative and operative treatment

Dental
trade

Also dental industry direct sales

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, primarilyin 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 consumer, 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.

Laboratories

Providers

Manufacture of dental products

Dentists
Dental hygienists
Orthodontists
Oral and maxillofacial surgery

Expanding on these hypotheses, this study primarilyaims 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 recommendations for action will be derived from this and common assumptions critically examined.
1 OECD

Health Data (US$ calculated OECD data basis 2011),
cf. also Widstrom, 2005.
2 N
 ote: 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.

Patients/
Consumers

Secondary dental health market

4 cf. Rebmann Research, 2012.


5 see footnote 2.
6 cf. CBI, 2009.

Source: cf. CBI, 2009.

7 cf. Kossioni, 2012.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE ONE

S1

6 | 7

SCHEDULE ONE
STRATEGIES GOVERNED BY STRUCTURAL TRENDS

Greater demand for cosmetic


products and prevention

S1

Important stations

Growing prosperity

Changing
job profile

Improved dental health transforms


the product environment
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

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

Multimorbidity demands an adaptation


of care structures
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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE ONE

8 | 9

DENTAL CARE
PAST AND PRESENT

S1

Development of dental expenditure


in the primary health market
The 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 noted for poor dental health, the role played by dental
prosthetic therapy was reduced through a combination of an altered patient deductible and intensified

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

Belgium

2.2%

Germany
France

6.4%

4.5%

Netherlands

5.4%

4.1%

Austria

5.1%

Switzerland

6.2%

Spain
UK

8.9%

4.1%
4.3%

Denmark
Italy

14.7 %

7.6%

no data
5.0%
4.1%
4.4%
Dental expenditure 1980 (% of total expenditure)

Dental expenditure 2009 (% of total expenditure)


Source: OECD Health Data, 2012.

prevention. Since these changes, Germans now enjoy 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 demand
Dental health all over Europe has improved considerably 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 considerably.9 The WHOs 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 typically 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 simple tooth extraction on the one hand to high-end
care which includes cosmetic dentistry and dental
bleaching.

As the two main diseases encountered in dentistry, caries and periodontitis, are avoidable in most
cases, public prevention programmes such as fluoridation, 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 population frequently exhibits a positive dental status (i.e.
dental care may be limited to checkups and cleaning which can also be realised by dental hygienists).
Increasingly more elderly people retain their own
teeth longer as a result, but periodontal conditions in these medium and higher age groups have
increased.12

Almost 90% of German senior citizens currently suffer from some form of periodontitis.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 practices
Less 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 feminisation of professions and the accompanying increase in part-time work associated 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.

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

Belgium
Germany

Denmark

4.3%

1.4%
2.2%

0.8%

2.1%

0.6%

4.0%

1.1%

Spain
UK

2.4%

0.9%

Austria
Switzerland

4.2%*

1.2%

Italy

Additionally, technological progress means that the level of investments required 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.

6.3%*

0.7%

France
Netherlands

3.9%*

0.9%

1.3%
0.7%

3.1%
3.1%*

DMFT values: average number of decayed-missing-filled teeth (DMFT)


*Available data between 1983 and 1987 was used in the case of some countries.

1985
2010
Source: OECD Health Data, 2012.

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 ramifications for the service they offer.14

care for disabled people is also increasing in importance in the context of demography. 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.

In addition to the growth in competition from alternative forms of care, the


increase in patients suffering from comorbidities has also promoted strengthened cooperation between dentists and other disciplines. The provision of home
8 cf. Mathews, 2007.
9 OECD 2011 (latest available data) and Knig 2010.
10 cf. ZZ, 2012 (1).
11 cf. Mathews, 2007.
12 cf. Kossioni, 2012 and Widstrm, 2005.
13 cf. ZZ, 2012 (1).
14 cf. Dental Tribune, 2011.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE TWO

S2

10 | 11

SCHEDULE TWO
STRATEGIES GOVERNED BY SOCIAL TRENDS

Non-vital
dental services

Quality requirements

S2

Important stations

Double ageing

Economic situation

Complementary
dentistry

Increased life expectancy and, simultaneously,


a lower birth rate (double ageing) are
changing dental treatment
Dental health needs should be considered in a more
differentiated manner (older sick/older healthy people)
The spectrum of treatment is changing

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

Quality strategies benefit from increasing standards and a growing


demand in many countries
Quality is more important than price
The demand for high-quality products is growing
in the secondary health market

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

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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE TWO

12 | 13

DEMOGRAPHIC DEVELOPMENT
AND DEMAND FOR DENTAL
SERVICES

S2

Practically every European society is confronted with demographic change, although 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 coming 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.

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


17.08%

Belgium

24.2%
20.63%

Germany
France

16.6%

Netherlands

15.45%

24.4%
25.9%

17.65%

Austria

26.1%

16.29%

Switzerland

25.2%

15.26%

Denmark

30.2%

24.1%
20.08%

Italy

16.74%

Spain

16.35%

UK

28.6%
24.8%

21.9%

2010 or latest available data


2035
Source: European Health for All Database (DFA-DB), WHO Regional Office for Europe, as of: 2011.

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 primarycauses 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 basedon the following 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 behaviour of patients with regard to care and professional 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, meaning that private expenditure for dental health in
particular increases as one grows older.16
However: most correlations encountered in conventional 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,

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 qualification).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 expenditure is not taken into consideration in this respect.20 Dental implants and expensive 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 fewprimarily healthy patients and is probably also financed 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 economic 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, appearance) and, on the other, not insignificantly through the media.

Growing demand and prosperity the


significance of the secondary health market
The secondary health market is a relatively ill-defined 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

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

Germany

Netherlands

Austria

Switzerland

Spain

100%

80%

60%

40%

20%

0%
1524 y.

2534 y.

3544 y.

4554 y.

5564 y.

6574 y.

7584 y.

85 y. and more

Source: Eurostat survey, 2002.

Colloquially speaking, the secondary health market 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 contribution 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, wellness, health tourism and organic and functional

food.22 Cosmetic and aesthetic products in the dental 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
t hrough prevention-oriented demand which, depending on the health system involved, is covered
to a greater or lesser degree by publicly funded
dental care. These services are primarily available in the freely funded secondary health market
in Germany. Accordingly, the share of the secondary market in the overall oral health market
would currently be 29.6% and rise to about 40%
by 2030.24
A nother trend is evident in complementary dentistry in the context of holistic medicine.25 This
includes collaborations with otolaryngologists,
pulmonologists, orthopaedic surgeons or physiotherapists.

