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Review
The global prevalence of dental healthcare needs and unmet dental needs among adolescents: a systematic review and meta-analysis
Mahin Ghafari1orcid, Samira Bahadivand-Chegini2orcid, Tayebeh Nadi2orcid, Amin Doosti-Irani2,3orcid
Epidemiol Health 2019;41:e2019046.
DOI: https://doi.org/10.4178/epih.e2019046
Published online: October 27, 2019

1Department of Public Health, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran

2Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran

3Research Center for Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran

Correspondence: Amin Doosti-Irani  Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran  E-mail: a.doosti@umsha.ac.ir
• Received: August 26, 2019   • Accepted: October 27, 2019

©2019, Korean Society of Epidemiology

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • 9 Scopus
  • OBJECTIVES
    Access to dental healthcare services is a major determinant of dental health in communities. This meta-analysis was conducted to estimate the global prevalence of dental needs and of unmet dental needs in adolescents.
  • METHODS
    PubMed, Web of Science, and Scopus were searched in June 2018. The summary measures included the prevalence of met and unmet dental needs. A meta-analysis was performed using the inverse variance method to obtain pooled summary measures. Out of 41,661 retrieved articles, 57 were ultimately included.
  • RESULTS
    The pooled prevalence of orthodontic treatment needs was 46.0% (95% confidence interval [CI], 38.0 to 53.0), that of general treatment needs was 59.0% (95% CI, 42.0 to 75.0), that of periodontal treatment needs was 71.0% (95% CI, 46.0 to 96.0), and that of malocclusion treatment needs was 39.0% (95% CI, 28.0 to 50.0). The pooled prevalence of unmet dental needs was 34.0% (95% CI, 27.0 to 40.0).
  • CONCLUSIONS
    The highest and lowest prevalence of unmet dental needs were found in Southeast Asia and Europe, respectively. The prevalence of dental needs was higher in the countries of the Americas and Europe than in other World Health Organization (WHO) regions. The prevalence of unmet dental needs was higher in Southeast Asia and Africa than in other WHO regions.
Access to dental healthcare services is a major determinant of dental health in communities. Dental problems, including dental cavities, are most prevalent among adolescents [1].
The global weighted means of decayed, missing, and filled teeth for adolescents aged 12 years old in 2011 and 2015 were 1.67 and 1.86, respectively [2]. In 2010, approximately 2.4 billion people and 621 million children were affected by untreated caries in permanent and deciduous teeth, respectively, and untreated caries in permanent teeth was the most prevalent dental condition worldwide [3]. In the USA, it was reported that 21% of children aged 6-11 years and 58% of adolescents aged 12-19 years had experienced dental caries. In 2011-2012, the prevalence of untreated dental caries was about 6.0% in children and 15.3% in adolescents [4].
Untreated dental cavities have been reported to cause severe pain, infection, and problems with eating, speaking, and learning in children and adolescents [1].
Adolescents constitute a noteworthy age group, as they have specific healthcare needs [5]. Dental healthcare is an important need in this group, given its effects on quality of life and its potential to improve general health. Dental problems remain a huge burden in children and adolescents in certain regions of the world [6]; nevertheless, the prevalence of dental needs in these age groups has not been estimated in some communities [7,8].
Unmet healthcare needs have been defined as the difference between the healthcare services required to cope with a health problem and the services received [9]. Unmet healthcare needs are common in adolescents and are an independent risk factor for health outcomes in adults [10], meaning that they can impose heavy costs on the community, health system, and individuals [7]. Unmet dental needs in adolescents can have consequences that affect quality of life in adulthood. Several studies have been published regarding the prevalence of needs and unmet needs for dental healthcare. However, there are discrepancies in the results of the published studies. The present systematic review and meta-analysis was therefore conducted to estimate the global prevalence of dental needs and unmet dental needs in adolescents by the type of dental care, World Health Organization (WHO) region, and sex.
The design of this study is a systematic review and meta-analysis.
As part of a comprehensive systematic review, the present review was conducted to determine the prevalence of dental healthcare needs and unmet dental needs in adolescents. This systematic review was conducted and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [11] (Supplementary Material 1).
Eligibility criteria
The present review included all retrieved cross-sectional studies that were conducted to estimate dental healthcare needs and unmet dental needs in adolescents. The studies included were not limited regarding the year, location, or language of the study, the sex and race of adolescents studied, or the type of dental health needs and unmet needs studied. According to the WHO, adolescents include individuals aged 10-19 years [12].
Unmet needs were defined as the difference between the healthcare needs present and the healthcare needs that were fulfilled to address the health problems under consideration [9].
Identifying the relevant studies
