Covid-19: loss of teeth and dazzling smiles

The oral health of part of the Italian population is worsening as consequence of more than one year of healthcare access restrictions, procrastination, and waiver to dental care. At the same time, the market of aesthetic dentistry is rapidly growing.

Key-Stone’s researches have compared these phenomena, through the analysis of a sample of over 4,000 Italians who were interviewed in three different periods: before the total lock-down, after the most acute phase of the pandemic, and in the period following the vaccination campaign against Covid-19.

These surveys show a recovery of lost accesses, a greater attention paid to hygiene, aesthetics, and prevention, as well as an increase in the gap between patients who can afford dental care and those forced to undergo dental extraction.

Gradual return to normal

The end of the state of emergency and the slow return to normal allow for an initial analysis of how much Covid has affected dental treatments and, consequently, Italians’ oral health. Key-Stone carries out at least once a year now studies on the population representing target patients going to Italian dental practices (average age between 20 and 75 years).

The recurrent nature of these analyses made it possible to study the time span from the end of 2019 – before Covid-19 pandemic – to the immediate post-lockdown and the period following the vaccination campaign. The results highlight a gradual return to normal, despite the awareness that the virus circulation is still high.

Impact of Covid-19 on oral health

Lockdown: worsening of oral health conditions

Thanks to a study carried out in collaboration with the Italian Society of Periodontology and Implantology, when the lockdown of spring 2020 took place there was a worsening of Italians’ oral health. In particular, gums and caries problems, as well as accidents related to prostheses and the impossibility of solving ruptures have emerged. This situation coincided with the reduction in the clinical activity of the practices, which were only able to take care of urgencies.

Post-lockdown: recovery of dental business

In the phase following the lockdown measures, there was a strong recovery in dental performance. The abrupt closure of the clinics had discontinued treatments being performed or planned in that period. Treatment plans with advance payments meant that professionals had liquidity to resume their activity with and were able to treat their already acquired patients.

Increase in the activity of some key services

Prevention: oral hygiene and check-up visits

The situation has currently stabilized, so some considerations can be made based on data analysis.

First of all, in light of the outcomes of the last research conducted in January 2022 on a sample of about 1,800 patients, there is an increase in oral hygiene sessions and check-up visits. These two activities together make up approximately 50% of the dental practices’ performance.

The reason for this data can be related to three main factors:

  • Patients’ greater attention to oral health;
  • Culture of prevention promoted by dental hygienists and dentists;
  • Management of periodic recalls leading to greater patient loyalty to the clinic.

Moreover, it is necessary to focus on the data referring to carried-out treatments (caries and devitalizations) to note how almost the entire activity of the practice (87%) – in terms of number of treatment – is focused on prevention and small treatments.

Looking for dazzling smiles

Another interesting fact is the increase of treatments related to aesthetics, such as bleaching (+24% compared to 2018) and transparent aligners (+130% compared to 2018). It should also be considered that many patients see professional oral hygiene as aimed at aesthetics, rather than at prevention.

In addition to these findings, sales data referring to materials used for the “polishing after oral hygiene confirm the trend growth, registering a +16% compared to 2018 sales, with a significant increase precisely for “prophy powders” with a +30%, compared to 2018.

Problems affecting access to care

It is also interesting to point out – but this time with a negative meaning – the considerable increase in patients claiming to have undergone tooth extractions (+7%), compared to the pre-Covid period. These are mainly patients with low education level and belonging to a low-income social group. This data confirms the economic difficulties preventing part of the population to access oral care and rehabilitation, since the increase in extractions does not correspond to an increase in prosthesis, which remain rather stable, compared to the pre-Covid period.

Honestly, it is hard to predict the future of the sector.

The current geopolitical situation does not allow forecasts to be made. However, we can certainly say that the market has recovered to 2019 levels, the population go again to the dentist and the number of accesses lost during the period of total lockdown and post-lockdown – when patients were afraid to go to the dentist- are recovering.

Even on the economic front, the signs are not that bad. Despite the difficulties, workers seem to have saved their jobs; the pandemic and the collapse of consumption have made it possible to save money, which many people seem to want to invest in the improvement or restoration of their oral health.

Anyway, the data making us think the most refer to the reduction of almost 20% of access to dental offices during 2020, which – together with the procrastination of some treatments – has significantly worsened the average health condition of Italians. In particular, this happened for untreated inflammatory situations, such as gingivitis, which was reported by large part of those who have faced dental problems, with direct consequences on the increase of need for extractions and periodontal care in general.

From Italy, the signs of the demand boom for invisible aligners in Europe

Problems of malocclusion for two out of three Italians

Almost two out of three Italian adults affirm to have dental malocclusion or misalignment problems. The demand for clear aligners in dental clinics is already booming.

This is demonstrated by an extensive market study carried out by Key-Stone Research Institute, which integrated data both from industry and dental practices.

Key-Stone analyzed the phenomenon thanks to an extensive survey, carried out on a representative sample of 2,878 Italians, aged between 20 and 50 years, representing more than half of the national population.

The study shows that 55% declare problems of malocclusion, already corrected in adulthood with orthodontic braces in 19% of cases. For that matter, this is a share also confirmed by plenty of international literature.

Malocclusion: the Italians’ perception

The Italians’ perception about this problem is very interesting, as well as the great desire to solve it. These aspects were investigated on over 1,000 individuals, that is 36% of the sample who reported a malocclusion yet untreated (at least 8 million people in the age group investigated).

Among them:

  • 60% complain of dental misalignment, considering it to be minor
  • 34% consider the problem as moderately severe
  • 6% consider the misalignment as very evident

The age group between 25 and 35 years is the most sensitive to the issue, judging the imperfection generally to be more evident.

Impact on the aesthetic and functional levels

Malocclusion mainly concerns aesthetics and, according to the interviewees, it worsens their appearance in 90% of cases, albeit with different levels of perceived severity.

Anyway, the problems mentioned by the sample are not only aesthetic. The survey provided for the possibility of reporting different symptoms (multiple choice):

  • in 28% of cases, difficulties in chewing were mentioned
  • in 28% of cases, gum problems emerge
  • difficult oral hygiene, as disclosed by about one third of the sample
  • orthopedic and postural issues, albeit to a lesser extent
  • only 20% do not report any functional problems related to malocclusion

The propensity to solve the problem

Although with different degrees of motivation, 72% of the sample affirmed to be interested in correcting their malocclusion or misalignment. In particular, half of them (36% of total respondents) show a high motivation. Translating this into numbers, it deals with over 3 million Italians, mostly women – twice as many as men – with a significant greater interest as the evidence of the defect increases.
The strong propensity to correct their smile exceeds 50% for those who complain of a very evident misalignment and, more generally, it is over 40% among those who have both aesthetic and functional problems.

Restoring a perfect smile with the aligners

Among those wishing to correct their smile, 62% would prefer to use a transparent aligner system. For another 30%, the type of device does not matter, but it would be very important to them to solve the problem of dental misalignment. It is above all those who present more serious dental conditions who want to solve the problem, regardless of the type of medical device the orthodontist will suggest.

Limits and forecasts

Slightly more than 70% of the interviewees have already considered the possibility to consult a dentist to solve the problem, but the economic barrier is the most named brake in accepting orthodontic treatments in the short term, particularly during this time of uncertainty due to the pandemic. Nowadays, part of the population is, in fact, more cautious when taking into consideration expenses likely impacting on the family budget.