Fig. 8 Costs for dental care relative to age in Germany

Other growth drivers are the growing interest in


aesthetic dentistry, although this area strongly depends on the economic situation. As a consequence,
these effects are also to be observed in relation to
oral health products in the retail trade, strengthening 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 annum in the last decade.26

150%

15 c f. NHS, 2008.

125%

16 cf. Klingenberger, 2012.


17 c f. Kossioni, 2012.

100%

18 cf. Eurobarometer, 2010.


19 cf. Eurobarometer, 2010.
20 N ote: data on the distribution of private expenditure
according to age is not available.
21 cf. Klingenberger, 2012, S. 44.

75%

50%

Men 2010

22 cf. Klingenberger, 2012.


23 N ote: 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.
24 cf. Klingenberger, 2012.
25 cf. ZZ, 2012.
26 cf. ZZ, 2012.

Women 2010

25%

0%
0-

1-

5-

10-

15- 20- 25-

30-

35-

40- 45-

50- 55-

60-

65-

70- 75-

80-

85- 90-

Source: cf. Barmer GEK dental report, 2012.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE THREE

S3

14 | 15

SCHEDULE THREE
STRATEGIES GOVERNED BY product technology

Identification of regional
market penetration

S3

High-quality and
basic services

Expand
cross-selling

Important stations

Monitoring of micro/
macroenvironment

Digital technology transforms


the value-added chain

Digitalisation demands
product adaptations

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

Dental technology varies between


high-quality and basic services

Market intertwining of products and


cross-selling options offer potential
e.g. implants and regenerative products

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

Micro and macro-factors are decisive when it comes


to privately funded, but non-essential products
Implants, regenerative technologies, cosmetics, aesthetics

Products which depend directly on demand are


relatively independent of micro/macro-factors
Full prostheses, restorative treatment, prevention, CAD/CAM systems/digital technology

Weak market penetration harbours opportunities


for growth in some countries

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE THREE

S3

DIGITALISATION CHANGES
STRUCTURES AND PROCESSES
Digital technologies alter the interaction between
dental professional groups
New technologies mean that many working procedures are replaced by computer-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. Fully-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 computer-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 laboratories to access the latest technology without the necessity to invest in complex
and maintenance-intensive milling equipment. The quality of centralised milling machinery is well defined, enabling technicians to react in a flexible manner
to customer wishes.27
Strategic collaborations are necessary
More than three of every four dental labs are still small or medium-sized facilities. 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

16 | 17

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 solutions. Common goals are evident here, as dentists
themselves demonstrate their capability to patients
through dental technology quality. Collaborations
and common strategies between dentists and dental technicians should be developed to maintain the
affordability of good quality in the actual country.
The involvement of dental technicians in the clarification of patients is therefore regarded as important.
New production techniques
influence quality and price
Dental 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. Qualified training is regarded as a central factor if the
medium and high-end dental technology segments
are to be retained in Europe. However, problems relating 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

EUROPE: QUALITY DOMINATES


Taken as a whole, the EU market is strong and,
in terms of quality, the image of European products bearing the CE seal is excellent. In addition,
the increasing uniformity of market approval
requirements and standards within the EU facilitates 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 increasingly regarded as such, in as much as it is assured
political and state support. A clear goal will illustrate an aim to maintain the attractiveness of
the market for medical products within the EU
to avoid endangering the competitiveness and innovativeness of the domestic industry. Promoting 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 institutions and collaborations will continue. In
addition to this, an increasing number of collaborations 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

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

14,283

Belgium
Germany

4,172
15,895

France

16,210

Netherlands
12,904

Austria
7,967

Switzerland

12,333

Denmark

Competition from discounters is encountered regionally 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 established 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 discounters. 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 administration and an appropriate sales organisation)
3.
One stop shop distributors (which combine
their own products with established products
in distribution)31

Italy
Spain

5,126
9,599

UK

25,956

Source: cf. ADDE Survey, 2012.

In addition, large providers offer established basic products at low prices or include 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.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE THREE

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 included 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 areas. National framework conditions relating to the payment situation and trading 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 nonessentials on offer.

Categorising of dental market segments


Products and market segments differ considerably in terms of their customer structure, growth trends, innovation and quality specifications. It is therefore 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 segments are listed independently of payment and, consequently, only partially
included in internationally accessible data on dental health expenditure (e.g.
OECD, WHO).

18 | 19

Consumables and supplies


Dental materials and products
Materials for dental fillings
Hygiene and disinfectants

Dental products/Metal implants etal.


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

Fig. 10 Market segments in the dental industry

6% technical service

Teeth delivered
Incl. digital prosthetics, implants
Miscellaneous
Included here arecosmetic products for customers
(aesthetic treatments, toothpaste, mouthwashes,
whiteners, etc.)

22% equipment
2% teeth
55% consumables
15% miscellaneous

Source: cf. ADDE Survey, 2012.

PRODUCT TRENDS IN INDIVIDUAL SEGEMENTS


Consumables and supplies
Consumables and supplies account for the majority of the so-called dental market, 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%

Fig. 11 Global implant market

In the area of consumables, demands are continuously increasing with regard to material variety,
value for money and service (i.e. innovations will
play a significant role). The market for dental pharmaceutical 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 consisting of ceramics and non-precious metals, which
lead one to expect a proportional drop in sales. In
general, classic materials and technologies will increasingly 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.

4550% Europe
2530% North America
1520% Asia Pacific
510% rest of world

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

Implants
The 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 premium, value and discount segments. Discount implants make up the smallest and most fragmented
part of the market. These products mainly compete

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 implants has enabled many low-price competitors to enlarge their market shares
in practically every European market. In particular, low-cost players from outside Europe are attracted by this. Similar to many aspiring/new European competitors, 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 crisis, 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 (1520%) which
patients have to bear. Material prices between countries only differ in this respect 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 1520% 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 todays figure of about
20% to 2530%.39

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE THREE

20 | 21

The fact that many dentists are presently still less than familiar with implantology 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 implantology is frequently (still) not regarded as a formal specialisation, an overall
improvement appears to be occurring which will have a positive effect on demand. 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 themselves support their dental customers with training seminars in this respect.
Although a downturn resulting from the recession is apparent in Europe, patients confidence in this technology is also growing. For this reason, significant 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

Fig. 12 Market penetration of implants

Belgium

no data
110

Germany
55

France
Netherlands

no data
110

Austria

115

Switzerland
Denmark

no data
190

Italy
160

Spain
UK

20
Details per 10,000 inhabitants in 2011

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

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 implant market:40
Italy: Currently the second largest implant market in Europe. However, the downward price spiral will make it difficult to achieve profits here.
Spain: The market here is expected to shrink further 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 double the rate in the rest of Europe are forecast.
China: Increasing prosperity offers market opportunities.
Eastern Europe: The greatest growth rates are anticipated 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).