The international databases PubMed, Web of Science, and Scopus were searched in June 2018. The keywords used for searching PubMed were as follows: (adolescent [MeSH Terms] OR “teen” [Text Word] OR homeless youth [MeSH Terms] OR “street adolescents” [Text Word]) AND (health services needs and demand [MeSH Terms] OR “unmet needs” [Text Word] OR needs assessment [MeSH Terms] OR “health needs” [Text Word] OR “unmet health needs” [Text Word] OR “health service needs” [Text Word] OR “delay medical care” [Text Word]) AND (oral health [MeSH Terms] OR dental health services [MeSH Terms]). In Web of Science and Scopus, we searched the mentioned keywords as the topic (TS) and TITLE-ABS-KEY, respectively.
Data extraction and assessing the risk of bias
Endnote X7 software was used to the manage the results of our initial search. Two authors (TN and SBC) were in charge of screening the titles and abstracts of the studies obtained from the databases. The full texts of the selected studies were then evaluated based on the eligibility criteria. Any disagreements between the investigators were resolved through discussion and consultation with a third author (ADI). The kappa value for agreement between two authors in the screening of the title and abstract was 84%.
Three authors (TN, SBC, and ADI) were responsible for data extraction. The data extracted from the included studies comprised the name of the first author, the year of publication, the location (country) of the study, the type of study population, the sex and mean/median age of participants, the type of health need(s) and unmet need(s), the sample size, the number of participants with health needs, and the number of participants with unmet health needs.
Two authors (TN and SBC) were in charge of quality assessments. The Joanna Briggs Institute critical appraisal checklist was used for evaluating the studies that reported prevalence rates and for assessing the risk of bias [13]. The items selected from the Joanna Briggs Institute checklist included (1) the appropriateness of the sampling frame in terms of addressing the target population, (2) the appropriateness of the sampling method, (3) the adequacy of the sample size, (4) the provision of a detailed description of the subjects and the study setting, (5) the use of a valid method for identifying the outcomes (i.e., dental needs and unmet dental needs), (6) the appropriateness of the statistical analysis, and (7) the adequacy of the response rate and the appropriate management of a potential low rate.
Statistical analysis
The chi-square test was used to examine heterogeneity among the results of the included studies. Between-study variance was assessed using the tau-square test, and the I-square statistic was used to quantify heterogeneity [14].
The summary measures, including the prevalence of dental healthcare needs and unmet dental needs, were extracted from the included studies, and their standard errors were calculated. Meta-analysis was performed using the inverse variance method to obtain the pooled summary measure. In the cases of out-of-range confidence intervals (CIs) in the subgroup analysis, the metaprop command was used. A random-effects model was also applied. A p-value of less than 0.05 was considered to indicate statistical significance. The data were analyzed in Review Manager 5.3 (Cochrane Collaboration, Copenhagen, Denmark) and Stata version 11 (StataCorp., College Station, TX, USA).
Ethics statement
The study protocol was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.RES.1397.69).
Included studies
Out of the 41,661 studies retrieved from searching the international databases and 62 found from scanning the references of the selected studies, 57 studies [15-71] were ultimately included in this systematic review (Figure 1). A study by Al-Sarheed et al. [22] was divided into 3 studies for the purposes of this analysis because it reported dental healthcare needs in 3 groups of adolescents: the general population, visually-impaired adolescents, and adolescents with hearing loss. Table 1 presents the characteristics of the included studies, which included 167,316 adolescents who were evaluated in terms of their dental healthcare needs and 123,821 who were evaluated in terms of their unmet dental healthcare needs. Results of the risk of bias assessment are shown in the forest plots in Figures 2-4.
Prevalence of dental healthcare needs
The overall prevalence of dental healthcare needs was 49.0% (95% CI, 42.0 to 56.0) across all types of dental care. Table 2 presents the overall prevalence by WHO region, sex, and year of publication of the study. The present review reported the prevalence of each type of dental healthcare need. Orthodontic treatment needs were reported in 54.2% of the studies, general needs in 23.7%, periodontal needs in 6.8%, and malocclusion needs in 12.3%.
The prevalence of orthodontic treatment needs was reported in 32 studies. The pooled prevalence of orthodontic treatment needs was 46.0% (95% CI, 38.0 to 53.0; I2=99%) (Figure 2). With regard to WHO region, the highest prevalence was associated with countries in Europe (51.6%; 95% CI, 42.8 to 60.4) and the lowest with countries in Southeast Asia (28.8%; 95% CI, 26.9 to 30.7) (Table 3).
Twelve studies reported the prevalence of general treatment needs in adolescents. The pooled prevalence of general treatment needs was 59.0% (95% CI, 42.0 to 75.0) (Figure 3A). The highest prevalence rates were found in the Eastern Mediterranean region (84.2%; 95% CI, 82.3 to 86.0) and the Africa (78.0%; 95% CI, 77.0 to 80.0). The lowest prevalence was observed in Europe (24.0%; 95% CI, 22.0 to 25.0).
None of the 12 studies were conducted in the Western Pacific region (Table 3).
The pooled prevalence of periodontal treatment needs was 71.0% (95% CI, 46.0 to 96.0) (Figure 3B). The highest prevalence, 93.0% (95% CI, 91.6 to 94.5), was found in the Eastern Mediterranean region (Table 3).