In any case, 6% have already decided to go to the dental office to solve the problem and, if the doctor evaluates positively the need to carry out the alignment orthodontic treatment, it can be estimated that almost half a million people could undergo corrective treatments soon.

Over 150,000 treatments with aligners in 2021

According to Key-Stone researchers, this figure is consistent with the measurements carried out by the research institute itself, specialized in the dental sector at international level. In fact, data coming from industry and dental practices indicate that in 2019 over 80,000 treatments with aligners were carried out (in the vast majority of cases on adults). In 2021, over 150,000 treatments will be carried out, which is twice the previous figure, after having experienced an evident slowdown in growth in 2020, due to the pandemic.

According to Key-Stone’s estimates, this is an investment for Italians which will exceed 300 million Euros by 2021 and will continue its double-digit growth in the next few years.

Patients treated with aligners

Motivation for treatment

Within the starting sample, 200 cases involving subjects who recently underwent orthodontic treatment with transparent aligners were also studied. The goal is to evaluate the reasons leading them to the treatment and the overall perceived experience.

Considering the 200 patients treated, it emerged that the psychological component is absolutely dominant in the motivation for treatment:

  • 44% in fact stated that they wanted to solve the discomfort first of all with themselves
  • 35% claimed that they wanted to improve the relationship with others, showing a social discomfort as well.


In general, the experience and perception of the treatment outcome are very positive, with 34% of treated patients affirming to have achieved a better result than expected and, undoubtedly, beyond the initial expectations. The main factors causing satisfaction are:

  • first of all, the competence and interpersonal skills of the clinician and of the clinic staff in general
  • the final result, on average very satisfactory
  • comfort and transparency as distinctive elements of the treatment.

Overall, over 85% would re-undergo the treatment and recommend it to friends and family. This means that, in addition to the strong interest of a part of the population in solving their misalignment, the positive experience of friends and relatives generates a driving force in the sector, fostering positive references and organically stimulating the demand.

Confidence and vision towards the recovery

There is no doubt that the economic uncertainties due to a post-pandemic economic and social crisis will be of medium duration. It would be unthinkable to suddenly emerge from this crisis that leaves millions of jobs lost on the battlefield but, just as happened in the five-year period 2009-2013, those who have confidence and vision today will be more likely to thrive in the near future. A not-so-dark future for the dental sector, currently showing negative data, but which already proves to be on the recovery path: this is the time for confidence. From Spain, an example of the trend in the dental sector.

Consumables and equipment: trends 2020

The market for dental products and equipment reflects quite faithfully the performance of the overall dental sector.

In particular, the purchase of consumable products is strongly correlated with the demand for services, while the purchase of equipment and technologies in general represents an investment strongly connected to the professionals’ confidence in the future.

The final results of the research conducted by Key-Stone in Spain on behalf of FENIN (Federación Española de Empresas de Tecnología Sanitaria) are explanatory: the industry and distribution market lost 20%, in particular 18% in consumable products and 27% in sales of equipment.

However, some considerations must be made while looking at these trend data. In fact, an aggregate analysis of this kind, without going into details of the segments making up the two sectors (consumables and equipment) can be misleading. Therefore, let’s now look at the results of this research in greater detail.

The impact of Covid-19

Although the consumables sector is undoubtedly a direct indicator of demand for dental services, during 2020, due to the pandemic, the value of disinfectants and Personal Protective Equipment (PPE) purchases increased disproportionately, thus generating a strong increase in sales -and therefore in costs for clinics- not directly related to the demand for services. Therefore, in order to analyze the value and trends of consumables as a performance indicator of the entire sector, it is necessary to deduct the value of hygiene and disposable products in general.

It should be considered that the sector of consumables, including also implantology and orthodontics (without aligners), had a total value of 605 million (VAT exempt) in 2019, which became little less than 500 in 2020. Among these 500 million, the share related to hygiene and disposable products was approximately 47 million (with a weight of 9%), while it was 30 in 2019 (with a weight of 5%). All this leads us to affirm that these products have undoubtedly positively conditioned the sales of consumable products, but with a limited weight, since the whole Consumables sector not counting the “Covid products” decreased by 21%; a sector trend that we can consider very plausible.

Within the heterogeneity of the consumable product families, implantology shows the strongest decrease, with a trend of -28% (with a third less implants placed), while the contraction of orthodontics is quite limited, with a reduction of 19%. Even products for prostheses faced a reduction of just -17%, but this is due to the fact that, even before last spring’s confinement, there were hundreds of thousands of patients which had undergone implant surgery shortly before, on whom a prosthesis would have been placed in the following months. The long wave of negative effects reflecting on the prosthetics will likely be more evident in these first months of 2021.

The sharp drop in equipment sales, except for some devices strongly related to the health emergency (autoclaves, sanitizers and handpieces), is rather clearly due to strong economic and health uncertainty, which caused a temporary standstill of large part of the investments aiming at the renovation of clinics and technologies.

Negative data already attesting a recovery

The cumulated quarterly data (where Q1 refers to the trends of the first three months of the year, Q2 to those of the first six months, etc.) show a very positive recovery of the market, almost as if to tell us about a sector that traumatically experienced more than two months of total confinement in spring 2020, but which is recovering rather quickly his usual rhythms.

In particular, the recovery trend in equipment sales has a constant rate even though it closed the year 2020 with a very negative sign.

If it is true that the great uncertainty of last spring has led many dentists to suspend their investments, it is equally true that the indispensability of dental care for the population has ensured that dental clinics return to work at full speed. Not only there was a physiological positive rebound in the months from June to August 2020, but also in the period between October and December the activity returned to values only slightly lower than in the same period of 2019.

The competitive advantage of proactive dentists

This new situation of full recovery and a certain optimism when thinking about the phase following the vaccination campaign have led some dentists, certainly the most positive and proactive ones, to reconsider their intentions of renovation and relaunch of the activity, resuming their investments in technologies. Not only digital technologies, but also renovation of clinics, replacement of dental chairs, X-ray equipment, etc.

We must consider that this very serious crisis could change the competitive scenario, as dental clinics financially weaker or run by dentists close to retirement are certainly considering the hypothesis to sell or close the dental practice, while other dentists and entrepreneurs are strongly motivated to invest, in order to make available to citizens more modern, well-equipped and organized clinics.

If it is true that it will be quite normal to see a strong recovery in investments by dentists and technicians in the second half of 2021, it should be also taken into account that those who already lay a certain trust in a coming recovery of the dental activity today and are investing during these current uncertain months, can only achieve a strong competitive advantage over the others.

The article has been published on Gaceta Dental in Spanish.

The change of paradigm for the post-Covid-19 dental practice

The organizational and economic patterns for the post-Covid-19 dental practice radically change.

For years we have held to be true, rightly I believe, that through the “saturation of the chair time” that is, by using the available production time as much as possible, we would have reached the maximum profitability, within the boundaries set by the business model of the dental practice.

So, if we had managed to get each dental unit to work up to about 85% of the time available (while still leaving space for the management of the peaks), we could have achieved the optimization of the management.

Eventually looking for further improvement in other areas (costs, prices, mix of services, etc.), but no longer in the already achieved ability to make the most out of the structure. Few succeeded, for some it was a kind of mirage. Never as now, the use of the past is more appropriate, a past that will soon be a distant past.

The change of the organizational model

A small, microscopic, biological parasite has changed our lives, all over the world, we will see for how long but in the meantime, to return with our feet on the ground, it has already changed the organizational model of dental offices, and many other environments where waiting times and gatherings were the habit.