Digital technologies also


transform products
Digitalisation is also rapidly forging ahead in the
dental area. Experts assume that significant shares
of turnover will be generated through digital prosthetics and other technically based services, both in
the dental practice and laboratory market. The consequence 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 regarded as trend indicators, the outlook for digital
technologies is positive. Major producers are increasingly investing in new technologies and applications in the area of digital dental medicine,
particularly prosthetics. Indications and production 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.

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 anticipated that turnover in the area of cost-intensive, individually milled abutments will increase by almost 7 % per annum up until 2016.42
New technologies are rapidly conquering the market. Tapered internal connections, for example, are among the latest innovations and currently represent the connection type exhibiting the strongest growth in the dental implant 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 considered 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 products: 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 manufacturers.46

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 H eraeus 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 development portfolio (and numerous clinical studies).
34 cf. businesscoot.com, 2012
35 cf. businesscoot.com, 2012
36 cf. Heraeus, 2011.

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

37 cf. Heraeus, 2011.


38 cf. Millennium Research Group, 2012.
39 c f. Achermann, 2012.
40 c f. Millennium Research Group, 2011
and cf. Straumann, 2012.
41 cf. www.marketresearch.com.
42 c f. Millennium Research Group, 2012.
43 cf. Dental Tribune, 2012.
44 cf. Dental Tribune, 2012.
45 cf. Dental Tribune, 2012.
46 cf. Dental Tribune, 2012.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE FOUR

S4

22 | 23

SCHEDULE FOUR
STRATEGIES FOR THE MICROENVIRONMENT

Main target group: wealthy


older people

S4

Identification of high
coverage densities

Secondary
health market

Important stations

Microenvironmental
analysis

under-mobilized
target groups

Identification of
affluent regions

Demand is governed by the microenvironment


(e.g. medical condition, age and social status of patients)
Healthy, educated, affluent older people
form a significant user group
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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE FOUR

S4
SALES SUCCESS DEPENDS
ON CLEAR REGIONAL
KNOWLEDGE
A successful marketing strategy begins with analysis of market conditions at the location:
There are patients at every location who can be
mobilised. A contemporary study of the utilisation 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 insurance 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). According 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 examinations, 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-

gartens 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 participation 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 under certain circumstances (in comparison to paediatricians). In countries with
strongly public healthcare systems (DK, UK), programs of this nature have existed 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 calculus 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 taken advantage of.

24 | 25

Fig. 13 Density of dentists (inhabitants per dentist)

1,509

Belgium
1,206

Germany

1,531

France

2,334

Netherlands
2,021

Austria
1,670

Switzerland
1,212

Denmark

1,061

Italy

1,707

Spain

2,077

UK

Source: cf. ADDE, 2012.

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


6,695

Belgium

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

Germany

1,231
3,578

France

4,053

Netherlands

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 Regional 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%).

2,943

Austria

3,650

Switzerland

3,265

Denmark
Italy
Spain
UK

2,160
2,935
8,712
Source: cf. ADDE, 2012.

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
Dentists
Around 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 demand 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%). Considerable 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 European 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 population 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 dental hygienists.52
Regional fluctuations
The density of dentists fluctuates considerably on a regional level. In addition to
fluctuations between countries, clear differences are also evident within countries. 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 demand
A current study forecasts that the dental market
will experience a constant growth rate for the foreseeable 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 demand is familiar from the health market. This implies that, relatively independent of the actual treatment requirement, the more services are offered, the
more frequently health services will be availed of.
The indirect relationship between the customer (patient) and provider (doctor) in particular is the causal 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 services.55 This can be a consequence of supply-induced
demand. However, the growing demands of insured
customers relating to dental health doubtlessly represent a further factor.
That dental health demand is not necessarily a
consequence of supply and, consequently, a supply-induced demand phenomenon is illustrated by
a further perspective of the study. A comparison between dental services demanded by urban and rural
patients surprisingly indicated a higher level of demand among the rural population, even though the
density of dentists in rural areas is about 24% lower. Overall, rural utilisation is 3% greater than the
urban level. When viewed conversely, considerable

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


2,581

Belgium
1,825

Germany

2,533

France

3,837

Netherlands
2,222

Austria

2,305

Switzerland
Denmark
Italy

1,142
1,495
2,837

Spain
UK

1,662
Source: OECD Health Data, 2009.

mobilisation potential still appears to exist as a consequence in conurbations in


a generally multicultural patient pool. Dentists who can adapt to suit the special 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 c f. Widstrm, 2010.
51 c f. Widstrm, 2010.
52 c f. Widstrm, 2010.
53 N ote: 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 c f. Global Information Inc., 2012.
55 c f. Saekel, 2010.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE FIVE

S5

26 | 27

SCHEDULE FIVE
STRATEGIES FOR THE MACROENVIRONMENT

Prosperity in
the countries

Private funding share

S5

Important stations

Public
financing

Growth in
the countries

Consideration of cultural
preferences

Countries in which dental services are


for the most part covered promise a
stable market
Countries with unchanging/growing prosperity
(measured relative to GDP) offer a suitable environment for rather more quality-oriented strategies
Countries in which there is a high level of
private funding are more receptive to growth,
but also harbour risks
Price strategies are primarily appreciated
in countries with a shrinking GDP
Consideration should be given to cultural preferences,
particularly with regard to non-essential services

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE FIVE

28 | 29

DENTAL MARKETS AND


THE ECONOMIC SITUATION

S5

How does the economic situation of a country and


the liquidity of patients (and, possibly, the economic situation of dental service providers) influence
the demand for dental treatment?
Firstly, there are indications that the economic situation of patients (their income) generally influences the demand for dental treatment. Due to the
costs involved, people with lower incomes evidently
avoid having necessary or desirable treatment realised with greater frequency, and this is largely un-

3.9

1.4

Germany

5.7

2.1

France
Netherlands

0.8

Austria

2.0
1.5

2.8

Switzerland
Denmark

2.4

Italy
Spain
UK

8.8

4.2
no data

4.6
0.8
0.6

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 againby 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

8.9

4.4

What is the relationship between dental services which must be privately funded and demand?56 This question 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 private 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. Prevention 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.