Nine studies reported the prevalence of malocclusion treatment needs in adolescents. The pooled prevalence of this type of need was 39.0% (95% CI, 28.0 to 50.0) (Figure 3C).
Prevalence of unmet dental healthcare needs
Nine studies reported the prevalence of unmet dental healthcare needs. The pooled prevalence of unmet dental needs was 34.0% (95% CI, 27.0 to 40.0) (Figure 4). The highest prevalence of unmet needs was found in Southeast Asia (72.3%; 95% CI, 70.1 to 74.5) and the lowest in Europe (11.8%; 95% CI, 3.4 to 20.3) (Table 2). Table 3 presents the prevalence of unmet needs by type of dental need and WHO region.
According to the results of the present systematic review, dental healthcare is a major global need in adolescents. Across all types of dental care, about 50% of adolescents worldwide were found to require dental healthcare services, and 34.0% were found to have unmet dental healthcare needs. The highest prevalence of these needs was observed in countries in the Americas and Europe, and the lowest was seen in Africa and the Western Pacific region. The seemingly higher prevalence observed in the Americas and Europe compared to Africa and the Western Pacific can be explained by the lower number of studies conducted in developing countries and their lower sample sizes compared to studies conducted in developed countries. The larger number of studies conducted on dental healthcare in developed countries suggests the greater perceived importance of dental health among adolescents in these countries. Developed countries therefore appear to have made more serious efforts than developing countries to identify dental health problems in adolescents.
In contrast, the prevalence of unmet dental healthcare needs was lower in Europe and the Americas than in the other regions of the WHO. This prevalence was higher in Southeast Asia and Africa than in the other regions. Unmet dental needs therefore appear to be mainly associated with developing countries. In low-income and middle-income countries, the cost of dental healthcare can put a substantial financial burden on households [72]. In addition, members of the general public in these countries are not adequately protected against the high costs of dental healthcare [72]. A study conducted in Iran showed that the cost of essential dental care was an important determinant of catastrophic healthcare expenditures [73]. The high expenditures required for dental healthcare and the lack of associated insurance coverage in many countries, especially low-income and middle-income countries, can contribute to the high prevalence of unmet dental healthcare needs in these countries.
Globally, unmet dental needs are common in adolescents. Unmet dental needs are an independent risk factor for oral health outcomes in adulthood [10], meaning that they can impose a high burden on the community, health system, and individuals [7]. Therefore, addressing unmet dental needs is important in terms of public health. Unmet dental needs affect the dental health-associated quality of life in adolescents [74]. Improving dental healthcare services and meeting dental healthcare needs can therefore promote overall quality of life in adolescents; nevertheless, given the high expenditures required for dental healthcare, policy-makers are recommended to more effectively provide households with the financial support they need for this highly expensive care. Moreover, the total number of people with unmet oral healthcare needs increased from 2.5 billion in 1990 to 3.5 billion in 2015, suggesting that oral health remains a global public health challenge [75], as emphasized by the global results of the present study in adolescents.
Worldwide, there is a lack of knowledge about certain types of dental healthcare needs; for instance, no compelling evidence was found regarding the global prevalence of unmet periodontal and malocclusion treatment needs. The lack of knowledge regarding the prevalence of unmet dental healthcare needs is more serious at a global than at a local scale. The 9 studies included in the present review regarding unmet dental needs were limited to unmet general and orthodontic dental treatment needs. We therefore recommend that further studies be conducted on unmet dental healthcare needs in adolescents, especially in low-income and middle-income countries.
The present systematic review and meta-analysis was faced with high heterogeneity between the results obtained in the included studies. Homogeneity was not achieved, despite conducting the subgroup analysis by WHO region and type of dental healthcare. The high heterogeneity observed can be explained by differences in the setting, time, and location of studies, in the type of dental healthcare, in the methods of evaluating of dental health needs and unmet needs, and in the quality of the included studies.
The major limitations of the present systematic review and meta-analysis included the low quality of some of the included studies and their use of different tools and criteria for detecting dental healthcare needs. In addition, our results may be affected by selection bias due to lack of access to the full text of some papers as well as the potential existence of studies in the gray literature, such as theses and annual unpublished reports by nations regarding the prevalence of need and unmet needs.
The results obtained from this systematic review suggest that the prevalence of dental healthcare needs and unmet dental healthcare needs is globally significant in adolescents. The prevalence of dental healthcare needs was higher in the countries of the Americas and Europe than in other WHO regions. Unmet needs were more prevalent in Southeast Asia and Africa than in other WHO regions.
Supplementary material is available at http://www.e-epih.org/.
epih-41-e2019046-supplementary.pdf