In the specific case of the dental practice, the issues of waiting and crowding in the waiting room, the punctuality of operators and patients, the efficient organization of appointments, had long been on the agenda of things to improve, and for someone the improvement project was already well advanced.

Clearly, we are talking about dental practices in full activity, not those (about 30%) in the decline phase and with a demand that is progressively decreasing, often in parallel with the progressive increase in the age of the owner, who accompanies himself and his study towards a logical and biological quiescence.

But the central theme of this radical change is the organization of the working model. It is not only in the specific topic of the patient gatherings, easily resolved with an improvement in the management of the agenda, but the great problem also lies above all in the change of clinical and extra-clinical protocols, which will forcefully reduce the objective production capacity of the dental practice.

The Italian situation

All this already seems very clear in the mind of Italian dentists, who, interviewed in the last week of March (in collaboration with IDI Evolution for the activity of the collection of the questionnaires), as part of Key-Stone research, declare in 41% of the cases that the most likely possibility (the question was a single choice to indicate the most relevant aspect) is that they will have to transform clinical protocols and, in 35% of the cases, to improve the management of the appointments.

Only 15% focused on the increase in costs for the greater use of PPE (Personal Protective Equipment) and 9% of dentists (which doubles for those over 55) think that in the end it will not change much compared to their previous daily practice.

Although the data collection method (online only) could contain some possible systematic error, the sample size, made up of 1,028 dentists, encouraged us to publish the survey, which is believed to be reliable.

Clearly, these are points of view, moreover at a particular time, knowing perfectly well that mood and awareness change day by day during this interminable lockdown phase. Until official protection guidelines for operators and patients are published, objective conclusions cannot be drawn. Only then, it will be possible to make real and reliable calculations of times and costs of this sort of Copernican revolution of dentistry.

Personally, I believe that the real big problem of the coming months, or maybe years, will not be so much that of the demand for treatments, or rather the economic power of the families, instead, the objective capacity of the dental practices is the focus, because there is no doubt that, for the same working hours, fewer patients can be accommodated.

The concept of “dilution”

And here comes the concept of “dilution”.

It will not be so much from the ability to saturate the practice that efficiency and profit can be achieved: this would only produce chaos, conflict and health insecurity.

The key factor of success will be the possibility and ability to dilute in an optimized way the practice activity.

Everyone will find their own solutions:

  • longer appointments to perform more treatments at once
  • the extension of opening hours
  • the use of digital technologies also to reduce delays and risks in the supply chain
  • teledentistry for the development of some remote services
  • serious and rigorous engineering of the workflows
  • the elimination of some operatory units to increase the waiting spaces
  • the reduction of the staff if the unsustainability of the fixed costs, compared to the demand that can be granted, is ascertained.

The competitive scenario

The competitive scenario may also change, with the possible closure of a significant part of dental practices (already stated in the same survey by 14% of the sample) and the likely unsustainability of some low-cost models.

But all this will, paradoxically, only exacerbate the problem of a possible excess of demand compared to the capacity and, incredibly, the real criticality could be the production capacity in a business model that must in any case generate a correct profitability.

The choice, on the other hand, to reduce the priority on prevention, hygiene, check-up visits, by someone ventilated since they would produce a reduced unit value, would be a misfortune for the entire system, for the organic expansion of the patient base and for the dental health of citizens.

We can only trust in the balance of the guidelines defined by the competent authorities, which take into account the health of operators and patients, but also the difference in risk of the different treatments and the indispensable economic sustainability of the dental practice.

Then, it will be the vision, intelligence, and entrepreneurial ability of those who will have to reorganize their profession to make the difference, and it is not said that the competitive advantages achieved in the past are a sure factor of success for the future.

The article has been published on Dental Tribune in Italian, English and French.

The recovery phases in the dental sector

We are all asking ourselves “when” we will return to normal life after this pandemic, but although this is the most pressing issue, the most disturbing question is probably “how” this hypothetical normality will be.

The pandemic impact

Perhaps also for this reason, all over the world we speak more and more often of “new normal”, namely that phase, which will probably last for years, characterized by at least three influencing variables coming into play:

  • the management of the endemic phase of the virus
  • the new logics of socialization
  • the great economic crisis ahead of us.

These three points certainly don’t need much comment. As regards the management of the endemic phase, it is rather obvious that the timing for achieving herd immunity, the real effectiveness of vaccines also against any other variants, the modalities and programming for periodic boosters are all factors affecting both behavior and social organization. In the workplace, remote work will in any case be more frequently exploited and business travel limited (a return to the level of air traffic recorded in 2019 is expected not before 2025). Certain economic sectors will suffer the impact of the pandemic for a long time, for example those most affected by remote work, which will become regular practice even for just a few days a week (with an impact on services related to commuting, food services, etc.), or the retail trade, if we consider the enormous impact of the development of e-commerce and its inexorable acquisition of market shares. At the same time, some areas will also considerably grow, such as IT, pharmaceuticals, delivery services, etc. There will also be sectors strongly supported by the European Recovery Fund, but these too will only allow the development of specific sectors, according to each national Government’s plan, whose fundamentals are based on ecological transition, digital transformation, employment and smart, sustainable and inclusive growth, measures looking to the next generation, including education and skills development, etc.

As anticipated, not all sectors will have the same support. The dramatic collapse of gross product, production, and export, as well as the significant rise in public debt, will take years to return to 2019 levels. Unfortunately, the only aspect we are sure about is the uncertainty regarding these factors.

Despite everything, as we will see here following, the dental sector can be considered as central and essential to the health of the population.

Let’s see then throughout this article some thoughts on the impact of the pandemic in Italy and on the probable recovery dynamics occurring in the dental sector.

My job, as head of the Key-Stone research institute, is to collect, process and analyze data, but I am often also asked to produce forecasts and strategic guidelines. Well, over this year my writings, interventions and seminars have been numerous, however, I have always explained the serious lack we have faced, that is the uncertainty due to the total absence of past data. This aspect makes it impossible to work on mathematical models, moreover, there are just few similarities with past pandemics, since in the last serious ones the social and healthcare context was totally different.

Nonetheless, in this catastrophic year, Governments, international organizations, the biggest world strategic consultants, all research institutes (including Key-Stone), companies and associations, have begun to collect and catalog qualitative information and quantitative data, developing economic forecasts and theories on the post-Covid-19 recovery.

Also in relation to the Italian dental sector, we can count on numerous researches and studies carried out this year, and thanks to this contribution I would like to share some food for thought, by explaining what we believe the steps to recovery will be, in terms of demand for dental services.

As I have already had the opportunity to write, the current crisis arises from an interruption in interconnections. During the three-month lockdown, we were prevented from moving, from consuming, although there would have been financial possibilities, in theory. But even later, until today, if we give up buying and consuming certain products or services, it is often not because of a shortage of money, but rather because of an objective unfeasibility connected to social distancing policies. In addition to that, we must take job uncertainty into account, another dominant word in recent months; an uncertainty that now affects many millions of Italian families, especially considering those who work in sectors heavily affected by the pandemic (travel, tourism, food service, non-food retail trade, etc.).

But what happens in consumption, when we are faced with a phase of uncertainty or, worse, of real or imminent worsening of the family economic situation? First, all those spending decisions that are deemed unnecessary or simply not indispensable are postponed. Unfortunately, among these, we also find the expenses for dental services.

