International Dental Journal (2002) 52.

1-8

The burden of restorative dental

treatment for children in Third World
countries
Robert Yee
Kathmandu, Nepal
Aubrey Sheiham
London, UK

Objective: To analyse whether developing countries have sufficient health All systems of dental care are based
dollars to treat existing diseases in general and dental caries in particular in upon the imperative of t r e a h g
their child population. Methods: Assessments of the costs of treating restoratively all dental caries kavi-
existing and future caries by the conventional approach. Analysis of ties. Indeed equitable access to treat
WHO dental databases and spreadsheet calculations of costs based dental caries is a goal for most
upon population projections, prevalence and trends in patterns of caries. dental planners and most dental
Findings: Even though the caries levels are low and most of the disease expenditure is on treatment. The
occurs on the occlusal and the buccal/lingualsurfaces, more than 90% of treatment of dental caries is an
the dental caries remains untreated in Third World countries. Calculations expensive proposition for govern-
reveal that to restore the permanent dentition of the child population of ments of both developed and
low-income nations using traditional amalgam restorative dentistry would developing countries and costs
cost between f 1,024 ($US1618) and f2,224 ($US3513) per 1,OOO children
between 5 per cent and 10 per cent
of mixed ages from 6 to 18 years. This exceeds the available resources for
the provisionof an essential public health care packagefor the children of
of total health expenditure in some
15 to 29 low-income countries. Conclusions: To treat caries with the industrialised countries’.’. In most
traditional method of restorative dentistry is beyond the financial capabili- developing low-income countries
ties of the majority of low-income nations, as three-quarters of these the prevalence of caries is about 80
countries do not even have sufficient resources to finance an essential per cent and over 90 per cent of
package of health care services for their children. caries is untreated3.The severity of
caries is relatively low. For low-
Key words: Planning, costs, treatment, dental caries income nations, financial resources
are limited and even basic health
care and education are a burden
for many. Often the poor are faced
with the hard choice of putting food
on the table for the family or
having conventional treatment to
restore carious teeth. The argument
by proponents of the conventional
restorative approach is that if there
is a need, the poor deserve to have
high quality dentistry. However,
when assessing people’s needs for
dental care and prescribing dental
care, the resources available for the
procedures must be considered4.
Correspondenceto: Dr. Robert Yee, UnitedMissionto Nepal, Oral Health Programme, P.O. If resources are scarce and unlikely
Box 126, Kathmandu, Nepal. Email: rrsyeeO hotmail.com to be available in the near future, it
Q 2002 FDVWorld Dental Press
-1001-05
2
is unethical to continue to prescribe
treatments that are not affordable.
These problems raise dilemmas
for planners of oral health services.
For countries with low gross
domestic product (GDP) and
limited resources for health care,
what is the cost of restorative
dentistry to treat current levels of
caries? How can the needs for
caries treatment of children in
developing countries be met in the
context of limited resources? How
feasible is it for most Third World
low-income nations to treat exist-
ing levels of dental caries with
current financial resources?
The objective of this study was
to analyse whether developing
countries have sufficient health
dollars to treat existing diseases in
generd and dental caries in particu-
lar in their child population, by
assessing the costs of treating caries
by the conventional approach.
Before addressing the oral health
needs of children in low-income
countries and the resources required
to meet those needs, it is necessary
to keep oral health problems in
perspective by first investigating the
general health of the child popula-
tion of low-income countries.
Therefore, we broadly describe the
health and diseases of the child
population of developing nations,
and then examine an integrated
strategy for the provision of basic
health care and the cost of imple-
menting such a strategy.
Diseases of the child
population in developing
countries
Despite great advances this half-
century, one in five children in
developing countries do not live to
experience their fifth birthdaf. The
absolute number of malnourished
children is growing worldwide.
Half of South Asia’s children are
malnourished and in Africa, one in
three children is underweight6,
rendering many chronically vulner-
able to illness and intellectual
disability. Ten disease conditions
International Dental Journal (2002) Vol. 52/No.l
caused 71 per cent of the 660
million disability adjusted life years
(DALYs) lost in children under 15
years old in 1990’. Because chil-
dren become ill from several
conditions, the WHO integrated the
health facilities and the tasks of
health care workers to prevent and
treat illness caused by the five
major conditions* and the World
Bank designed an essential national
package of health services to
enable developing countries to help
resolve health problem^'.^*'^ . Pack-
aging the interventions takes into
account the common risk factor
approach” and makes the inte-
grated management of the major
childhood diseases more cost-
effective,because clusters of diseases
can often be treated together
sharing the same treatment
protocols, the same drugs and the
same services.
Cost of an integrated health
strategy
The cost of a minimum package
of preventative and health service
cost-effective interventions in
low-income countries directed at
the ten disease conditions was
calculated to be US$l2 per person
and US$7 (US$7,000 per 1,000 chil-
dren) for children per year for
low-income nations’. The public
health component of the essential
package (school health programmes,
expanded immunisation, micro-
nutrient supplementation, and
essential public health interventions)
would cost US$4,000 per 1,000
children. Properly delivered, the
essential package of health care
would eliminate 21 per cent to 38
per cent of the burden of mortality
and disability in children under 15
years in developing countries.
Low-income countries are not
only burdened with disease and
disability, but are also handicapped
by limited resources to provide
health services. They have enormous
debt repayment and structural
adjustment. Although the purpose
of structural adjustments was to
achieve an environment for sustain-
able growth, the effects of the
austerity measures resulted in
budget cuts for health, education
and food subsidies that were detri-
mental for many low-income
countries. Privatisation of hospitals,
health centres and the introduction
of user fees also made health care a
luxury item for the poor. Due to
economic difficulties, some African
nations have virtually ceased to
invest in health and the proportion
of the G N P allocated to health has
been cut or has not increased”.
With pressure on governments
to control costs of health services,
the private sector is playing an
important role in the delivery of
services. Recent studies show that
more than 40 per cent of the health
care in developing countries is
financed privately, through non-
government organisations (NGO),
international non-government organi-
sations (INGO), charities, insurance
and household payment^^^'"'^.
Analysing data from 12 devel-
oping countries, Gaag and Barham”
determined that the poor spend a
greater proportion of their per
capita household expenditure than
the rich on health care. This leaves
the poor with less to spend on
other necessities such as food, water,
sanitation and education, which
have a great impact on health.
Expenditures on health
Health expenditure was defined as
all expenditures incurred by preven-
tive and curative health services for
individuals, and on population-
based public health programmes
with a direct impact on health
status (e.g., family planning
programmes, nutrition programmes,
and health education)”J5.Excluded
were relief and food programmes,
and environmental programmes
related to water and sanitation.
Public expenditure was defined as
government and parastatal (health
components of social security and
social insurance programmes)
spending on health, while private