The authors have no conflicts of interest to declare for this study.

AUTHOR CONTRIBUTIONS

Conceptualization: MG, ADI. Data curation: SBC, TN, ADI. Formal analysis: ADI. Methodology: ADI, SBC, TN. Funding acquisition: ADI. Project administration: MG. Visualization: MG, ADI, TN, SBC. Writing – original draft: MG, ADI, TN, SBC. Writing – review & editing: MG, ADI, TN, SBC.

We would like to thank the Vice Chancellor for Research and Technology at Hamadan University of Medical Sciences for the support of this study (ID: 970225943).
Figure 1.
Flowchart depicting the stages through which articles were retrieved and eligibility criteria were checked for the meta-analysis.
epih-41-e2019046f1.jpg
Figure 2.
Prevalence of orthodontic treatment needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
epih-41-e2019046f2.jpg
Figure 3.
Prevalence of (A) general dental treatment needs, (B) periodontal treatment needs, and (C) malocclusion treatment needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
epih-41-e2019046f3.jpg
Figure 4.
Total prevalence of unmet dental needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
epih-41-e2019046f4.jpg
Table 1.
Characteristics of included studies
Study Country WHO region Study population Age (yr) Sex Sample size (n) Need Unmet Type of dental health need(s)
Bilgic et al., 2015 [26] Turkey Southeast Asia General 12-16 Both 2,250 648 Orthodontic treatment
DHC
Bolin et al., 2006 [29] USA Americas Adolescents in a juvenile detention facility 12-17 Both 419 310 208 Overall dental treatment needs
Dental caries
Vignarajah, 1994 [71] Antigua and Barbuda Americas General 12-19 Both 702 494 Periodontal treatment needs
De Baets et al., 2012 [37] Belgium European General 11-16 Female 223 180 Orthodontic treatment
DHC
Agaku et al., 2015 [16] USA Americas General 6-17 Both 65,593 10,338 Overall dental treatment needs
Appropriate and timely preventive or therapeutic dental healthcare
Kulkami et al., 2002 [49] India Southeast Asia General 11-15 Both 2005 1,159 Overall dental treatment needs
Dental caries
Ajayi et al., 2010 [17] Nigeria African General 12-19 Both 1,532 165 135 Traumatized treatment
Traumatized anterior teeth
Ghijselings et al., 2014 [44] Belgium European General 11-16 Both 386 310 Orthodontic treatment
DHC
Al-Haddad et al., 2010 [18] Yemen Eastern Mediterranean General 6-14 Both 1,489 1,253 Overall dental treatment needs
Nagarajappa et al., 2012 [56] India Southeast Asia General 12-15 Both 900 740 Periodontal treatment needs
Al-Huwaizi et al., 2009 [20] Iraq Eastern Mediterranean General 13 Both 998 413 Orthodontic treatment
DAI
Bissar et al., 2007 [28] Germany European General 11-13 Both 502 51 38 Overall dental treatment needs
Restorative treatment need
Otuyemi et al., 1997 [60] Nigeria African General 12-18 Both 704 271 Orthodontic treatment
DHC
Rubin et al., 2016 [63] Uganda African General 5-17 Female 153 151 Overall dental treatment needs
Borzabadi-Farahani et al., 2009 [30] Iran Eastern Mediterranean General 11-14 Both 496 281 Orthodontic treatment
DHC
Alonge et al., 1999 [21] Saint Vincent and the Grenadines Americas General 7-15 Both 1,646 662 Periodontal treatment needs
Safavi et al., 2009 [65] Iran Eastern Mediterranean General 14-16 Both 5,091 4,079 Orthodontic treatment
DHC
Burden et al., 1994 [31] Northern Ireland European General 15-16 Both 506 154 82 Orthodontic treatment
Salinas-Martínez et al., 2014 [66] Mexico Americas General 13 Both 301 223 Overall dental treatment needs
Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean Visually impaired adolescents 11-16 Both 77 21 Orthodontic treatment
DHC
Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean Hearing-impaired adolescents 11-16 Both 210 62 Orthodontic treatment
DHC
Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean General 11-16 Both 494 108 Orthodontic treatment
DHC
Carvalho et al., 2013 [34] Brazil Americas General 12-14 Both 300 198 Overall dental treatment needs
Dental caries
Danaei et al., 2007 [35] Iran Eastern Mediterranean General 12-15 Both 900 269 Orthodontic treatment
DAI
Dandi et al., 2011 [36] India Southeast Asia General 12 Both 2,203 1,573 1,137 Overall dental treatment needs
Dental pain
Artun et al., 2006 [23] Kuwait Eastern Mediterranean General 13-14 Both 1,583 330 290 Orthodontic treatment
El-Angbawi et al., 1982 [38] Saudi Arabia Eastern Mediterranean General 13-15 Both 1,174 1,092 Periodontal treatment needs
Baubiniene et al., 2009 [25] Lithuania European General 10-15 Male 4,235 1,806 Orthodontic treatment
Eslamipour et al., 2010 [40] Iran Eastern Mediterranean General 11-20 Both 748 331 Orthodontic treatment
DAI
Abdullah et al., 2001 [15] Malaysia Western Pacific General 12-13 Both 5,112 2,449 Orthodontic treatment
DHC
Abu Alhaija et al., 2004 [19] Jordan Eastern Mediterranean General 12-14 Both 1,002 252 Orthodontic treatment
DHC
Baca-Garcia et al., 2004 [24] Spain European General 14-20 Both 744 308 Orthodontic treatment
DAI
Birkeland et al., 1996 [27] Norway European General 11 Both 359 191 Orthodontic treatment
DAI
Burden et al., 1994 [33] UK European General 11-12 Both 1,829 600 Overall dental treatment needs
Burden et al., 1995 [32] Ireland European General 11-12 Both 1,107 697 Orthodontic treatment
Esa et al., 2001 [39] Malaysia Western Pacific General 12-13 Both 1,519 566 Malocclusion and orthodontic treatment need
Espeland et al., 1999 [41] Norway European General 16-20 Both 250 82 Orthodontic treatment
Estioko et al., 1994 [42] Australia Western Pacific General 12-16 Both 268 98 Malocclusion and orthodontic treatment need
Foster et al., 1974 [43] UK European General 11-12 Both 1,000 599 Malocclusion and orthodontic treatment need
Hamdan., 2001 [45] Jordan Eastern Mediterranean General 14-17 Both 320 160 Orthodontic treatment
DHC
Hedayati et al., 2007 [46] Iran Eastern Mediterranean General 11-14 Both 1,965 869 Orthodontic treatment
DHC
Josefsson et al., 2007 [47] Sweden European General 12-13 Both 476 307 Orthodontic treatment
DHC
Kerosuo et al., 2004 [48] Kuwait Eastern Mediterranean General 14-18 Both 139 82 Orthodontic treatment
DHC
Lewis et al., 2005 [50] USA Americas Children with special healthcare needs ≤17 Both 38,866 30,815 3,205 Overall dental treatment needs
Liepa et al., 2003 [51] Latvia European General 12-13 Both 505 222 Malocclusion and orthodontic treatment need
Manzanera et al., 2009 [52] Spain European General 12-16 Both 655 139 Orthodontic treatment
DHC
Marques et al., 2007 [53] Brazil Americas General 13-15 Both 600 462 Malocclusion and orthodontic treatment need DAI
Mashoto et al., 2009 [54] Tanzania African General 10-19 Both 1,780 790 Overall dental treatment needs
Mugonzibwa et al., 2004 [55] Tanzania African General 9-18 Both 295 164 Orthodontic treatment
DHC
Nalweyiso et al., 2004 [57] Uganda African General 12 Both 181 65 Overall dental treatment needs
Nobile et al., 2007 [58] Italy European General 11-15 Both 546 325 Orthodontic treatment
DHC
Otuyemi et al., 1997 [60] Nigeria African General 12-18 Both 703 159 Malocclusion and orthodontic treatment need
Perillo et al., 2010 [61] Italy European General 12 Both 703 451 Orthodontic treatment
DHC
Puertes-Fernández et al., 2011 [62] Spain European General 12 Both 248 97 Orthodontic treatment
DHC
Rwakatema et al., 2007 [64] Tanzania African General 12-15 Both 289 102 Orthodontic treatment
DAI
Shivakumar et al., 2009 [67] India Southeast Asia General 12-15 Both 1,000 199 Malocclusion and orthodontic treatment need
Shivakumar et al., 2010 [68] India Southeast Asia General 12-15 Both 1,800 362 Malocclusion and orthodontic treatment need
Souames et al., 2006 [69] France European General 9-12 Both 511 255 Orthodontic treatment
DHC
Thilander et al., 2001 [70] Colombia Americas General 5-17 Both 4,724 1,504 Malocclusion and orthodontic treatment need