Analysis of the short-term impact on dental treatments

In November 2020, Key-Stone interviewed 1,200 Italian families and it emerged that one in four Italians, aged between 20 and 74, would have renounced the dentist, except for urgent needs, until the end of 2021. These are 13 million Italians, whose uncertainties due to the pandemic are now added to their traditional economic and cultural problems. The percentage rises to about 40% for those who have had or think they have precarious employment and economic situation because of the pandemic.
However, considering that a part of the population would have renounced the dentist anyway (most of them because of structural economic reasons not attributable to Covid-19), 61% of these undoubtedly attribute this choice directly to the pandemic, because of the consequent worsening of their economic situation or for fear of being infected.
On the other hand, a positive note comes from the segment of children and adolescents: according to Key-Stone’s research, the intention to give up on treatments is reduced in the case of children aged between 6 and 19, whether it deals with more expensive treatments -such as orthodontic ones- or checkups and routine treatments.
In conclusion, the real effect of the pandemic would cause a reduction in the demand for dental services estimated around -13%, at least one billion less in dental expenditure and therefore in lost revenues for the sector.

Possible future needs

In this context, Key-Stone explored the topic in depth, trying to understand which areas of need are most felt by the population and which is the expected procrastination time for treatments.

First of all, it is worth remembering that the citizens interviewed do not always have the clinical skills to be able to judge their own needs in terms of dental services, moreover the climate of trust can change suddenly depending on the overall pandemic situation and on personal experience.

The research conducted confirmed how a certain fear for infection, but above all economic and employment uncertainty has pushed part of the population to postpone non-urgent dental care. This situation is also quite usual in times of famine, crises when confidence in the future decreases. In fact, it is normal for people to prefer to solve basic needs (in our case pain or urgent functional problems), neglecting other expenses that may be postponed.

By re-processing the data coming from the research, we have extrapolated the percentage of adult population claiming to be likely in need of certain dental therapies and treatments, even if not in the immediate future.

In Figure 1 we can see a ranking of the main treatments, first of all, fillings then oral hygiene, concerning almost half of the interviewees, immediately followed by extractions, implants (with consequent prostheses), and traditional orthodontics. There are fewer esthetic needs, such as veneers, or treatments with aligners.

Intention to postpone dental treatments

To the same people who stated possible future needs, we asked if they thought to be treated soon or if they would have preferred to postpone dental care as later as possible, or even to give it up. In Figure 2, we can see how the intention to postpone dental treatments is higher for those rated as more expensive. It is slightly surprising that some treatments more related to esthetic needs have a rather high procrastination rate even though patients who manifest these needs have medium-high levels of education and income.

Map of the potential needs and the intervention priority

By matching the results of the potential needs with the intervention priority (i.e. the reverse of the intention to postpone), it is possible to have a clearer representation (Figure 3) of the therapeutic areas that could be most affected in the short term, a period that we could probably frame up to the end of 2021.

The areas of implants and prostheses will probably have greater difficulties in recovering in the short term, while others -more related to restoration– could move faster towards a normal condition. The situation of orthodontics is peculiar, since for adults it may present a certain slow recovery, while as regards therapies for children (not shown in this chart), a much smaller crisis is expected, as explained here following.

However, the scenario just outlined depends on the type of the dental practice patients, considering their average socio-economic level, the working sector of their families and the geographical areas where they live, in the event that the local economy is particularly affected by the effects of the confinement measures.

The dental treatments are essential

At the same time, this research reveals some very important information, already widely emphasized in the media, namely that 30% of those who during the phase of total confinement (March-May 2020) had problems with their teeth or mouth without having been able or willing to go to the dentist, reported a worsening in their oral situation. The numbers coming from the research carried out by Key-Stone for SIdP at the end of the lockdown period speak for themselves: over 10 million Italians had problems with their teeth and gums during the ten-week confinement and about 3 million state that the situation has worsened because of the impossibility to go to the dentist. It is therefore unquestionable that dental treatments must be considered essential.

We are therefore dealing with a sector, and indeed also a market, where the fundamentals are solid, where long-term structural crises cannot be foreseen, but which can contract or expand based on economic and social external phenomena, which lead to the postponement of certain treatments in particular periods.

Medium-long term recovery dynamics

According to the main theories on post-pandemic recovery, we must consider that after a first phase of giving up certain goods, especially services (which are generally postponed in the process of hierarchizing personal and family expenses) by part of the population, there will be a physiological long-term settlement (probably for at least a year) during which the population, gradually emerging from economic hardship or uncertainty, will resume even the most expensive treatments. In the meantime, it should not be forgotten that, unfortunately, some of those who have delayed oral care for too long will have a more compromised oral situation. Following this recovery, however, the demand for services should settle at slightly lower levels, following the trend that was already taking place in the three-year period 2017-2019. In this analysis, the observation of what happened during the great recession 2008-2013, with an exceptional recovery in dental care in the following two-year period 2014-2015 and the subsequent slowdown in growth up to the stagnant or slightly declining situation reported by ISTAT in 2018 and 2019, helps us a lot.  As far as dental care is concerned, even the first phase of lockdown resulted in a strong recovery in summer 2020. It was very intense and short-lived, due not to the citizens’ waivers, but to the numerous tratments interrupted between March and May.

The recovery phases

In Figure 4, we can see the possible recovery phases characterizing the dental sector.

Let’s identify and analyze the six phases described in the model, and let’s make some reflections.

Pre Covid-19 

The results obtained by the study about the last pre-Covid years should not be overlooked, as they are a key indicator of the sector business fundamentals. Obviously, if the clinic was under development and was in a financially prosperous position, it is very likely that it will recover more quickly, perhaps by increasing its market share, at the expense of those who already had problems in their own business, with declining results, difficulty in generating profit and financial weakness. For practices that were already having problems, the shock of this crisis could be lethal and some of them may decide to reduce their activity or close.


The almost total impossibility to access the clinic has had a devastating impact on their financial situation, as well as a long-term impact on the organizational system. Despite the possibility to benefit from payroll subsidies to reduce the impact of personnel expenses, during the three-month lockdown the dental practices’ owners had to incur the fixed costs, many of them by using their own resources and drawing upon personal assets, while some dentists have turned to banks for a loan. But these expenses will have to be recovered, or in any case, be returned to the family assets: it would therefore be appropriate to plan the profits for the next few years to calculate the payback times of the investment.

Technical rebound 

The more-than-10-week total confinement halted an enormous amount of work, which poured into the clinics in the period May-September 2020, to carry out the suspended treatments and those for which patients had already decided. According to an accurate survey carried out by Key-Stone, the treatments remained blocked would have covered about 50 working days; the research was able to objectively affirm that at the resumption, in the second half of May, more than one billion euros treatments were resumed in the sector (more than 30,000 euros work to be completed on average per dental practice).

But it was a short-lived recovery. It must be remembered that, in the meantime, no new patients showed up for almost three months and new treatments took place only in the autumn, partially compromised by the lack of new visits in the previous period.

Prioritization needs 

Since October 2020 there has been a new reduction in accesses and new patients compared to the same months of 2019, due to subsequent restrictions on mobility and increasing economic uncertainty. In this period, which will probably last until the end of spring 2021, the general performance has settled a few points below the results of 2019 and, as regards implantology, this reduction is quite important (on average -9% implants placed between October 2020 and February 2021 considering the same months of the previous year).
Recovering from the emergency phase (and much will depend on how long the vaccination campaign will take), the workload will gradually increase, but for a few million families directly affected by the crisis -because of the impact on their job and financial situation- that mechanism of expenses hierarchization will be frequent, leaving part of the treatments still in difficulty. This is a phase whose duration is unknown, but observing the macroeconomic predictions made by relevant institutions, the clearest positive signs will probably occur in 2022.
Those who manage a dental practice must take this aspect into account, since they could face a slowdown in recovery during this year, always compared to 2019, which is the reference year. In any case, this is a phase that will not last particularly long, but it is essential that the financial system of the clinic leaves room for a possibly extended resistance.