Fig. 17 Non-fulfilled treatment demand relative to income

Belgium

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 dental care can be relatively lower than is demographically expected.

11.7

6.7
6.5

Lowest income quintile (%)


Total population (%)
Source: Eurostat, 2009/2010.

This all suggests that chiefly uninsured indication areas and those which are not absolutely necessary depend 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. 18 Private expenditure vs. rate of change of economic development

X-axis:

100%

Switzerland
Spain

56 N ote: dental services funded privately vary considerably between different countries, but are difficult to quantify uniformly.
The proportion of private expenditure for dental medicine is
therefore drawn upon as an approximate value.
57 cf. Straumann, 2012.

Y-axis: proportion of private expenditure relative to total outlay for dental services 2011

X: -2.20%
Y: 97.20%
0: 118.31

Italy
80%

rate of change GDP 20082011

Y-axis: 
proportion of private expenditure
relative to total outlay for dental
services 2011
Circle size: per capita dental expenditure

X: 3.3%
Y: 91.00%
0: 463.30

X: 0.30%
Y: 97.00%
0: 211.10

UK
X: 5.20%
Y: 69.30%
0: 127.98
60%

Austria

Denmark

X: 6.40%
Y: 39.60%
0: 215.66

X: 2.20%
Y: 70.50%
0: 230.64

France
X: 3.30%
Y: 25.30%
0: 184.60

40%

Netherlands

20%

X: 1.30%
Y: 25.00%
0: 191.80

Belgium
X: 6.80%
Y: 28.10%
0: 88.32

Germany
X: 4.80%
Y: 25.90%
0: 287.34
0%
2%

0%

2%

4%

6%

X-axis: rate of change GDP 20082011

58 c f. Dental Tribune, 2012.


59 cf. Heraeus, 2012.

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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SIX

S6

30 | 31

SCHEDULE SIX
NATIONAL STRATEGIES, BY AND LARGE

Health policy vs.


economic power

S6

Important stations

Special
care programs

Payment, contracts, approval

The success of many dental products is


significantly influenced by the economic
power of a country
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

Each health system also offers special health programs


for dental health care

SCHEDULE

FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SIX

32 | 33

THE MARKET ENVIRONMENT


BECOMES MORE DIFFICULT

S6

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.

Europe accounts for about 30% of the global dental 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 number of manufacturers of dental products, occupying
first place ahead of France, Italy and Great Britain.
Alone the 200 member companies of the Associa-

Fig. 19 Development of health expenditure in an international comparison: 19962009; share in GDP in%
USA

UK

Germany

Switzerland

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 implant market.63 The European market is covered 6080% 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

France

20%

Health systems and dental care


It is becoming increasingly advisable for the manufacturers of dental products to adapt with greater intensity to the distinctive peculiarities of specific countries. These are addressed below in strategic recommendations for individual countries, a collection of relevant market data and the depiction of key systemic
relationships relating to dental medicine.

15%

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

10%

5%

0%
1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

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

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 expenditure 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.

Scientifically speaking, countries are frequently


grouped together according to the insurance system involved but, from the point of view of the dental 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 independently 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 sector
No 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 insurance. 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.

Fig. 20 Public health expenditure and expenditure for social insurance (2009)
Belgium
10.93%

64.65%

24.42%

6.74%

70.52%

22.73%

Germany

France
3.85%

73.72%

22.43%

Netherlands
8.53%

77.15%

14.32%

Austria
44.79%

32.34%

22.87%

Switzerland
18.95%

46.27%

34.78%

Denmark
15.44%

84.56%
Italy

21%

79%
Spain

no data

UK
8.9%

83.20%
Public expenditure (except social insurance)

Social insurance

7.9%

Private expenditure
Source: OECD Health data, 2012.

60 c f. CBI, 2009.
61 cf. VDDI, 2012.
62 cf. Straumann, 2012.
63 cf. Finanz und Wirtschaft, 18.08.2012.
64 cf. ADDE, 2012.
65 c f. Dental Tribune, 2011.
66 N ote: e.g. Denmark, Finland, Iceland, Ireland, Lithuania,
Malta, Norway, Sweden and the UK.

Public health systems financed through taxes


Systems 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 providers. Dental expenditure is for the greater part covered by the insurance.

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

S7

34 | 35

SCHEDULE SEVEN
SOCIAL INSURANCE SYSTEMS IN DETAIL

Belgium

S7

Austria

France

Important stations

Germany

Netherlands

Switzerland

Dental care is covered to varying degrees in these


countries. Nevertheless, the demand for quality
and aesthetic products is strong
Relative to the state systems of the UK and
Denmark, average dental health is poorer
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
Prevention and dental hygiene will also
tend to grow in importance here
The dental infrastructure is in the
main good, the density of dentists
and dental labs is high

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

Belgium

36 | 37

Belgium

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ______________________________ Belgium ____________ Deviation _____


Volume of the market
Population _____________________________________________________________________________________________________________________________________________________________________ 10,700,000 ___________________________________
Gross domestic product ____________________________________________________________________________________________________________________________________ 401,100,000,000 ___________________________________

Dentists work primarilyin 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.

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 ___________________________________
Volume of the dental market
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 _________________________ _____

The trend towards aesthetic dental treatment


is expressed in above-average growth in, for
example, ceramic inlays.*

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 _________________________ _____

* cf. Simer A., 2010.

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.

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/km).
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 convention 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 (additional 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 themselves.
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 remunerated 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

Germany

38 | 39

Germany

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ____________________________ Germany ____________ Deviation _____


Volume of the market
Population ______________________________________________________________________________________________________________________________________________________________________ 81,310,000 ___________________________________
Gross domestic product ________________________________________________________________________________________________________________________________ 2,794,500,000,000 ___________________________________

The majority of dentists work in private practices, with remuneration of basic


care and part of dental prosthetics.