WHO, World Health Organization; DHC, dental health component; DAI, Dental Aesthetic Index.

Table 2.
Prevalence of any dental healthcare need and unmet needs among adolescents based on WHO region and sex
Variables Need
Unmet need
n Prevalence (95% CI) I2 p-value n Prevalence (95% CI) I2 p-value
WHO region Americas 8 64.1 (45.3, 82.8) 99.9 <0.001 3 23.2 (18.0, 28.5) 99.7 <0.001
Southeast Asia 6 46.7 (25.4, 68.0) 99.8 <0.001 1 72.3 (70.1, 74.5) - -
African 7 34.4 (19.5, 49.4) 99.4 <0.001 2 58.9 (13.9, 100) 99.0 <0.001
European 18 43.7 (13.7, 73.7) 99.6 <0.001 2 11.8 (3.4, 20.3) 94.5 <0.001
Eastern Mediterranean 15 47.2 (32.6, 61.8) 99.8 <0.001 1 18.3 (16.4, 20.2) - -
Western Pacific 3 40.8 (32.3, 49.3) 96.9 <0.001 - - - -
Sex Male 19 50.0 (37.5, 63.5) 99.7 <0.001 3 37.9 (4.6, 71.2) 99.9 <0.001
Female 21 49.8 (36.8, 62.9) 99.7 <0.001 3 33.8 (29.0, 38.7) 99.8 <0.001
Both 33 47.9 (38.4, 57.3) 99.8 <0.001 6 33.3 (19.1, 47.6) 99.4 <0.001
Year (range) 1974-1999 12 47.8 (31.8, 63.8) 99.7 <0.001 1 16.2 (13.0, 19.4) - -
2000-2004 13 40.1 (34.2, 47.1) 98.6 <0.001 1 35.9 (28.9, 42.9) - -
2005-2009 19 48.2 (36.5, 59.9) 99.9 <0.001 4 21.1 (11.9, 30.3) 99.1 <0.001
2010-2016 13 60.0 (41.0, 79.1) 99.9 <0.001 3 56.6 (10.3, 99.0) 99.8 <0.001
Sample size (n) ≤500 19 54.5 (41.9, 67.2) 99.3 <0.001 2 43.0 (29.6, 56.5) 90.1 <0.001
501-1,000 18 44.8 (34.1, 55.5) 99.5 <0.001 2 11.8 (3.40, 20.3) 94.5 <0.001
≥1,001 20 47.8 (36.0, 59.6) 99.9 <0.001 5 38.9 (30.5, 47.2) 99.9 <0.001
Total 57 49.0 (42.0, 56.0) 99.9 <0.001 9 34.0 (27.0, 40.0) 99.9 <0.001

WHO, World Health Organization; CI, confidence interval.