Physiological rebound 

The procrastination of dental services for over a year generates a huge “lung” of treatments that are finally performed over a long period of time (even years), as families recover an acceptable economic situation, trust in the future and, in part, in the event that the oral condition does not worsen in terms of urgency (as anticipated, this phenomenon has already been documented in the two-year period 2014-2015). It is therefore very likely to witness an expansive cycle which, like after the “Great Recession”, could last for at least a couple of years, with undoubted advantages for those dental practices which will be able to plan their business in an entrepreneurial way, combining trust -that I often mention as a fundamental ingredient to overcome this crisis- and financial planning/control capacity, not to forget the strategic vision contributing to a successful value proposition.

New normal 

There are no clear forecasts on what the health situation, social dynamics and economic weight of the different sectors will be in the endemic period.

Certainly, we cannot fall into the error of believing that the “new normal” is a return to the conditions prior to Covid-19. We are facing a radical transformation, thanks to which some fundamentals of the social organization and economic system will undergo profound changes. We all hope this evolution moves towards an improvement in life quality for an increasingly large part of the population. 

In the new situation of normality, the demand for dental treatments could slow down its development following the physiological rebound resulting from the treatments procrastination (as happened in the three-year period 2017-2019). In actual fact, this may lead to what we indicate in the chart as baseline, which represents the level of demand we would probably have had without the impact of the pandemic.

Anyway, those who have worked well in recent years, investing in clinical skills, facilities, technologies, training, and entrepreneurial management, will probably find themselves in a more prosperous situation than the one in which they were before this shocking health catastrophe.

The development of the Italian dental sector from 2010 to 2019

The Italian dental sector has experienced decades of flourishing growth. In recent years, price competition and stagnant consumption have led to an abrupt slowdown in the sector development. Despite this, the heterogeneous composition of the business makes it possible to intercept excellent improvement opportunities for certain types of products. Let’s find out which ones.

Here below is a detailed analysis of what has been the development of the Italian dental sector in the last few years before the pandemic outbreak, an event that has changed the dynamics and logic taking place in various sectors. The aim is to highlight the factors deeply influencing the dental sector and the opportunities for development, according to the characteristics and performance of the business itself.

GDP and birth rate: factors impacting the dental sector

We cannot talk about 2019 without considering the previous period which the 2019 has been the expected outcome of. Many will remember, with a combination of concern and hope, that ten years ago the still vivid and persistent post Lehman Brothers crisis from September 15, 2008 was there, an event that led to the so-called “great recession”. The signs of this crisis are still present today with effects that have lasted longer than one could imagine; a sort of “structural crisis”, a juxtaposition of terms that is clearly an oxymoron. A never overcome crisis, which has mainly concerned Italy. I will borrow the report from the CPI Observatory of the Università Cattolica of Milan, which tells us how these recent years before the pandemic crisis that affected the world have been, from the point of view of economic development, the worst since the Unification of Italy. Two factors have been the most relevant ones and both concern the dental sector, albeit in different ways: the slowdown in GDP and the collapse of the birth rate.

GDP slowdown

With regard to the former, GDP grew on average at a rate of half of the previous decade’s one (despite the collapse of 2008) and less than in the 1940s, the most difficult years because of the devastation of World War II. There is no doubt that this slowdown in the economy has directly impacted the behavior of Italians, not only because of the more limited spending capacity of a significant share of the population but also and especially for the social effects related to job insecurity, fragility of savings and general uncertainty felt by the population about the future, emphasized by the very precarious political situation.

The collapse of the birth rate

From a demographic perspective, however, Italy has begun its population drop process in 2017, like never before, and the trend is estimated as intrinsically structural. But the aspect we need to focus on is the real collapse in the birth rate, with just over 4.9 million births in the last decade and over 5.5 million in the previous one; a total of 600,000 fewer children born in the decade, in other words, a decreased birth-rate of 11%. This is a problem which is definitely worsening: if we take as an example 2019 over 2009, the decreasing birth-rate exceeds 24%, with less than 430,000 births compared to 578,000 in 2009.

Italy experienced its first population decline only in 2017, thanks to the demographic balances originating from migratory phenomena. In fact, Italy is a country that has aged, economically stuck, and whose social stratification has experienced the compensation for its natural demographic reduction through migratory flows.

All these aspects have had a huge impact on the dental system, too. This is because the sector is in fact a world at the service of the population to cure pathologies and to meet functional and aesthetic needs. But it is also a sector in which over 90% of patients pay out of their own pockets and in which the socio-economic and socio-cultural aspects are of significant importance.

The dental sector trends from 2010 to 2019

To briefly take stock of these past ten years, let’s go back for a moment to the beginning of the analyzed season. In 2010 the country was slightly recovering after the terrible two-year period caused by the international crisis, two years during which the flow of patients to the dental practices had decreased (about one million fewer), anyway it was possible to witness a modest recovery. The real “tragedy” occurred at the end of 2011, when we ended up on the brink of default and the famous maneuver – metaphorically called “tears and blood” – of the newly formed Monti’s government threw Italians into despair and concern, thus inducing the collapse of consumption, above all because of the lack of confidence. 2012 and 2013 turned out to be very bad years also from the dental sector perspective; Key-Stone researches, but also other institutes, confirmed a drop of about 3 million patients. Moreover, Istat recorded an important reduction in the average expenditure for dental care among Italians (1.5 billion less in 2013 than in 2011). The dental products and equipment segment also suffered a severe slowdown and, for the first time ever, the dental market (intended as products and equipment) experienced recession: it had never happened before.

2014 brought a certain recovery, that I called “the renaissance of the dental sector” on the occasion of an important conference organized by UNIDI, with a real boom in performance and accesses to dental practices in 2015. However, it was clearly a sort of “technical rebound”, due to the fact that hundreds of thousands of families had postponed important but not urgent oral treatments, especially of prosthetic and orthodontic nature; a variety of services that gradually diluted, leading to a new slowdown in growth, even if the market has not experienced other drops in terms of number of patients and volume of services since then. There has been a reduction in consumption to almost stagnation in the last two years, but without reaching the level of recession.

The situation is different for dental clinics, whose sector continues to witness a progressive reduction in revenues despite the slight increase in number of treatments; this is due to different reasons, which we could summarize in a more competitive market characterized by price contraction and a substantially “healthier” population than in the past. This is a topic that must be explored in terms of possible future developments not only of market values, but rather also of the variety of services and patients in the decade that has just begun.

But let’s go back to the past ten years, because if what has been explained so far has had an important impact on the sector of consumption of dental products, closely linked to the flow of patients to the dental practice, the world of technologies has experienced a completely different trend, deeply influenced by two main drivers: digital revolution and fiscal incentives on investments.

While the abrupt appearance of digital technology can be considered a structural factor, the role of tax incentives is more related to the cyclicity of economy (even if it was protracted, I would say dragged for a couple of years further than expected), which has impacted the professional market with a real cyclical trend, typical of businesses stimulated by short-term legislative measures.