sector health expenditure referred
to spendingby all non-governmental
organisations, individuals, house-
holds, private organisations and
non-profit organisations. Total
health expenditure included spend-
ing by both public and private
sector spending and external assist-
ance. The total health expenditure
and the public health expenditure
over a 5 year period, 1990-1995,
for children age 0-14 years in
low-income countries was calcu-
lated’3*.’5*’6.
The total health expen-
diture per 1,000 children was
lowest in Ethiopia, $3,449; Sierra
Leone, $4,660; and Mozambique,
$4,889. The highest levels were
between $30,000 and $38,779 in
countries like Honduras, Cameroon,
Armenia, Zimbabwe and Nicara-
gua. Expenditure on public health
in those countries was also pitifully
low during the period 1990-1 995.
At the lower end of the scale were
Tanzania and Uganda with $795
and $1,256 per 1,000 children while
Sri Lanka and Nicaragua spent
$19,536 and $22,095 per 1,000 chil-
dren respectively.
Based o n the total health
expenditure, all 48 low-income
countries except for six African
countries (Ethiopia, Sierra Leone,
Mozambique, Madagascar,Tanzania,
Burundi) and one Asian country,
Vietnam, would be able to fully
provide an essential package of
health services (USg67.00 per child
or US$7,000 per 1,000 children)
for children age 0-14 years. All
could afford the public health
component of the essential pack-
age costing $US4,000 per 1,000
children. These findings are
corroborated by the statistics of
New Internationahst‘’ which lists the
bottom five countries on health
expenditure as Mozambique (US$5/
capita), Lao Democratic Republic
(US$5/capita), Tanzania (US$4/
capita), Sierra Leone (US$4/capita)
and Vietnam (US$3/capita). Is the
picture as rosy as it seems? Can
governments of low-income coun-
tries truly provide for the essential
health of their children?
Public expenditure on health
Based on government health
expenditure (public expenditure)
only, 30 countries would not be
able to provide an essential health
care package for their children
without financial aid and without
placing additional burdens on their
people. The governments of
Tanzania and Sierra Leone would
only be able to fund the expanded
immunisation programme plus a
school health programme o r
chemotherapy against tuberculosis
for children age 0-1 4, while other
nations faced with the same
circumstances would similarly have
to choose where to place their avail-
able finances to gain the greatest
health outcome. The governments
of India, Ghana, Mauritania, Togo,
Haiti, Kenya and Guinea-Bissau
could at least afford the public
health component of the essential
package.
However, the total extent of
governmental health resources is
not fully devoted to the priority of
an essential health package for chil-
dren. Studies conducted by the
World Bank in conjunction with
six Pacific countries, showed that
the percentage of government
health expenditure devoted to
hospital based curative services
ranged from 48 to 67 per cent, and
curative health care as a percentage
of public health expenditure,
ranged from 80 to 89 per centI8.In
Nepal more than 40 per cent of
the government health sector
expenditure in 1994/95 was allocated
to the maintenance of hospitals and
curative careI9.The World Bank“’
also reported that recurrent hospi-
tal and curative budgets absorb 40-
80 per cent of public spending on
health in developing countries. In
the mid-l980s, nearly 80 per cent
of Brazil’s public spending on
health was devoted to high-cost
hospitals located in urban areas and
the affluent southern part of the
coun*.
Even the small amount of
external aid for assistance to finance
Yee and Sheiham: Restorative dental treatment for children in Third World countries
3
health programmes is inappropri-
ately allocated. If the governments
of the 48 low-income nations only
expended a conservative 40 per cent
of their budget on hospital and
curative services, 75 per cent of the
countries would still have difficulty
in providing for the health needs
of its children. Only 12 of 48 coun-
tries would be able to afford an
essential package of health services
for their childred. It appears that
75 per cent of 48 low-income
countries are unable to provide
US$7 per child for a minimum
package of public health interven-
tions and eight low-income nations
spend US$l or less per child for
such essential health care.
Mortality and morbidity
amongst children of developing
countries is unacceptably high. The
resources commissioned to tackle
the determinants of health and
disease are scarce or inappropri-
ately or disproportionatelyallocated
in favour of curative services, and
the poor have had to pay more for
services. It has prompted one offi-
cial to say: “The main threat to
children’s rights.. . is not violations
and abuse of human rights, but
lack of effective primary health care
systems backed up with adequate
resources to ensure child survival
and de~elopment.”~’. Against this
background, what is the dental
caries burden and what resources
are required to treat caries, which
ranks low on the list of health
priorities?