Table 3.
Prevalence of specific dental healthcare needs and unmet needs among adolescents based on WHO region
Variables Need
Unmet need
n Prevalence (95% CI) I2 n Prevalence (95% CI) I2
Orthodontic treatment Americas - - - - - -
Southeast Asia 1 28.8 (26.9, 30.7) - - - -
African 3 43.0 (31.9, 54.2) 93.6 - - -
European 14 51.6 (42.8, 60.4) 98.9 1 16.2 (13.0, 19.4) -
Eastern Mediterranean 13 40.8 (25.6, 56.0) 99.7 1 18.3 (16.4, 20.2) -
Western Pacific 1 47.9 (46.5, 49.3) - - - -
General dental treatment needs Americas 4 73.7 (67.9, 79.5) 90.1 3 23.2 (18.0, 28.5) 99.7
Southeast Asia 2 64.6 (51.3, 77.9) 98.8 1 72.3 (70.1, 74.5) -
African 3 78.0 (77.0, 80.0) 99.8 2 58.9 (13.9, 100) 99.0
European 2 24.0 (22.0, 25.0) 99.9 1 7.6 (5.3, 9.9) -
Eastern Mediterranean 1 84.2 (82.3, 86.0) - - - -
Western Pacific - - - - - -
Malocclusion treatment Americas 2 54.4 (10.1, 98.6) 99.8 - - -
Southeast Asia 2 20.0 (18.6, 21.5) 00.0 - - -
African 1 22.6 (19.5, 25.7) - - - -
European 2 52.0 (36.4, 67.6) 97.1 - - -
Eastern Mediterranean - - - - - -
Western Pacific 2 37.2 (34.9, 39.4) 00.0 - - -
Periodontal treatment needs Americas 2 55.3 (25.7, 84.8) 99.5 - - -
Southeast Asia 1 82.2 (79.7, 84.7) - - - -
African - - - - - -
European - - - - - -
Eastern Mediterranean 1 93.0 (91.6, 94.5) - - - -
Western Pacific - - -

WHO, World Health Organization region; CI, confidence interval.