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 ___________________________________
Volume of the dental market
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 ___________________________________

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.

Total sales value of dental market, minus software ______________________________________________________________________________________________ 2,308,000,000 ___________________________________
Total number of dental dealers __________________________________________________________________________________________________________________________________________________160___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 62.00% _________________________ _____
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 ____________________________________________________________________________________________________________________________ 4,100___________________________________
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
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 0.70 _________________________ _____
Density of market
Number of practicing physicians/doctors _________________________________________________________________________________________________________________________ 300,829___________________________________

The demand for quality products is growing.

Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 3.70 _________________________ _____
Number of practising dentists ______________________________________________________________________________________________________________________________________________ 67,808___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.834 _________________________ _____
Number of dental practices __________________________________________________________________________________________________________________________________________________46,670___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.574 _________________________ _____
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___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.241 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 3.46 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ___________________________________4,149 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 2.55 _________________________ _____
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.

The system
Political background
Germany is a federal republic consisting of 16 federal states with a parliamentary 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 reimbursement, 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, Medical Association (rztekammer)), 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-Wettbewerbsstrkungsgesetz)). Requirements planning was adapted
in 2007 in the case of orthodontists to reflect the falling demand for treatment, 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 prosthetics 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

France

40 | 41

France

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ________________________________ France ____________ Deviation _____


Volume of the market
Population _____________________________________________________________________________________________________________________________________________________________________ 62,810,000 ___________________________________
Gross domestic product _________________________________________________________________________________________________________________________________ 2,169,000,000,000 ___________________________________

The French generally consider teeth


to be relatively unimportant.
After all, the quality of life is defined
through other things.

Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 1.70% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _______________________________ 11.90% _________________________ _____
Total health expenditure ____________________________________________________________________________________________________________________________________ 257,700,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% ________________________________ 4.50% _________________________ _____
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% 

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.

Total sales value of sundries _____________________________________________________________________________________________________________________________________551,000,000 ___________________________________


Total sales value of metal implants __________________________________________________________________________________________________________________________ 150,000,000 ___________________________________
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 _______________________________ 2,388 _________________________ _____
Number of new dental X-ray units installed ___________________________________________________________________________________________________________________________ 5.000 ___________________________________
Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.080 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% ________________________________ 25.3% _________________________ _____
Proportion private expenditure of total expenditure for dental services _____________________________________________________________ 2,930,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 1.20 _________________________ _____
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 practising dentists ______________________________________________________________________________________________________________________________________________41,000 ___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.653 _________________________ _____
Number of dental practices __________________________________________________________________________________________________________________________________________________ 27,500___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.438 _________________________ _____
Number of dental technicians _______________________________________________________________________________________________________________________________________________ 17,550___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.279 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) ________________________________________________________________________ 3,950___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.063 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 __________________________________ 10.38 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ________________________________ 15,902 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 1.31 _________________________ _____
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.

The system
Political background
Independent republic with a bicameral parliament. A region consists of
commune and department levels with arrondissments. Of 63 million inhabitants, 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 (Rgime gnral dassurance 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: private 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 rgionale de sant) 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 indicated 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 medical 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 operations. 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 representatives 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 distributed to schoolchildren in the context of dental
health education.
The dental health of children has improved considerably. 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. Prevention programmes have only existed since 2004.
The pharmaceutical industry is obliged to pay
1% of its turnover and additional taxes on advertising 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

NETHERLANDS

42 | 43

Netherlands

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () _______________________ Netherlands ____________ Deviation _____


Volume of the market
Population _____________________________________________________________________________________________________________________________________________________________________ 16,730,000 ___________________________________
Gross domestic product ___________________________________________________________________________________________________________________________________ 656,600,000,000 ___________________________________
Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________1.30% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _______________________________ 11.90% _________________________ _____
Total health expenditure _____________________________________________________________________________________________________________________________________ 78,300,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment ___________________________________________________ .12% _________________________________ 4.10% _________________________ _____

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-andcoming 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.

Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 3,200,000,000 ___________________________________
Total sales value of dental market, minus software _________________________________________________________________________________________________ 266,000,000 ___________________________________
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___________________________________
Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.057 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% ______________________________ 25.00% _________________________ _____
Proportion private expenditure of total expenditure for dental services ________________________________________________________________ 800,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 0.90 _________________________ _____
Density of market
Number of practicing physicians/doctors ___________________________________________________________________________________________________________________________ 50,525___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 3.02 _________________________ _____
Number of practising dentists _________________________________________________________________________________________________________________________________________________7,119___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.426 _________________________ _____
Number of dental practices ___________________________________________________________________________________________________________________________________________________ 5,800___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.347 _________________________ _____
Number of dental technicians _________________________________________________________________________________________________________________________________________________ 4,100___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.245 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) ________________________________________________________________________ 1,025___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.061 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 6.95 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ________________________________ 16,322 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 0.73 _________________________ _____
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.

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/km). 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/private health insurance, and nobody is entitled to refuse this.
A large proportion of the population has voluntary supplementary insurance (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 incomerelated
contributions from insured persons and a fixed basic premium which insured 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 research. The FHI sector association supports numerous clusters, including on
a cross-border level. Specialised German SMEs can find good locations for
subsidiaries and collaborations in this structure. Products from highly innovative manufacturers are mainly channelled into a growing export trade.
Dental technology sector turnover: around of companies generated greater 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

Austria

44 | 45

Austria

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ________________________________ Austria ____________ Deviation _____


Volume of the market
Population _______________________________________________________________________________________________________________________________________________________________________ 8,430,000 ___________________________________
Gross domestic product ___________________________________________________________________________________________________________________________________ 327,600,000,000 ___________________________________

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.

Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 3.10% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _______________________________ 11.10% _________________________ _____
Total health expenditure _____________________________________________________________________________________________________________________________________ 36,400,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% _________________________________5.00% _________________________ _____
Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 1,800,000,000 ___________________________________
Total sales value of dental market, minus software _________________________________________________________________________________________________ 186,000,000 ___________________________________
Total number of dental dealers ___________________________________________________________________________________________________________________________________________________ 46___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% _______________________________15.00% _________________________ _____
Total sales value of sundries ____________________________________________________________________________________________________________________________________ 106,000,000 ___________________________________
Total sales value of metal implants ____________________________________________________________________________________________________________________________ 30,000,000 ___________________________________
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 _______________________________ 3,559 _________________________ _____

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.