Methods
Estimating the dental caries
burden in developing
countries
The W H O Global Oral Data
Bank22 has information on the
prevalence of caries in many coun-
tries. However, Fejerskov and
colleague^*^.^^ warn that caution
must be exercised in interpreting
the data due to paucity of infor-
mation concerning the study
populations. Few studies have been
designed for national estimates and
4
Table 1 Mean 12-year-old DMFT for low, middle and high-income
countries (Source; WHO Data base 1999)
Country category
Low income countries
Middle income countries
High income countries
Table 2 Caries treatment needs in the deciduous dentition of children of
low-, middle- and high-income countries.
Category
Low income African nations
Low income Asian nations
Middle income nations
High income nations
N = number of surveys
Table 3 Caries treatment needs in the permanent dentition of children of
low-, middle- and high-income countries.
Category
Low income African nations
Low income Asian nations
Middle income nations
High income nations
untreated caries % = (D/ DMFT) x 100
there are differences in diagnostic
criteria employed. Therefore the
data presented must be viewed with
these limitations in mind. Access-
ing data from the WHO Global
Oral Data Bankz2 through the
Internet, the 12-year-old DMFT is
compiled and calculated for low-
income countries, middle-income
countries and high-income coun-
tries. The mean 12-year-old DMFT
for the 45 low-income nations is
1.9. For middle and high-income
countries the DMFT is 3.3 and 2.1
respectively (Table I).
The WHO Global Oral Data
Bank contains very little informa-
tion concerning the dmft for
children, and the m e t caries treat-
ment needs of children in the
developing world. However, a
review of the dental literature over
the last ten years, where the D(d)
component of DMFT (dmft) was
reported, yielded substantial infor-
mation, which was compiled. The
information is summarised and
presented in Tables 2 and 3. The
unmet treatment needs is expressed
as a ratio of the proportion of the
mean decayed teeth (D or d) of the
International Dental Journal (2002) Vol. 52/No.l
~
N Mean 12-year-old DMFT
45 1.9 (SD 1.6)
55 3.3 (SD 1.7)
26 2.1 (SD 0.8)
N dmft Untreated caries %
7 3.1 95
5 4.1 94
16 4.3 84
5 1.6 52
N DMFT Untreated caries %
14 2.0 87
19 2.4 90
33 3.4 71
9 2.3 22
N = number of surveys
population to the mean DMFT
(dmft) of the population, and is
presented as the percentage of
untreated caries. For low-income
African and Asian nations, the
percentage of untreated caries
approximates 95 per cent in the
caries in the primary dentition and
89 per cent in the permanent denti-
tion. The untreated caries far
exceeds the treatment requirements
of children living in high-income
countries
Based on the 12-year-old
DMFT, WHO provides a scale for
categorisingthe severity of caries: a
DMFT between 0.0 and 1.1 is
considered to be very low, 2.8 to
4.4 is moderate, and a figure of 6.6
or more is considered to be highu.
For most low-income nations the
level of severity is low to very low.
Although epidemiological data on
caries of children in developing
countries is scarce, knowledge of
the life history and patterns of
caries can be utilised to give a more
detailed epidemiological picture
and to divulge more specific infor-
mation useful for planning cost
effective public health interventions.
Prediction of future caries
The best predictor of caries at a
future age is past caries experiencez5.
For a given level of caries experi-
ence (DMFT) for a specific age,
the future level of caries for the
age cohort can be predicted from
trend lines at 6,12,15 and 18 years
(Figure I), if there is no effective
interventionz6.There is also a rela-
tionship between various tooth
surfaces and the total mean DFS
(surface DFS/total DFS), which can
be expressed as a curvilinear
mathematical formula for each of
the carious surfaces”. Using the
12-year-old DMFTs reported in the
WHO Global Oral Data Bank2*,
the DMFS, DFS by surface and
the prevalence was estimated for
each low-income nation by apply-
ing the appropriate formulae. From
the mean DMFT of 1.9 for the
12-year-olds of 45 low-income
nations, the DFS by site can be
estimated from the calculated total
DMFS (3.0), which is 2.1 on the
occlusal surface, 1.2 on the buccal/
lingual surface, and 0.1 on the
proximal surface (Table 9. Proxi-
mal DFS as a percentage of total
DMFS was only estimated to be
2.2 per cent, which indicates that
the overwhelming majority of the
caries lesions are on the occlusal,
buccal and lingual surfaces, requir-
ing single surface restorations. The
corresponding DMFT for this 12-
year-old cohort up to age 18 years
can be predicted prospectively
and to age 6 years retrospectively
from trend curves of standardised
DMFT by age (Figure I). If no
preventive intervention is available,
at age 18, the DMFT for the
cohort would rise to 6.0, total
DMFS to 9.5, occlusal DFS to 6.5,
buccal/lingual DFS to 3.7, proxi-
mal DFS to 0.3.
Findings
Estimation of traditional
restorative dental treatment
casts
From the epidemiological informa-
tion and appraisals, demographic
 5