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    Related articles
    The global prevalence of dental healthcare needs and unmet dental needs among adolescents: a systematic review and meta-analysis
    Image Image Image Image
    Figure 1. Flowchart depicting the stages through which articles were retrieved and eligibility criteria were checked for the meta-analysis.
    Figure 2. Prevalence of orthodontic treatment needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
    Figure 3. Prevalence of (A) general dental treatment needs, (B) periodontal treatment needs, and (C) malocclusion treatment needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
    Figure 4. Total prevalence of unmet dental needs among adolescents. SE, standard error; CI, confidence interval; df, degree of freedom.
    The global prevalence of dental healthcare needs and unmet dental needs among adolescents: a systematic review and meta-analysis
    Study Country WHO region Study population Age (yr) Sex Sample size (n) Need Unmet Type of dental health need(s)
    Bilgic et al., 2015 [26] Turkey Southeast Asia General 12-16 Both 2,250 648 Orthodontic treatment
    DHC
    Bolin et al., 2006 [29] USA Americas Adolescents in a juvenile detention facility 12-17 Both 419 310 208 Overall dental treatment needs
    Dental caries
    Vignarajah, 1994 [71] Antigua and Barbuda Americas General 12-19 Both 702 494 Periodontal treatment needs
    De Baets et al., 2012 [37] Belgium European General 11-16 Female 223 180 Orthodontic treatment
    DHC
    Agaku et al., 2015 [16] USA Americas General 6-17 Both 65,593 10,338 Overall dental treatment needs
    Appropriate and timely preventive or therapeutic dental healthcare
    Kulkami et al., 2002 [49] India Southeast Asia General 11-15 Both 2005 1,159 Overall dental treatment needs
    Dental caries
    Ajayi et al., 2010 [17] Nigeria African General 12-19 Both 1,532 165 135 Traumatized treatment
    Traumatized anterior teeth
    Ghijselings et al., 2014 [44] Belgium European General 11-16 Both 386 310 Orthodontic treatment
    DHC
    Al-Haddad et al., 2010 [18] Yemen Eastern Mediterranean General 6-14 Both 1,489 1,253 Overall dental treatment needs
    Nagarajappa et al., 2012 [56] India Southeast Asia General 12-15 Both 900 740 Periodontal treatment needs
    Al-Huwaizi et al., 2009 [20] Iraq Eastern Mediterranean General 13 Both 998 413 Orthodontic treatment
    DAI
    Bissar et al., 2007 [28] Germany European General 11-13 Both 502 51 38 Overall dental treatment needs
    Restorative treatment need
    Otuyemi et al., 1997 [60] Nigeria African General 12-18 Both 704 271 Orthodontic treatment
    DHC
    Rubin et al., 2016 [63] Uganda African General 5-17 Female 153 151 Overall dental treatment needs
    Borzabadi-Farahani et al., 2009 [30] Iran Eastern Mediterranean General 11-14 Both 496 281 Orthodontic treatment
    DHC
    Alonge et al., 1999 [21] Saint Vincent and the Grenadines Americas General 7-15 Both 1,646 662 Periodontal treatment needs
    Safavi et al., 2009 [65] Iran Eastern Mediterranean General 14-16 Both 5,091 4,079 Orthodontic treatment
    DHC
    Burden et al., 1994 [31] Northern Ireland European General 15-16 Both 506 154 82 Orthodontic treatment
    Salinas-Martínez et al., 2014 [66] Mexico Americas General 13 Both 301 223 Overall dental treatment needs
    Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean Visually impaired adolescents 11-16 Both 77 21 Orthodontic treatment
    DHC
    Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean Hearing-impaired adolescents 11-16 Both 210 62 Orthodontic treatment
    DHC
    Al-Sarheed et al., 2003 [22] Saudi Arabia Eastern Mediterranean General 11-16 Both 494 108 Orthodontic treatment
    DHC
    Carvalho et al., 2013 [34] Brazil Americas General 12-14 Both 300 198 Overall dental treatment needs
    Dental caries
    Danaei et al., 2007 [35] Iran Eastern Mediterranean General 12-15 Both 900 269 Orthodontic treatment
    DAI
    Dandi et al., 2011 [36] India Southeast Asia General 12 Both 2,203 1,573 1,137 Overall dental treatment needs
    Dental pain
    Artun et al., 2006 [23] Kuwait Eastern Mediterranean General 13-14 Both 1,583 330 290 Orthodontic treatment
    El-Angbawi et al., 1982 [38] Saudi Arabia Eastern Mediterranean General 13-15 Both 1,174 1,092 Periodontal treatment needs
    Baubiniene et al., 2009 [25] Lithuania European General 10-15 Male 4,235 1,806 Orthodontic treatment
    Eslamipour et al., 2010 [40] Iran Eastern Mediterranean General 11-20 Both 748 331 Orthodontic treatment
    DAI
    Abdullah et al., 2001 [15] Malaysia Western Pacific General 12-13 Both 5,112 2,449 Orthodontic treatment
    DHC
    Abu Alhaija et al., 2004 [19] Jordan Eastern Mediterranean General 12-14 Both 1,002 252 Orthodontic treatment
    DHC
    Baca-Garcia et al., 2004 [24] Spain European General 14-20 Both 744 308 Orthodontic treatment
    DAI
    Birkeland et al., 1996 [27] Norway European General 11 Both 359 191 Orthodontic treatment
    DAI
    Burden et al., 1994 [33] UK European General 11-12 Both 1,829 600 Overall dental treatment needs
    Burden et al., 1995 [32] Ireland European General 11-12 Both 1,107 697 Orthodontic treatment
    Esa et al., 2001 [39] Malaysia Western Pacific General 12-13 Both 1,519 566 Malocclusion and orthodontic treatment need
    Espeland et al., 1999 [41] Norway European General 16-20 Both 250 82 Orthodontic treatment
    Estioko et al., 1994 [42] Australia Western Pacific General 12-16 Both 268 98 Malocclusion and orthodontic treatment need