Number of new dental X-ray units installed ______________________________________________________________________________________________________________________________ 350___________________________________

Only basic dental care and some prophylaxis


services are covered by social insurance. About
half of treatment is paid for privately.

Dental health

Despite this, people are greatly interested


in high-quality dental prosthetics.

Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.042 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% _______________________________39.60% _________________________ _____
Proportion private expenditure of total expenditure for dental services ________________________________________________________________ 720,000,000 ___________________________________

Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 1.40 _________________________ _____
Density of market
Number of practicing physicians/doctors ___________________________________________________________________________________________________________________________ 40,464___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 4.80 _________________________ _____
Number of practising dentists ________________________________________________________________________________________________________________________________________________ 4,150___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.492 _________________________ _____
Number of dental practices ____________________________________________________________________________________________________________________________________________________3,790___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 ____________________________________ 0.45 _________________________ _____
Number of dental technicians ________________________________________________________________________________________________________________________________________________ 2,850___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.338 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) __________________________________________________________________________ 650___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.077 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 6.38 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ________________________________ 12,969 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 1.60 _________________________ _____
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.

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. Population 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. Consequently, there is no competition between insurance providers. The 21 providers of the public health insurance scheme are organised in the federation
of Austrian social insurers (Hauptverband der sterreichischen Sozialversicherungstrger).
About a third of the population has additional private insurance, mainly for
inpatient care (82%), private outpatient treatment (10%) and dental prosthetics. Approx. 5% of patients have supplementary dental insurance. The
seven private health insurers are organised in the association of insurance
companies (Verband der Versicherungsunternehmen sterreichs).
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 (SG) 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 ones 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 separate 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 doctors 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 capacity (i.e. without an insurance contract). Only dentists can become partners.
Dentists are represented by the Austrian Dental Chamber (sterreichische
Zahnrztekammer) 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 stipulations 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 Insurance 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 socially disadvantaged families tend to have poorer
dental health.
Sources
cf. Hit-Country Profile: Austria, 2006,
HiT summary Austria, 2006
cf. Simer, A., 2011
cf. ZZ
cf. Bodenwinkler et al., 2007
Further information
sterreichische Zahnrztekammer;
www.zahnaerztekammer.at
sterreichische Gesellschaft fr Zahn-, Mundund Kieferheilkunde, Verein Austriaischer
Dentists; www.oegzmk.at

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE SEVEN

Switzerland

46 | 47

Switzerland

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ________________________ Switzerland ____________ Deviation _____


Volume of the market
Population ________________________________________________________________________________________________________________________________________________________________________7,660,000 ___________________________________
Gross domestic product ___________________________________________________________________________________________________________________________________ 496,900,000,000 ___________________________________
Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 1.90% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _______________________________ 11.50% _________________________ _____
Total health expenditure _____________________________________________________________________________________________________________________________________ 57,200,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% ________________________________ 6.20% _________________________ _____
Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 3,500,000,000 ___________________________________

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.

Total sales value of dental market, minus software _________________________________________________________________________________________________ 120,000,000 ___________________________________
Total number of dental dealers ___________________________________________________________________________________________________________________________________________________ 22___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 53.00% _________________________ _____
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 

Nevertheless, the demand for quality products


is strong and the dental health of adolescents
above average.

Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% _______________________________91.00% _________________________ _____
Proportion private expenditure of total expenditure for dental services _____________________________________________________________ 3,230,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 0.80 _________________________ _____

Switzerland is also a location for major dental


technology companies.

Density of market
Number of practicing physicians/doctors ____________________________________________________________________________________________________________________________29,089___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 3.80 _________________________ _____
Number of practising dentists _______________________________________________________________________________________________________________________________________________ 4,590___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 ____________________________________ 0.60 _________________________ _____
Number of dental practices ____________________________________________________________________________________________________________________________________________________ 3,969___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.518 _________________________ _____
Number of dental technicians _________________________________________________________________________________________________________________________________________________ 2,100___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.274 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) ___________________________________________________________________________962___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 ___________________________________0.126 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 4.77 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ___________________________________7,957 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 1.36 _________________________ _____
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.

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 km 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 worlds 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 worlds 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 imports 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
20003000 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 prices 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 masticatory 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
whichprimarily covers orthodontics. Supplementary insurance to cover
dental care costs is expensive.

Distinctive features
Swiss purchasers of dental and other medical 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 Switzerland in order to try to retain ones own teeth for
as long as possible.
Where an inlay or crown is necessary, the majority of Swiss opt for ceramic.
Customs clearance is necessary when shipping
dental technology products from Germany to
customers in Switzerland, but this is normally 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 medical 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

S8

48 | 49

SCHEDULE EIGHT
PUBLIC/STATE HEALTH SYSTEMS IN DETAIL

Denmark

S8

Spain

Important stations

Italy

United Kingdom

Dental care in these countries is paid for privately


in most cases and, in part, also provided outside
the healthcare system
The dental medical infrastructure is in the
main good, with state organisations in part
also playing a role in purchasing
Where care and, in particular, prevention are regarded
as very important (UK and Denmark), dental health
is above average
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
Nevertheless, the demand for quality and aesthetic products is great,
but depends heavily on the economic situation

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE EIGHT

Denmark

50 | 51

Denmark

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ____________________________ Denmark ____________ Deviation _____


Volume of the market
Population _______________________________________________________________________________________________________________________________________________________________________ 5,540,000 ___________________________________
Gross domestic product ___________________________________________________________________________________________________________________________________ 260,000,000,000 ___________________________________

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.

Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 1.10% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _______________________________ 11.40% _________________________ _____
Total health expenditure ______________________________________________________________________________________________________________________________________29,700,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% ________________________________ 4.30% _________________________ _____
Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 1,300,000,000 ___________________________________
Total sales value of dental market, minus software ____________________________________________________________________________________________________51,000,000 ___________________________________
Total number of dental dealers ___________________________________________________________________________________________________________________________________________________ 40___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 45.00% _________________________ _____
Total sales value of sundries 
Total sales value of metal implants 
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 

The public health system plays a central role,


including in purchasing.

Number of new dental X-ray units installed _______________________________________________________________________________________________________________________________130___________________________________


Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.023 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% ______________________________ 70.50% _________________________ _____

Approx. 80% of dental care is provided through


private funding, and some patients have private
supplementary insurance.