16 -

14 -
12 -
10 -
*g 8
6

6 8

Figurn 1. Sandardised DMFTby age trend curves for childrenage 6 to 18 yearsa.

Table 4 Estimates of DMFS by surface and prevalence of caries in the 12-year-old cohort of low-income nations.

Age
6 7 8 9 10 11 12 13 14 15 16 17 18
Mean DMFT 0.4 0.4 0.4 0.8 1.2 1.5 1.9 2.5 3.2 4 4.5 5.2 6.0
Total DMFS 0.8 0.8 0.8 1.4 2.0 2.4 3.0 3.9 4.9 6.2 7.0 8.2 9.5
Occlusal DFS 0.6 0.6 0.6 1.0 1.4 1.7 2.1 2.7 3.4 4.3 4.8 5.6 6.5
BucclLing DFS 0.3 0.3 0.3 0.6 0.8 1.0 1.2 1.5 2.0 2.4 2.7 3.2 3.7
Proximal DFS 0 0 0 0 0 0.1 0.1 0.1 0.1 0.2 0.2 0.3 0.3
Proximal DFS as
% of total DMFS 1.9 1.9 1.9 2.0 2.1 2.1 2.2 2.4 2.6 2.8 2.9 3.1 3.3
Caries prevalence % 37 37 37 53 66 73 81 88 93 97 98 99 99

information on the child population,
and from some basic assumptions,
the financial burden of treating
existing and future caries in the
permanent dentition can be estimated.
From a given level of DMFT for
12-year-olds, the retrospective
and prospective DMFT for the
cohort and the distribution of
caries by site for each age level can
be estimated based on the caries
epidemiological principles deline-
ated in the previous section of this
paper. The number of restorations
per thousand children, both single
surface and two or three surface,
can therefore be calculated based
on the formula:
Number of fillings = (annual
caries increment + no. of teeth to
be refilled) x 1,000 where:
annualcaries increment = current
year’s DMFT minus previous
year’s DMFT
number of teeth to be refilled
= previous year’s DMFT x per
cent failure rate of the restora-
tions.
From the knowledge of the
relationship between DMFT and
total DMFS, and site specific DFS
to total DMFS, the number of
multi-surface restorations and one
surface restorations can be esti-
mated, as well as the cost for
treating the carious teeth for 1,000
children, presently and in the future.
The following assumptions are
made in the computations: some
restorations will fail; primary
dentition is ignored; no teeth are
extracted (DMFT = DFT); inten- ‘
sity of caries attack is similar in all
age groups (6-18 years of age);
Yee and Sheiham: Restorative dental treatment for children in Third World countries
number of children is evenly
distributed between the ages of 6-
18 years of age.
The following input variables
were used to estimate the caries
treatment costs: The mean 12-year-
old DMFT for the 45 low-income
nations will be used as the starting
point to estimate the DMFT, proxi-
mal and one surface DMFS (Table
3,and annual caries increment for
the 12-year-old cohort from 6 years
to 18. The failure or survival rate
of restorations is usually reported
as the number of years when 50
per cent of restorations placed will
fail or survive. Some estimated
cumulative failure rates for amal-
gam restorations are: 11.5 yearsz8,
10 years”, 9 years3’, 7.5 years3’and
4.7 years3’. Walls et a/.33reported a
failure rate of 70 per cent in 5 years
6

Table 5 Cost of treating caries in the 12-year-old cohort of low-income nations.