The role of services in the professional dental market

Generally speaking, however, the domestic sector has suffered greatly due to the overall economic trend (the flourishing of the dental industry is, in fact, closely linked to exports) and to the slow social and cultural transformation of the country. For this reason, if we look at the total added value provided by the professional dental sector (including consumables, equipment and services), we note how the total increase in business is only 14%, if compared to 2010 values, little more than what obtained with the GDP (at current prices). However, this figure is not completely honest.

During the analyzed period, in fact, the professional dental sector has been enriched with services: the industry began to produce customized medical devices (aligners instead of brackets; prosthetic structures instead of alloys and ceramics), to which the progressive computerization of dental practices and the greater need for technical assistance must be added.

Well, if we look at the total added value of products and equipment only, excluding services, we can picture in the same graph how, during this period, the overall added value of the sector (net of services) is only 7%, far lower than the overall GDP trend.

Impact of digital equipment and centralization of customized medical devices

Let’s now approach in more detail the trend characterizing the main product families, highlighting how what we just described here above is confirmed by the evolution of the different markets. To perform this trend analysis, we used fixed-base 2010 trends, precisely in order to study the period as a whole and not just individual years which, as we have seen, are the result of particular situations.

The market segmentation applied in this occasion brings to light the fact that some sectors have proved to be particularly dynamic more than others, and which, if not isolated, they may mislead the evaluation of the overall sector trend. Dynamics totally influenced by the so-called “digital revolution”. As a matter of fact, digital technologies, in addition to having had a fundamental impact on the modernization of dental practices and laboratories, have also played an important role in terms of materials (in particular Cad-Cam) and have implicitly allowed the enormous development of a new market, that of custom-made devices such as prosthetic structures and, of course, orthodontic aligners, which have quintupled their value in ten years.

The graph shows, like the previous ones, the accumulated trend with fixed basis. In general, the trend of the lines in the graph allows us to observe both the slight decrease in the two-year period 2012-2013 and the signs of recovery from 2014. In particular, we observe the enormous impact of digital technology and centralization of customized medical devices (digital flow prosthetic structures and orthodontic aligners) beginning in 2015.

For a more in-depth quantitative analysis, it is very useful to adopt a trend indicator technically called CAGR (Compound Annual Growth Rate); it is in fact the average trend rate recorded during the years under examination which gives a precise idea of the real trends.

The chart gives us the chance to observe how in the more traditional domains of the market only the classic “consumables” have grown with positive sign, amounting to around 1% on average per year. On the other side, albeit for different reasons, the more traditional equipment, implantology and orthodontics sectors are falling. With regard to these last two product lines, it should be remembered that the negative figures are not only due to the possible reduction in consumption – therefore to a possible decrease in demand – but also to dynamics causing the progressive reduction of the average prices.


In conclusion, as anticipated, the Italian dental sector development has slowed down in a probably irreversible way due to dynamics of price competition and stagnation in consumption. Despite this, it is possible to detect development opportunities, in particular in the domain of services for the dental practice and for the laboratory.

One year of the pandemic in the European dental sector

The economic impact of the pandemic on the dental sector proved to be dramatic but only during the first phase, which developed from March to May 2020 and in which government measures of lockdowns had often included the closing of dental practices. In this article, we will identify the trends in the dental industry for the consumable products and how these very trends can also help us better understand the dynamics of the demand for dental services.

Before discussing the trends that characterized the year of the pandemic, an introduction must be given explaining some of the market concepts that are taken for granted in the industry and distribution world but which could be less known by dentists and non-commercial operators.

First of all, it must be considered that the sector is divided into two large segments:

  • consumer products
  • equipment.

While the consumption of products is directly correlated with the number and type of dental treatments, therefore, the demand, investments in equipment are strongly conditioned by the climate of confidence and trust of dentists and dental technicians.

Remaining in the field of consumables, another much more technical issue concerns the difference between:

  • the retail business (also called “sell-out”), which refers to the purchases of dental practices and laboratories
  • the wholesale business (also called “sell-in”), which refers to sales through the distribution channel such as dental dealers.

It is true that the two businesses are directly related because as the demand for retail products increases, there is a demand by distributors for supply from manufacturers, however, this correlation is not always in sync because it largely depends on the stock of the dental dealers. This is exactly why sell-in and sell-out do not always move in sync and the purpose of this article is to also analyze how the pandemic has affected these two businesses in a different way.

Impact on demand

Here in Europe, we find ourselves in a condition where precise data regarding the demand for dental services are missing, but the real possibility to analyze the evolution of the numbers and types of dental treatments is to evaluate the trends in the purchases of consumer dental products by dentists.

Therefore, if we consider the evolution of the consumption by dentists during the pandemic (excluding products mainly related to Covid-19, such as those for hygiene, PPE, and disposables in general), we can acquire a fairly clear idea of what the demand for dental treatments was. Even if dentists had possibly reduced their inventories during the period of greatest financial stress, in the long term of a year, the consumptions (of products such as impression materials, cements, restorative products, endodontics, anesthesia, etc.) are strongly correlated to the influx of patients to clinics and so we can declare that the trend curves relating to the business of consumable products can be very similar to those of the dental sector in general.

The Italian and Spanish markets

Currently, the Key-Stone research institute, specializing in dental research at a global level, measures the dental retail markets through the “Sell-out Analysis” research in just four European countries (Italy, Poland, Portugal, and Spain) but with the advent of the pandemic, in particular for the Italian and Spanish markets, a monthly analysis was carried out, based on the sales data of a sample of dental dealers covering over 70% of sales in each of the two countries (the total sales of 2019 of the panel of dealers exceeded 500 million euros in Italy and 220 million euros in Spain).

As we can see in Figure 1, which indicates the monthly trends of the two countries, the evolution of the business activity is quite similar. The trends presented are those of the accumulated value up to December, also indicated as “year to date”, while for January and February 2021 the so-called MAT “Moving Annual Total” is indicated, namely, the 12 months “March 20-February 21″ vs ” March 19-February-20 “, which we would consider the true first full year of the pandemic compared to the previous 12 months.

It is worth noting that these are two countries that have had a very similar digression of the pandemic in terms of timing and with respect to the political choices of confinement, and unfortunately, for the incidence of infections and deaths concerning the population. Italy activated a total lockdown 10 days before Spain did but, apart from this, the similarities are very high. Even dental and welfare systems are the same, with a weight of over 90% of the private sector, even though the DSO (Dental Service Organizations) channel in Spain, namely that of the dental chains, carries a greater weight than in Italy.

As can see in Figure 1, referring to the trend in the consumption by dentists, excluding products related to Covid-19, while Spain had already started the 2020 year with a slight decrease, which was a mere 2% in the first two months, Italy instead registered a growth of 2% in the same period. This issue is very interesting since the two markets experienced, and continue to experience, their own development dynamics regardless of the pandemic. Italy was in a stagnant or slight growth situation and Spain was already suffering from a recessionary condition linked mainly to a crisis situation that had emerged in the DSO channel, in particular, with the sudden closing of an important brand. Overall consumptions in Spain were therefore already in decline and, following the lockdown, the business recovery continues to hover around 3 points lower than in Italy.