    Foster et al., 1974 [43] UK European General 11-12 Both 1,000 599 Malocclusion and orthodontic treatment need
    Hamdan., 2001 [45] Jordan Eastern Mediterranean General 14-17 Both 320 160 Orthodontic treatment
    DHC
    Hedayati et al., 2007 [46] Iran Eastern Mediterranean General 11-14 Both 1,965 869 Orthodontic treatment
    DHC
    Josefsson et al., 2007 [47] Sweden European General 12-13 Both 476 307 Orthodontic treatment
    DHC
    Kerosuo et al., 2004 [48] Kuwait Eastern Mediterranean General 14-18 Both 139 82 Orthodontic treatment
    DHC
    Lewis et al., 2005 [50] USA Americas Children with special healthcare needs ≤17 Both 38,866 30,815 3,205 Overall dental treatment needs
    Liepa et al., 2003 [51] Latvia European General 12-13 Both 505 222 Malocclusion and orthodontic treatment need
    Manzanera et al., 2009 [52] Spain European General 12-16 Both 655 139 Orthodontic treatment
    DHC
    Marques et al., 2007 [53] Brazil Americas General 13-15 Both 600 462 Malocclusion and orthodontic treatment need DAI
    Mashoto et al., 2009 [54] Tanzania African General 10-19 Both 1,780 790 Overall dental treatment needs
    Mugonzibwa et al., 2004 [55] Tanzania African General 9-18 Both 295 164 Orthodontic treatment
    DHC
    Nalweyiso et al., 2004 [57] Uganda African General 12 Both 181 65 Overall dental treatment needs
    Nobile et al., 2007 [58] Italy European General 11-15 Both 546 325 Orthodontic treatment
    DHC
    Otuyemi et al., 1997 [60] Nigeria African General 12-18 Both 703 159 Malocclusion and orthodontic treatment need
    Perillo et al., 2010 [61] Italy European General 12 Both 703 451 Orthodontic treatment
    DHC
    Puertes-Fernández et al., 2011 [62] Spain European General 12 Both 248 97 Orthodontic treatment
    DHC
    Rwakatema et al., 2007 [64] Tanzania African General 12-15 Both 289 102 Orthodontic treatment
    DAI
    Shivakumar et al., 2009 [67] India Southeast Asia General 12-15 Both 1,000 199 Malocclusion and orthodontic treatment need
    Shivakumar et al., 2010 [68] India Southeast Asia General 12-15 Both 1,800 362 Malocclusion and orthodontic treatment need
    Souames et al., 2006 [69] France European General 9-12 Both 511 255 Orthodontic treatment
    DHC
    Thilander et al., 2001 [70] Colombia Americas General 5-17 Both 4,724 1,504 Malocclusion and orthodontic treatment need
    Variables Need
    Unmet need
    n Prevalence (95% CI) I2 p-value n Prevalence (95% CI) I2 p-value
    WHO region Americas 8 64.1 (45.3, 82.8) 99.9 <0.001 3 23.2 (18.0, 28.5) 99.7 <0.001
    Southeast Asia 6 46.7 (25.4, 68.0) 99.8 <0.001 1 72.3 (70.1, 74.5) - -
    African 7 34.4 (19.5, 49.4) 99.4 <0.001 2 58.9 (13.9, 100) 99.0 <0.001
    European 18 43.7 (13.7, 73.7) 99.6 <0.001 2 11.8 (3.4, 20.3) 94.5 <0.001
    Eastern Mediterranean 15 47.2 (32.6, 61.8) 99.8 <0.001 1 18.3 (16.4, 20.2) - -
    Western Pacific 3 40.8 (32.3, 49.3) 96.9 <0.001 - - - -
    Sex Male 19 50.0 (37.5, 63.5) 99.7 <0.001 3 37.9 (4.6, 71.2) 99.9 <0.001
    Female 21 49.8 (36.8, 62.9) 99.7 <0.001 3 33.8 (29.0, 38.7) 99.8 <0.001
    Both 33 47.9 (38.4, 57.3) 99.8 <0.001 6 33.3 (19.1, 47.6) 99.4 <0.001
    Year (range) 1974-1999 12 47.8 (31.8, 63.8) 99.7 <0.001 1 16.2 (13.0, 19.4) - -
    2000-2004 13 40.1 (34.2, 47.1) 98.6 <0.001 1 35.9 (28.9, 42.9) - -
    2005-2009 19 48.2 (36.5, 59.9) 99.9 <0.001 4 21.1 (11.9, 30.3) 99.1 <0.001
    2010-2016 13 60.0 (41.0, 79.1) 99.9 <0.001 3 56.6 (10.3, 99.0) 99.8 <0.001
    Sample size (n) ≤500 19 54.5 (41.9, 67.2) 99.3 <0.001 2 43.0 (29.6, 56.5) 90.1 <0.001
    501-1,000 18 44.8 (34.1, 55.5) 99.5 <0.001 2 11.8 (3.40, 20.3) 94.5 <0.001
    ≥1,001 20 47.8 (36.0, 59.6) 99.9 <0.001 5 38.9 (30.5, 47.2) 99.9 <0.001
    Total 57 49.0 (42.0, 56.0) 99.9 <0.001 9 34.0 (27.0, 40.0) 99.9 <0.001
    Variables Need
    Unmet need
    n Prevalence (95% CI) I2 n Prevalence (95% CI) I2
    Orthodontic treatment Americas - - - - - -
    Southeast Asia 1 28.8 (26.9, 30.7) - - - -
    African 3 43.0 (31.9, 54.2) 93.6 - - -
    European 14 51.6 (42.8, 60.4) 98.9 1 16.2 (13.0, 19.4) -
    Eastern Mediterranean 13 40.8 (25.6, 56.0) 99.7 1 18.3 (16.4, 20.2) -
    Western Pacific 1 47.9 (46.5, 49.3) - - - -
    General dental treatment needs Americas 4 73.7 (67.9, 79.5) 90.1 3 23.2 (18.0, 28.5) 99.7
    Southeast Asia 2 64.6 (51.3, 77.9) 98.8 1 72.3 (70.1, 74.5) -
    African 3 78.0 (77.0, 80.0) 99.8 2 58.9 (13.9, 100) 99.0
    European 2 24.0 (22.0, 25.0) 99.9 1 7.6 (5.3, 9.9) -
    Eastern Mediterranean 1 84.2 (82.3, 86.0) - - - -
    Western Pacific - - - - - -
    Malocclusion treatment Americas 2 54.4 (10.1, 98.6) 99.8 - - -
    Southeast Asia 2 20.0 (18.6, 21.5) 00.0 - - -
    African 1 22.6 (19.5, 25.7) - - - -
    European 2 52.0 (36.4, 67.6) 97.1 - - -
    Eastern Mediterranean - - - - - -
    Western Pacific 2 37.2 (34.9, 39.4) 00.0 - - -
    Periodontal treatment needs Americas 2 55.3 (25.7, 84.8) 99.5 - - -
    Southeast Asia 1 82.2 (79.7, 84.7) - - - -
    African - - - - - -
    European - - - - - -
    Eastern Mediterranean 1 93.0 (91.6, 94.5) - - - -
    Western Pacific - - -
    Table 1. Characteristics of included studies

    WHO, World Health Organization; DHC, dental health component; DAI, Dental Aesthetic Index.

    Table 2. Prevalence of any dental healthcare need and unmet needs among adolescents based on WHO region and sex

    WHO, World Health Organization; CI, confidence interval.

    Table 3. Prevalence of specific dental healthcare needs and unmet needs among adolescents based on WHO region

    WHO, World Health Organization region; CI, confidence interval.


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