Amalgam Failure Rate of 7%

A B C D E F G H I J
6 0.4 1.9 98.1 0.00 28.0 27.5 0.4 178.2 281.53
7 0.4 1.9 98.1 0.00 28.0 27.5 3.3 205.2 324.28
8 0.4 1.9 98.1 0.00 28.0 27.5 3.3 205.2 324.28
9 0.8 2.0 98.0 0.40 28.4 27.8 3.3 207.9 328.47
10 1.2 2.1 97.9 0.40 56.4 55.2 4.0 387.9 612.90
11 1.5 2.1 97.9 0.30 84.3 82.5 7.3 592.6 936.32
12 1.9 2.2 97.8 0.45 105.5 103.1 10.6 754.3 1191.73
13 2.5 2.4 97.6 0.55 137.1 133.8 13.6 977.2 1544.04
14 3.2 2.6 97.4 0.70 175.7 171.1 17.9 1255.4 1983.47
15 4.0 2.8 97.2 0.80 224.8 218.5 23.4 1607.5 2539.92
16 4.5 2.9 97.1 0.50 280.5 272.4 30.0 2011.4 3177.98
17 5.2 3.1 96.9 0.70 315.7 305.9 37.0 2290.6 3619.10
18 6.0 3.3 96.7 0.80 364.8 352.8 42.6 2640.8 4172.39
Total cost 13314.19 21036.42
The cost of treating 1000 children of mixed age group1024. 17 1618.19
Amalaam Failure Rate of 10%
6 0.4 1.9 98.1 0.00 40.0 39.2 0.8 256.32 404.98
7 0.4 1.9 98.1 0.00 40.0 39.2 4.7 293.20 463.26
8 0.4 1.9 98.1 0.00 40.0 39.2 4.7 293.20 463.26
9 0.8 2.0 98.0 0.40 40.4 39.6 4.7 295.89 467.51
10 1.2 2.1 97.9 0.40 80.4 78.7 5.6 552.91 873.59
11 1.5 2.1 97.9 0.30 120.3 117.8 10.4 845.60 1336.05
12 1.9 2.2 97.8 0.45 150.5 147.1 15.1 1076.16 1700.33
13 2.5 2.4 97.6 0.55 195.6 190.9 19.4 1394.37 2203.10
14 3.2 2.6 97.4 0.70 250.7 244.2 25.6 1791.23 2830.14
15 4.0 2.8 97.2 0.80 320.8 31 1.8 33.4 2294.01 3624.53
16 4.5 2.9 97.1 0.50 400.5 388.9 42.8 2871.71 4537.30
17 5.2 3.1 96.9 0.70 450.7 436.7 52.9 3270.11 5166.78
18 6.0 3.3 96.7 0.80 520.8 503.6 60.9 3770.02 5956.64
Total cost 19004.73
The cost of treating 1000 children of mixed age group 1461.90 30027.47

___
Amalaam Failure Rate of 15%
~~ ~ ~

6 0.4 1.9 98.1 0.00 60.0 58.9 1.1 391 50 61 8.57

7 0.4 1.9 98.1 0.00 60.0 58.9 7.0 446.83 705.99
8 0.4 1.9 98.1 0.00 60.0 58.9 7.0 446.90 706.10
9 0.8 2.0 98.0 0.40 60.4 59.2 7.1 451 .OO 712.58
10 1.2 2.1 97.9 0.40 120.4 117.9 8.4 843.47 1332.68
11 1.5 2.1 97.9 0.30 180.3 176.5 15.6 1289.86 2037.98
12 1.9 2.2 97.8 0.45 225.5 220.5 22.6 1641.74 2593.95
13 2.5 2.4 97.6 0.55 293.1 286.0 29.1 21 27.95 3362.16
14 3.2 2.6 97.4 0.70 375.7 365.9 38.4 2734.40 4320.35
15 4.0 2.8 97.2 0.80 480.8 467.3 50.1 3502.26 5533.58
16 4.5 2.9 97.1 0.50 600.5 583.1 64.1 4384.84 6928.05
17 5.2 3.1 96.9 0.70 675.7 654.8 79.3 4993.92 7890.40
18 6.0 3.3 96.7 0.80 780.8 755.0 91.2 5652.14 8930.37
Total cost 28906.82 45672.77
The cost of treating 1000 children of mixed age group 2223.60 3513.29
A = age B = mean DMFT C = % two or three surface restorations
D = & one surface restorations
-
E = annual caries increment = current DMFT previous year’s DMFT
F = total no. restorations per 1000 children = (annual increment + (previous year’s
DMFT % failure rate)) 100, Formula = E(,,) + B(,,,)* X 1000, where X = 7%or 10%or
15%
G = no.of one surface restorations per 1000 Formula = D F/100
H = no.of two surface or three surface restorations per 1000 = 10% previous year’s
one surface restorations + (% two or three surface rest. per 1000)/100, Formula = 0.1
G(,.,)+ (C F)/lOO
I = total cost (f) of restoration per 1000 children, Formula = G ’6.35 + H 9.40
J = total cost (US$) of restorations per 1000 children, Formula = I 1.58, where El =
$US158