But let us see what the trend curves of these two countries tell us. First of all, the lowest moment of the market was reached in May 2020. It should be reminded that almost all of the dental practices in both countries completely shut down, carrying out only some urgent therapies, but in the month of April, product purchases had reached minimum levels. After the reopening from the total lockdown, starting at the end of May, we had witnessed a sudden and positive recovery of the market. To explain this strong rebound in the months following the reopening of practices, however, we must consider that the average portfolio of works that remained suspended due to the lockdown was very important (estimated to be about 112 days of works to be recovered). An estimated value of treatments of about 1.2 billion Euro that was suspended in March in Italy and just under 1 billion Euro in Spain meant a true “economic buffer” useful for the relaunching of the dental business, which, however, was also able to count on the access of new patients in the practices; patients who had problems during the lockdown or who made the decision to carry out new treatments. The recovery of those months looks to be rather robust and was promptly monitored by Key-Stone through the analysis on the purchases of consumable products by dentists.

Following the first strong recovery, the growth trend returned to almost zero in the autumn and with the second wave of the pandemic, despite dental practices remaining open, the overall monthly level of purchases (November 2020 – February 2021) stabilized at around -3% in both countries. If we consider slight inflation with average increases of all prices, precisely measured through the “Sell-out Analysis” research, we can state that the level of the number of treatments during these months is about 5%-6% less compared to those of the same months of 2019 (the year 2019 was used for the comparisons) and this situation may persist at least until the health emergency ends and a substantial share of the population has been vaccinated.

Great opportunities

Remaining on the previously discussed topic, this crisis in product consumption clearly refers to segments that are not related to the pandemic, since the enormous development of hygiene and protection products is offsetting the business of the distribution system. As mentioned in the introduction, we must consider equipment and durable goods, in general, to be a market by itself. In this article, only the trends related to consumables are being considered; a separate article should be dedicated to the equipment. Therefore, we will limit ourselves to saying that until the trust of the operators (dentists and dental technicians) is regained it will be very difficult to return to pre-Covid levels but, paradoxically, thanks to investments in new technologies and the renovations of dental centers, it will be possible to accelerate the recovery of a dental practice’s business and intercept new opportunities that this catastrophe still offers.

In particular, it can be cited as great opportunities:

  • the greater importance attributed to health issues by the population
  • the renewed centrality of the relationship of trust with the dentist
  • the advent of digital technology in the clinical, organizational, and marketing fields.
  • the financial and strategic weakness of thousands of practices.

These weaknesses are especially typical of small practices run by older dentists, generally with a less proactive attitude, with the risk of suffering the crisis in demand as well as organizational and management problems due to the adoption of new safety protocols which, inevitably, lengthen the times of occupation of the practice and reduce hourly revenues.

Impact on the industry

Now, let us return to talking about consumer products and their impact on business, this time, on that of the industry. As mentioned in the introduction, in the case of wholesale sales, the issue of warehouse inventories cannot be ignored. An analysis of 2018 financial statements of the dental dealers carried out by Key-Stone, demonstrates how inventories are worth just under 20% of the total purchases. Therefore, it is pretty standard to observe trends in the purchases of distributors which, although related to the retail sales, can show very different dynamics, especially with regards to the timing with which stocks are replenished.

What occurred during the lockdown was a true stop in the purchases of dental dealers which, in the face of serious unknown economic and financial difficulties due to the sudden block of the market, used as much as possible their stocks, and reduced purchases to the bare minimums, thus taking the risk of a reduction in the level of customer service but guaranteeing good financial resistance.

Key-Stone manages an international panel made up of the main manufacturers in the chemical consumable sector (impression materials, cements, restorations, prophylaxis, etc.), consisting of companies that had a turnover of over 800 million euro at sell-in in 2019 in Europe and it was possible to replicate the same exercise explained previously on the retail markets of Italy and Spain, by carrying out a monthly analysis of the sell-in sales in all European countries. Considering these 800 million euros, we can reasonably assume that approximately 150 million euros of the total inventories were normally stored in the warehouses of dealers throughout Europe.

The six important dental markets in Europe

In this article, we briefly present the results of the six most important markets in terms of business activities, whose total turnover in 2019 was approximately 520 million euros; these are Benelux, France, Germany, Italy, Spain, and the United Kingdom.

First of all, in Figure 2 we can see the sell-in trends on a monthly basis (trend of the month compared to the same month of the previous year, also called “Year over Year”), with a hefty collapse in purchases by distributors of all Europe (this phenomenon does not in fact concern only these countries), which in the months of April and May 2020 suffered its lowest point, after a month of January that had already started with a reduction, even though it was a technical phenomenon given the fact that the month of January is always considered quite inconstant over the years with regards to wholesale sales.

Only in the month of July did we witness the first positive figures of a second-half which, with its ups and downs, continued to grow slightly. It wasn’t until the months of January and February 2021 that we were able to witness a full recovery in the purchases of dental inventories; whose growth is a very evident sign of the replenishment of the inventories.

The analysis of the cumulated sales values allows us to observe how the slight overall recovery in the second half of 2020 and the large increase in the first two months of 2021 are certainly not enough to fill the negative gap accumulated in the full year of 2020.

Figure 3 allows us to observe how, thanks to the purchases during the first months of 2020, the lowest point of the total business is indicated at the end of the first half, while the retail sales analyzed previously for Italy and Spain indicated its historical minimum levels in May. However, and once again, this is determined by the purchasing policies of dealers across Europe, who at the most serious moment of the crisis had reacted by almost completely blocking their purchases, therefore, using their inventories to respond to the very weak demand during the months of lockdown.

Despite the good performance of the channel in the first months of 2021, it is interesting to point out that in February the overall value of the last 12 months of analysis shows a trend of -16%. This signifies that, most likely, the warehouse inventories of European distributors have been restored and during the 2021 year the sell-in sales will be consistent and aligned with retail ones, net of any new extraordinary situations due to the pandemic. In any case, we have isolated the sell-in of Italy in the graph in order to closely observe the correlations with the retail analysis shown previously. Once again, the trend curve is consistent but Italy shows a worse trend than the average and its retail one, indicating the strong phenomenon of destocking in this country. In Italy, the final result of the December sell-out at -15% (see Figure 1) is better than that of Spain (-18%) but despite this, the result of the Italian sell-in is much worse than the Spanish one as shown in Figure 4 (-31% vs -20%). This is simply another sign of the large warehouse inventories that were used by Italian dealers during the pandemic. On the other hand, the sell-in of Spain is consistent with the European average trend.

For now, if we carefully look at the analysis of the results of the full year, we can see how 2020 was truly a disastrous year for the dental industry, with closure at -22% in the total of the six markets analyzed and a -17% in all of Europe, thanks to the positive performance of Russia (+6% in local currency and -8% in euro) among the other main countries not analyzed in this article.

At the end of the year, the UK and Italy are the countries with the most evident collapse and, without a doubt, the two countries that also experienced the most dramatic impact of the pandemic during the first part of 2020, with the highest incidence of Covid cases and deaths. However, apart from the health implications in these countries, a certain weakness of the distribution system and a high level of inventories had probably contributed greatly to the sharp reduction in industry sales. In the UK, even the weight of public services, heavily involved in the management of the pandemic, may also have played an important role.

In any case, in February 2021 we can already see a big recovery in all the markets. In the green bars of Figure 5, we see the result of the first two months of 2021 compared to the same of 2020 (2021 Feb. YTD) and we can observe growth rates that are not compatible with those of the retail sales but clearly related to the replenishment of inventories. However, all of this will not be sufficient to recover all the business lost in 2020: in the red bars, in fact, we can see the trend of the last 12 months (2021 Feb. MAT) compared to the overall sales of 2019 and returning again to the -16% (OVERALL) already presented in Figure 3.