Proportion private expenditure of total expenditure for dental services ________________________________________________________________ 900,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 0.60 _________________________ _____
Density of market
Number of practicing physicians/doctors ____________________________________________________________________________________________________________________________ 19,401___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 3.50 _________________________ _____
Number of practising dentists _______________________________________________________________________________________________________________________________________________ 4,580___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.826 _________________________ _____
Number of dental practices ___________________________________________________________________________________________________________________________________________________ 3,080___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.556 _________________________ _____
Number of dental technicians _________________________________________________________________________________________________________________________________________________ 1,700___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.307 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) __________________________________________________________________________ 450___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.081 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ___________________________________10.18 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ________________________________ 12,318 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 2.54 _________________________ _____
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.

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.

2.1% (15.5%) is private (additional payments, fees and voluntary supplementary insurance). Cost increases occurprimarily in the inpatient sector.
Approx. 9% of all public health expenditure and 4.3% of all health
expenditure is for dental health.

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

Medical technology/Dental technology


There are, in total, around 1,000 Danish companies in the medical technology 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.

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.

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 additional new fees were introduced.
Dental care
Dentists
Dentists are remunerated on a fee-for-service basis. Prices are negotiated every second year in negotiations between the Danish Dental Society (Dansk
Tandlgeforening) and the Health Remuneration Negotiation Committee
(Sygesikringens Forhandlingsudvalg).
Dentists are not subject to any practice restrictions.

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 preventive 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,

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 themselves. These can avail of voluntary supplementary 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 hygienists 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 fluoridation 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE EIGHT

Italy

52 | 53

ITALY

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ____________________________________ Italy ____________ Deviation _____


Volume of the market
Population ______________________________________________________________________________________________________________________________________________________________________61,260,000 ___________________________________
Gross domestic product _________________________________________________________________________________________________________________________________ 1,717,700,000,000 ___________________________________

The majority of dental care is provided outside


the national health system.
This means Italy is relative sensitive
to general economic developments.

Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% ________________________________ 0.40% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _________________________________ 9.50% _________________________ _____
Total health expenditure ___________________________________________________________________________________________________________________________________ 163,700,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% ________________________________ 6.56% _________________________ _____
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___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 33.00% _________________________ _____

Despite this, Italy is one of the largest dental


markets in Europe and has a conspicuously
above-average density of dentists and dental
laboratories.

Total sales value of sundries _____________________________________________________________________________________________________________________________________510,000,000 ___________________________________


Total sales value of metal implants __________________________________________________________________________________________________________________________ 242,000,000 ___________________________________
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 _______________________________ 3,950 _________________________ _____
Number of new dental X-ray units installed ____________________________________________________________________________________________________________________________7,400___________________________________
Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 ___________________________________0.121 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% _______________________________ 97.00% _________________________ _____
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 physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 3.70 _________________________ _____
Number of practising dentists ______________________________________________________________________________________________________________________________________________ 57,000 ___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 ____________________________________ 0.93 _________________________ _____
Number of dental practices _________________________________________________________________________________________________________________________________________________ 36,400___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.594 _________________________ _____
Number of dental technicians ______________________________________________________________________________________________________________________________________________ 28,000 ___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.457 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) ______________________________________________________________________ 11,800___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 ___________________________________0.193 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 4.83 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ___________________________________5,192 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 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.

The system
Political background
Italy has been a parliamentary republic since 1948 with a bicameral parliament (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 insurance 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 governments 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 technology 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

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE EIGHT

SPAIN

54 | 55

SPAIN

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () __________________________________ Spain ____________ Deviation _____


Volume of the market
Population ______________________________________________________________________________________________________________________________________________________________________47,040,000___________________________________
Gross domestic product _________________________________________________________________________________________________________________________________1,166,800,000,000 ___________________________________

With average dental health expenditure and density of dentists, the dental health of adolescents is
among the worst in Europe.

Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 0.70% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _________________________________ 9.50% _________________________ _____
Total health expenditure ____________________________________________________________________________________________________________________________________ 111,300,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% _________________________________5.00% _________________________ _____
Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 5,600,000,000 ___________________________________

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.

Total sales value of dental market, minus software _________________________________________________________________________________________________ 486,000,000 ___________________________________
Total number of dental dealers _________________________________________________________________________________________________________________________________________________ 350___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 32.00% _________________________ _____
Total sales value of sundries ____________________________________________________________________________________________________________________________________ 209,000,000 ___________________________________
Total sales value of metal implants __________________________________________________________________________________________________________________________ 180,000,000 ___________________________________
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 _______________________________ 3,826 _________________________ _____
Number of new dental X-ray units installed ___________________________________________________________________________________________________________________________ 3,600___________________________________
Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.077 _________________________ _____
Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% _______________________________ 97.20% _________________________ _____
Proportion private expenditure of total expenditure for dental services ______________________________________________________________5,410,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 1.30 _________________________ _____
Density of market
Number of practicing physicians/doctors __________________________________________________________________________________________________________________________ 192,872___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 _____________________________________4.10 _________________________ _____
Number of practising dentists ______________________________________________________________________________________________________________________________________________ 27,000 ___________________________________
Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.574 _________________________ _____
Number of dental practices _________________________________________________________________________________________________________________________________________________ 18,500___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 __________________________________ 0.393 _________________________ _____
Number of dental technicians _______________________________________________________________________________________________________________________________________________ 15,700___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 __________________________________ 0.334 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) _______________________________________________________________________ 4,800___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 ___________________________________0.102 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 ____________________________________ 5.63 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 __________________________________ 9,800 _________________________ _____
Dental graduates per 100,000 inhabitants ________________________________________________________________________________ 1.88 ____________________________________ 3.08 _________________________ _____
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.

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 governments. 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 (inparticular 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, meaningtaxes (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
primarilyarises in the form of tax contributions (for the national health
service) and, to a lesser degree, contributions for voluntary supplementary
insurance.

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 policies which cover examinations, extractions and
prophylaxis services. Only 18% of the population chooses comprehensive private supplementary insurance.

Medical technology/Dental technology


Spains medical technology market generates a turnover of approx. 7.4
billion and employs around 32,000 people in 725 firms (as of 2008). Some
SMEs 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.

Distinctive features
According to the WHO World Health Report
2000, Spain had the 7th best health system in the
world.

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-forservice basis. Prices are considerably lower than in the UK. A checkup costs
around 10 , a filling about 4050 .