International Dental Journal (2002) Vol. 52lNo.l

 7

for in 6-year-olds. The longevity
and cost-effectiveness of a restora-
tion is determined by the type of
material used, age of the patient,
size and location of the restoration,
operator skills and diagnostic
criteria, remuneration system and
patient factors34.Also, amalgams
placed in permanent teeth of chil-
dren have a shorter lifespan than
of those placed in adult^^^.'^. In this
analysis, estimates of the treatment
costs are calculated using failure
rates of 7, 10 and 15 per cent. As
one surface amalgams fail, and are
refded, the cavities become increas-
ingly larger36,leading to multiple
surface restorations. The estimations
take this element into considera-
tion by factoring in 10 per cent of
the previous year’s one surface
restorations into the calculation of
the number of two/three surface
restorations.
The cost of restorations varies
from country to country, and also
within countries. Reliable informa-
tion is lacking. Therefore, in the
computations, the recent United
Kingdom National Health Service
fees of E6.35 ($US10.03) for a
single surface amalgam and A9.40
(96US14.85) for two o r more
surfaces will be applied3’.
Based on the above parameters,
the cost of treating caries in the
12-year-old cohort of low-income
nations from age 6 to 18 years
applying an amalgam failure rate
of 7,lO and 15 per cent is presented
in Table 5. The cost of traditional
treatment for 1,000 children of any
age level of the 12-year-old cohort
as well as the cost of treating 1,000
children of mixed age group (total
cost of treating 1,000 children from
each age group divided by 13 age
groups) is summarised in Table 6.
Based on a conservative annualised
failure rate for amalgam of 7 per
cent, the calculated cost of A1,024
($US1,618) to treat 1,000 children
of mixed ages, from 6 to 18 years,
exceeds the estimated available
public health expenditures for the
children of 15 low-income coun-
tries. If the amalgam failure rate of
10 per cent and 15 per cent is
applied, the cost per 1,000 children
is E1,461 ($US2,309) and A2,224
($US3,513), which would then
exceed the available public health
expenditures of 23 and 29 low-
income nations, respectively.
The total financial burden of
traditional restorative treatment for
the children aged 6-14 years of 45
low-income nations can be esti-
mated. Using population statistics
from World resource^'^, the child
population for this age group is
estimated to be 1,018,223 million.
This age range was chosen because
of the difficulty in estimating the
population of children from 6 to
18 years. Applying a failure rate of
7 per cent, the cost of traditional
restorative treatment for this mixed
age group is calculated to be A535
($US846) for 1,000 children. The
resultant appraisement of over
E545,200 million ($US861,416
million) is a very large expense for
caries treatment of the permanent
dentition.
The financial burden of restora-
tive treatment can be appraised for
each low-income nation utilising the
country’s specific 12-year-old
DMFT, and the same input vari-
ables and assumptions as outlined
previously. For example, utilising a
mean 12-year-old DMFT of 0.9
for the country of Nepal, the trend
data for the 12-year-old cohort
from age 6 to 14 years, the cost of
traditional restorative treatment with
the amalgam failure rate set at 7
per cent per year was calculated.
For 1,000 children of mixed age
group, 6 to 14 years, the cost
of traditional restorative dental
treatment approximates E288
($US456). The estimated popula-
tion of children for this age group
is 9.43 million. Therefore, the total
cost of restorative treatment for
this population of children would
be E2,723 million ($US4,303
million). This is almost 20 times the
total government, private and
foreign donor health expenditure
of $US223 million for the total
child and adult population of

Table 6 The cost of traditional restorative treatment of the 12-year-old cohort of low-income nations at various
age levels with the amalgam failure rate of 7%, 10%and 15% and mean 12-year-old DMFT of 1.9.

Age Amalgam Failure Rate of 7% Amalgam Failure Rate of 10% Amalgam Failure Rate of 15%
Cost (f) per 1000 ($us) Cost (f) per 1000 ($US) Cost (f) per 1000 ($US)
6 178 (281) 256 (408) 391 (618)
7 205 (324) 293 (463) 446 (705)
8 205 (324) 293 (463) 446 (706)
9 207 (328) 295 (467) 451 (712)
10 387 (612) 552 (873) 843 (1332)
11 592 (936) 845 (1336) 1289 (2038)
12 754 (1191) 1076 (1 700) 1641 (2594)
13 977 (1544) 1394 (2203) 2127 (3362)
14 1255 (1983) 1791 (2830) 2734 (4320)
15 1607 (2539) 2294 (3624) 3502 (5533)
16 2011 (3178) 2871 (4537) 4384 (6928)
17 2290 (3619) 3270 (5166) 4993 (7890)
18 2640 (4172) 3770 (5956) 5652 (8930)
Total 13314 (21036)
Cost of treating 1000 of mixed age group = f1024 (1618) 19004 (30027)
Cost of treating 1000 of mixed age group = El461 (2309) 28906 (45672)
Cost of treating 1000 of mixed age group = f2224 (3513)

Yee and Sheiham: Restorative dental treatment for children in Third World countries
8
Nepal in 1994/9519.
The use of E6.35 ($US10.03)
for a single surface amalgam and
E9.40 ($US14.85) for two or more
surfaces is an underestimation rather
than an overestimation of the cost
of restorative treatment for the
majority of people of low-income
countries. Since many governments
of low-income countries lack the
financial resources to provide the
essential package of preventive
health care, private households have
been burdened with the cost for
general health and dental treat-
ment9*'2-'4.Bratthall and Barmes3'
reported that in a provincial hospi-
tal in a district of Zimbabwe, 48
kilometres from Harare, a simple
filling would cost the equivalent of
US$2.50. For the same amount of
money, 1 to 2 kilograms of meat
could be obtained or two tubes of
toothpaste. The patient would have
to pay four to five times the
amount at a private clinic. In Nepal
the fee for a simple amalgam
restoration is approximately US$4.
This does not include the many
additional costs for rural families
who may have to travel by bus or
walk for a day or two to gain
access to the nearest dental facility.
Not including lost wages incurred
by the parent, the total expenses
(dental fees, return bus fare, meals
and lodging) for a child requiring a
single surface restoration may
amount to US$12. This may not
seem like very much, but for an
average Nepali earning less than
US960.75 a day, it is enough money
for food for a month. When faced
with the harsh realities of putting
food on the table and enduring the
suffering of a child's toothache or
having conventional treatment to
restore carious teeth, often the poor
do not have a choice.
Summary
A combination of ten conditions
caused the deaths of more than 7.5
million children in 1995 in devel-
oping countries. Malnutrition and
micronutrient deficiencies are also
International Dental Journal (2002) Vol. 52/No.l
implicated as determinants o f
paediatric oral conditions of
low-income nations. An integrated
strategy to deliver a minimum pack-
age of preventive health services
directed at these disease conditions
would cost an estimated $US7,000
per 1,000 children. However,
because of the scarcity of resources,
more than three-quarters of the 48
low-income countries are unable
to provide for such a basic pack-
age of healthcare.
The most prevalent oral disease
of public health concern in low-
income countries is dental caries.
Epidemiological information and
analysis reveals that the severity of
caries is low for the permanent
dentition of children of Third
World countries (mean 12-year-old
DMFT = 1.9) and the normative
treatment needs for caries is high
for both permanent (per cent
untreated caries > 87 per cent)
and primary dentition (per cent
untreated caries > 94 per cent).
The pattern and severity of disease
is mostly limited to the occlusal
and buccal/lingual surfaces of the
permanent dentition. Even though
caries is a low priority due to rela-
tively low mortality and morbidity
compared to other childhood
diseases39,the cost of traditional
restorative treatment is dispropor-
tionately expensive in relation to its
priority.
Current analysis indicates that
treatment by traditional restorative
dentistry for the permanent denti-
tion would cost between E1,024
($US1,618) and &2,224 ($US3,513)
per 1,000 children of mixed ages
from 6 to 18 years. This exceeds
the available resources for the
provision of an essential public
health care package for the children
of 15 to 29 low-income countries.
Conclusions
Millions of children in low-income
Countries die each year from diseases
and conditions, which are prevent-
able through such measures as
better nutrition, safe water and
immunisation. An integrated strat-
egy employing the common factor
approach would be invaluable in
stemming the tide of death and
disease among children of low-
income countries. To provide for
an integrated strategy to deliver a
minimum package of health care
services, would cost the govern-
ments of developing nations $US7
per child. Three-quarters of the
low-income nations do not have
sufficient resources to finance an
essential package of health care
services for the children of their
countries,due primarily to enormous
debt repayment and structural
adjustment, and vast expenditures
on hospital and curative services.
Although the level of dental caries
in low-income nations is catego-
rised as low (mean 12-year-old
DMFT = 1.9), requiring mostly
single surface restorations, approxi-
mately 90 per cent of the caries
remains untreated in both the
primary and permanent dentition.
Analysis utilising some epidemio-
logical disciplines has demonstrated
that to treat dental caries by tradi-
tional amalgam restorative dentistry
in the permanent dentition of the
child population would cost between
El ,024 ($USl,618) and E2,224
($US3,513) for 1,000 children of
mixed ages from 6 to 18 years.
This requires financial resources
beyond the capabilities of low-
income nations. Even though caries
is a low priority in relation to other
childhood diseases, untreated caries
in an age specific cohort will cost
more to treat in the future.
References
1 . Kohlmeier L, Kroke A, Potzsch J ,
Kohlmeier M, Marin K. ErnihnmgJ-
abhangige Krankheiten und ihre Kosten.
Baden-Baden: Nomos Verlagsgesell-
schaft, 1993: 327-328.
2. Schneider M, Beckmann M, Biene-
Dietrich, Gabanyi M, Hofmann U,
Kose A, Mill D, Spath B. Gerund-
heitsytcme im internationalen Vergleicb.
Eigenverlag, Augsburg, 1998: 142-
143.
3. Yee, R. Can third world countries