Sources
cf. Infodent, 2010
cf. ICEX 2009
cf. International Health Systems,
www.Kaiseredu.org
cf. Hit Country profile Spain, 2008

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | SCHEDULE EIGHT

UNited
Kingdom

56 | 57

UNITED KINGDOM

without assessment

neutral deviation

positive deviation

negative deviation

2011 _____________________________________________________________________________________________________________________________________ FIDE () ________________ United Kingdom ____________ Deviation _____


Volume of the market
Population _____________________________________________________________________________________________________________________________________________________________________ 62,060,000___________________________________
Gross domestic product ________________________________________________________________________________________________________________________________ 1,888,800,000,000 ___________________________________
Changes in GDP rel. to last year ______________________________________________________________________________________________ 1.58% _________________________________ 0.70% _________________________ _____
Total health expenditure of GDP __________________________________________________________________________________________ 10.83% _________________________________ 9.60% _________________________ _____
Total health expenditure ____________________________________________________________________________________________________________________________________ 182,100,000,000 ___________________________________
Volume of the dental market
Percentage of total health expenditure for dental treatment _________________________________________________ 5.12% ________________________________ 4.40% _________________________ _____

Despite below-average expenditure and density


of dentists, dental health has improved considerably due to national prevention programmes
and, together with Denmark and Germany,
is currently the best in Europe.

Proportion of total health expenditure for dental treatment (calculated) ____________________________________________________________ 8,000,000,000 ___________________________________
Total sales value of dental market, minus software _________________________________________________________________________________________________ 424,000,000 ___________________________________
Total number of dental dealers ___________________________________________________________________________________________________________________________________________________ 58___________________________________
Dental practices using intra-oral cameras ____________________________________________________________________________ 38.13% ______________________________ 40.00% _________________________ _____
Total sales value of sundries _____________________________________________________________________________________________________________________________________ 287,000,000 ___________________________________
Total sales value of metal implants ____________________________________________________________________________________________________________________________ 42,000,000 ___________________________________
Total sales value of metal implants per 1,000 inhabitants ____________________________________________________ 2,635 __________________________________ 671 _________________________ _____
Number of new dental X-ray units installed ______________________________________________________________________________________________________________________________ 350___________________________________
Number of new dental X-ray units installed per 1,000 inhabitants ___________________________________________ 0.07 __________________________________ 0.046 _________________________ _____

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.

Funding
Percentage private expenditure of total expenditure for dental services ____________________________55.46% ______________________________ 55.00% _________________________ _____
Proportion private expenditure of total expenditure for dental services ______________________________________________________________4,410,000,000 ___________________________________
Dental health
Dental health of 12-year-olds (2010, in DMFT) ____________________________________________________________________________0.96 ____________________________________ 0.70 _________________________ _____
Density of market
Number of practicing physicians/doctors __________________________________________________________________________________________________________________________ 175,280___________________________________
Density of physicians (practicing physicians per 1,000 inhabitants) _________________________________________ 3.54 ____________________________________ 2.80 _________________________ _____
Number of practising dentists ______________________________________________________________________________________________________________________________________________29,865___________________________________

The dental industry has proven to be


crisis resistant.

Density of dentists (practicing dentists per 1,000 inhabitants) _________________________________________________ 0.65 __________________________________ 0.474 _________________________ _____
Number of dental practices __________________________________________________________________________________________________________________________________________________ 11,737___________________________________
Density of dental practices (dental practices per 1,000 inhabitants) ________________________________________ 0.46 ___________________________________0.187 _________________________ _____
Number of dental technicians _________________________________________________________________________________________________________________________________________________ 7,121___________________________________
Dental technician density (dentists per 1,000 inhabitants) _____________________________________________________ 0.33 ___________________________________ 0.114 _________________________ _____
Total number of dental laboratories (dentists and commercial laboratories) _______________________________________________________________________ 2,390___________________________________
Dental laboratory density (dental laboratories per 1,000 inhabitants) ____________________________________ 0.11 __________________________________ 0.038 _________________________ _____
Dentists per dental laboratory ____________________________________________________________________________________________________7.45 __________________________________ 12.50 _________________________ _____
Citizens per dental laboratory _______________________________________________________________________________________________ 12,490 ________________________________ 26,192 _________________________ _____
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.

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 inhabitants are urban dwellers.

Around 80% of the entire budget of all public hospitals and doctors practices will be administered in future through a few hundred Clinical Commissioning 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.

The insurance system


The National Health Service (NHS) was introduced in 1948 as a classic taxbased healthcare system. The state thus assumed simultaneous responsibility
for the comprehensive health care of the entire population and, consequently, free and fair access to services for all.
The majority of services are free of charge to patients. NICE (National Institute 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 payments of trusts/funds.
Private supplementary insurance is growing, particularly
to cover dental care.

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 .

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 responsibility for regional care and increased competition between private and public
providers.

Dental care

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.

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 GPs, are primary care professionals whose services are provided 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 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 registered dental professionals (e.g. assistants, hygienists 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 prosthetics 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 centrally. Purchasing has since been privatised.
Sources
cf. Klein, R., 2006
cf. Oliver, A., 2006
cf. Darcy, 2008

cf. AHK-Grobritannien

SCHEDULE FOR THE EUROPEAN DENTAL MARKET | List of references

List of references
ADDE (2012): (Association of Dental Dealers
in Europe) and FIDE (The Federation of the
European Dental Industry): 2012 SURVEY on the
European Dental Trade (Market Trends).
(Note: acc. to the authors, data is based in part on
different national data which has been compiled
and, in part, on estimations)
Abele, E. (2011): Dentaltechnik der Zukunft,
Leitmarkt fr Medizinprodukte Made in
Germany; Metav Presseforum am 24.11.2011.
Institut fr Produktionsmanagement Technologie und Werkzeugmaschinen. (see www.
metav.de/cipp/md_metav/lib/all/lob/return_download,ticket,g_u_e_s_t/bid,579/
check_table,it_chap_downl_embed/~/METAV_
Presseforum_Prof_Abele_Dentaltechnik_der_
Zukunft_Praesentation.pdf)
Achermann, G. (Straumann 2012): How will dentistry look in 2020? Presentation: Capital Markets
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SCHEDULE FOR THE EUROPEAN DENTAL MARKET | Introduction

FURTHER Information
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