~~
afford to treat dental caries? Is the
Atraumatic Restorative Treatment
technique an effective and satisfac-
tory solution? Msc. Thesis. London:
University of London; 1999
4. Sheiham A, Spencer, J. Health needs
assessment. In Communio Oral Health.
Pine C (ed). pp. 39-50. Oxford: Reed
Educational and Professional Publish-
ing Ltd., 1997.
5. Murray C J, Lopez A D. The Global
Burden of Disease: Volume 7 . Geneva:
World Health Organisation, Harvard
School o f Public Health, and the
World Bank, 1996.
6. UNICEF. The State ofthe World's Chil-
dren 1998. Oxford: Oxford University
Press, 1998.
7. Bobadilla J L, Cowley P, Musgrove P,
et at. Design, content and financing of
an essential package of health serv-
ices. But World Health Organisation
1994 72: 653-662.
8. Gove S. Integrated management of
childhood illness by outpatient health
workers: technical basis and overview.
But World Health Organisation 1997 75
(supplement 1): 7-24.
9. Murray C J, Govindaraj R, Chellaraj
G. Global Domestic Expenditures in
Health. Background paper no. 13 for the
World Development Report 1993: Invest-
ing in Health. Washington D.C.: World
Bank; 1994.
10. World Bank. World Development Report
1993. Investing in Health. pp.72-107.
New York: Oxford University Press,
1993.
11. Sheiham A, Watt R. The common risk
factor approach: a rational basis for
promoting oral health. Comm Dent Oral
Epidemiol 2000 28: 399-406.
12. Gaag J V, Barham T. Health and health
expenditures in adjusting and non-
adjusting countries. Soc Sci Med 1998
46: 995-1 009.
13. Murray C J, Govindaraj R, Musgrove,
P. National health expenditures: a
global analysis. But World Health Or-
ganisation 1994 72: 623-637.
14. Murray C J, Govindaraj R, Chellaraj
G. Health Expenditures in Latin America.
World Bank Technical Paper No. 274.
Washington, D.C.: World Bank; 1995.
15. World Resources. World Resources,
1938199: A Guide to Global Enuiron-
nient, Environmental Change and Human
Health. A joint publication of World
Resources Institute, the United Nations
Environment Programme, the United
Nations Development Programme, the
World Bank. New York: Oxford Uni-
versity Press. http://www.wri.org/
wr-98-991
16. World Health Organisation. The World
Health Repori 7998: Life in the 21"cen-
tuy. A T 'ision /or All. Geneva: World
Health Organisation; 1998.
17. New Internationalist. Poor and rich -
the facts. New Internationalist 1999
310 19.
18. World Bank. Health Priorities and Op-
tions in the World Bank's Par@ Mem-
bers Countries. New York: Oxford Uni-
versity Press, 1994.
19. Nepal South Asia Centre. Nepal Human
Developmetit Report 1998. Kathmandu:
Nepal South Asia Centre, 1998.
20. World Bank. Brazil: Public Spending on
Social Programs; lssues and Options.
Washington, D.C.: World Bank, 1988.
21. Nukuro E T. The convention o n the
rights o f the child: first call for Pacific
children. Par@ Health Dialogue 1998
5: 91-93.
22. World Health Organisation. Global
Oral Daiu Bank. http:l/
whocollab.od.mah.se/index.html.
23. Fejerskov 0, Baelum V, Luan W-M,
et at. Caries prevalence in Africa and
the Peoples' Republic of China. Int
Den J 1994 44: 425-433.
24. Manji F, Fejerskov 0. Dental caries in
developing countries in relation to the
appropriate use of fluoride. J Dent Res
1990 69 (Spec Iss): 733-741.
25. Sheiham A. Oral health policy and pre-
vention. I n The Prevention of Oral Dis-
ease: 3rd. Edition. Murray J J (ed). pp
234-249. New York: Oxford Univer-
sity Press, 1996.
26. Kalsbeek H. Evidence of decrease in
prevalence of dental caries in the
Netherlands: an evaluation of epide-
miological caries surveys o n 4-6 and
11-15-year-old children, performed
between 1965 and 1980. J Dent Res
1982 61(Special Issue): 1321-1326.
27. McDonald S P, Sheiham A. The distri-
bution of caries on different tooth sur-
faces at varying levels o f caries - a
compilation of data from 18 previous
Yee and Sheiham: Restorative dental treatment for children in Third World countries
9
studies. Comni Dent Health 1992 9: 39-
48.
28. Lavelle C L. A cross-sectional longitu-
dinal survey into the durability o f
amalgam restorations. Dent 1976 4:
139-1 41.
29. Robinson A D. The life of a filling.
Br Dent J 1971 130: 206-208.
30.Qvist J , Qvist V, Mjer I. Placement
and longevity of amalgam restorations
in Denmark. Acta Odont ."rand 1990
48: 297-303.
31. Patterson N . The regular attender -
the longevity of restorations in a
general dental practice. Br Dent J 1984
157: 23-25.
32. Mj0r I A, Toffenetti F. Placement and
replacement of amalgam restorations
in Italy. Oper Dent 1992 17: 70-73.
33. Walls A W G, Wallwork M A, Holland
I S, et at. The longevity of occlusal
amalgam restorations in first perma-
nent molars o f child patients. Br Dent
J 1985 158: 133-136.
34. Mjer I A, Jokstad A, Qvist V. Longev-
ity of posterior restorations. Int Dent J
1990 40: 11-17.
35. Wendt I,, Koch G, Birkhed D. Replace-
ments of restorations in the primary
and young permanent dentition. Swed
Dent J 1998 22: 149-155.
36. Elderton R J. The quality of amalgam
restorations. In Allred H A (ed). Series
of Monographs in ihe Assessrnent of the
Quality of Dental Care. pp. 45-79.
London: London Hospital Medical
College, 1977.
3 7. N HS. Ainendnienf 83 to the .Ytuiemetrt of
Dental Remuneration. London: N H S
Executive, Department o f Health,
1999.
38. Bratthall D, Barmes D E. Oral Health.
I n Jamison D T , Mosley W H,
Measham A R, et at. (eds) Disease
Control Priorities in Developing Countries.
pp. 647-660. New York: Oxford Uni-
versity Press, 1993.
39. Murray C J, Lopez A D. The Global
Burden of Disease: Lblume 1 . pp. 541-
576. Geneva: World Health Organisa-
tion, Harvard School o f Public
Health, and the World Bank, 1996.
40. Sheiham, A. Impact o f dental treat-
ment o n the incidence of dental caries
in children and adults. Community
Dent Oral Epidemiol 1997 25: 104-12.