However, it is worth noting there is a certain heterogeneity in the recovery: markets such as the Benelux and France in particular, indicate acceptable overall declines for the rolling year (2021 Feb. MAT), and it is likely that in 2021 they will recover the values of 2019. However, it would be useless to deny that in absence of a true recovery in retail sales, and without a robust increase in the demand for dental treatments, a slowdown could inevitably occur starting in the spring of 2021.

A new phase

There is no doubt that as soon as the pandemic situation improves, reasonably in the second half of the year, a new phase will open. However, we must not think there will be an immediate recovery because, on the one hand, there will be another new economic rebound for just a few months, due to the essentiality of the dental treatments, for which an interruption or reduction of those treatments generates a subsequent expansion phase of a certain amount, but on the other hand, we will find ourselves in the face of a medium-term scenario (from 3 to 5 years) featured by a structural economic recession, with several economic sectors in severe crisis and a very severe impact on the employment levels of all the countries of the European area, especially those that were already structurally weak from a macroeconomic point of view.

In this regard, Key-Stone is preparing a new “post-pandemic outlook” report in which more precise forecasts will be made on the future dynamics of the market, but we can anticipate that a recovery of the 2019 value levels is estimated (even in regard to implantology – which had experienced a dramatic decline – and investments in technologies) only partially in the year 2022 and fully in the year 2023 throughout Europe.

An abnormal crisis

Previous international crises, and the 2008–2013 crisis in particular, have arisen from the collapse of the economic or financial system at the macroeconomic level, having an impact on businesses (for example, through the resulting credit crunch) and society, especially as a consequence of the resulting rise in unemployment. It is quite evident that all this has an impact on the real economy, or the purchasing power of families, creating a sharp drop in demand. All of this happened in the Western world in the 2008–2013 period. However, in the current case, it is different.

A crisis of interconnections

The economic and financial systems in Europe and the US were rather solid before the SARS-CoV-2 outbreak, being in full economic recovery and boasting positive fundamental indicators. What suddenly emerged with the pandemic was a crisis of interconnections or the impossibility of supplying and selling products and services owing to the need for physical distancing. In the lockdown phase, every country halted about 60% of its productive activity, causing an enormous economic shock, the magnitude of which is proportional to the lockdown duration. However, the origin is exogenous to the system, a sort of huge economic downturn that has struck the world.

It is precisely for this reason that, at the beginning, many economists thought that, when the external cause ceased, that is, at the end of the respective lockdowns, the economy would recover quickly. Experts call this a V-shaped recession, which is characterised by a rapid initial collapse, followed by a rapid subsequent recovery, and it was expected that the impact would have been limited as a direct consequence of the lockdown period. However, this was a rash and probably superficial evaluation because it did not take into account that the handling of the endemic phase would still have required a very long period of physical distancing, having evident consequences for the purchasing power of families and consumption.

Figure 1: Critical factors of an economic crisis

In addition to the economic and financial problems that have affected and will affect the production system, and small and medium-sized businesses, in particular, the methods of socialization have radically changed. On the one hand, we need to maintain a certain physical distance, and on the other, attitudes, behaviors, and prejudices are changing, and these will possibly result in an increase in social unrest. Given that this new way of life will partly reduce consumption owing to incapacity and production saturation, what interests us in this context is the possible transformation of the perception of dental practices and dental care by the population.

Dental practices situation

There has been clear and peremptory guidance for dental practices from competent institutes. We think that implementation of these principles, which provide for certain clinical protocols, patient management and the use of personal protective equipment, may be quite demanding in organisational and financial terms, but we believe that all practices will adopt them in order to guarantee the safety and health of their staff, collaborators and patients.

In all sincerity, we must always keep in mind that dentists have always worked in almost totally aseptic conditions. It is true that, in this case, we are dealing with pathogens that circulate by air, while dental practices have evolved to prohibit cross-contamination through blood, but the protective measures employed by dental professionals are already very high. The culture of protection and asepsis is already innate in the professionalism of workers in the dental field, and we firmly believe it will come naturally to employ more rigorous procedures.

As for patients, given that the relationship with a dentist is based on trust, we think it is very important to explain the procedures and devices adopted with available objective data while confirming the requisite behavior, focused on everyone’s safety.

Our qualitative research indicates that, when a dental expense exceeds about €1,000, it is no longer the individual choice of the patient, but enters into the basket of various family expenses. The expense is then evaluated and ranked according to other family needs, which are not always related to health. Clearly, non-urgent and higher value-added services, such as orthodontics and prosthetics, could more easily be postponed, but, according to dentists interviewed in April, treatments for aesthetic purposes will suffer above all, while those that solve functional problems may be less affected.

Given that all of this will have to be demonstrated, there is no doubt that, in a Maslowian theory, on a hypothetical scale from pain to pleasure (for socialising, a sense of belonging and esteem to others and to oneself) in the case of reduced financial possibilities or psychological resistance, therapies aimed at aesthetics will be the ones that may initially be reduced, because they are less compelling (Fig. 1).

What practice should do is learn how to sell. This is not unethical; we must put aside all the false prejudices related to semantics which could generate negative reactions. Learning how to sell signifies the greater effectiveness of transferring value in the proposal of treatments so that the patient clearly understands the importance of the treatment being proposed and fairness concerning the treatment cost. There are too many instances in which families postpone dental treatments in order to prioritize other non-health-related expenses in the hierarchy of family expenses. Even consumer credit, carried out with the support of credit institutions, is a good opportunity for encouraging access to patient care.

The paradigm of reopening

It is fundamental to accept that we will no longer be able to return to the dental profession as it was back in March. The organizational system will be different, patients will be different and certain costs will inevitably increase. If we cannot endure the acceptance of this change, this veritable rebooting of the dental profession will prove difficult.

Figure 2: The strategic path to reopening dental practices

The dental practice has three important assets:

  • its clinical expertise
  • its organization (understood as structure, technologies, group of people, processes)
  • its base of patients; ideally, all the patients treated in the last three to five years represent a referral source for a conventional practice. However, it is different for corporate dentistry, which is more oriented towards the use of marketing to attract new patients.

Nowadays, just over 75% of the turnover of a dental practice that has been open for at least five years is generated by “known” patients, that is, those who have been treated in the past and their relatives. Therefore, it is necessary to maintain and retain the great value represented by patients treated in the past.

Following this logic, there are three phases to reopening (Fig. 2):

  • resist
  • relaunch
  • redesign


The real problem with this first phase of the crisis is the lack of liquidity, which arises from the lack of revenue in the previous months and the impact of fixed costs in this period. Let us try to rationalize this situation. In Europe, dental procedures valued at more than €7 billion are performed per month. During the lockdown phase, treatments worth at least €12 billion have been suspended, not canceled, because millions of patients under treatment have been asked not to visit their dentist (according to Key-Stone surveys, the average duration of dental treatment is about 112 days, orthodontics excluded). They were undergoing treatments that must be resumed as soon as possible and in total safety. Then, millions of patients suffer oral health problems and they will have to visit a dentist in the coming months. Net of a possible reduction in spending power and patients’ increased fear of the dentist, dental treatments are not consumable; they are not meals that were not consumed in a restaurant or nights not spent in a hotel. The population will return to the dentist, but timelines and ways will change.

For a dental practice that has not collected revenue during the lockdown period and does not have variable costs (such as laboratory, materials and medical collaborators), but has had to bear fixed costs (such as rent, utilities and staff), the latter is the true problem. In addition to supporting his or her family, the owner of a dental practice has had to cover the fixed costs.

Given that social safety nets, such as the use of lay-offs, can help reduce staff costs, we suggest classifying fixed costs into three categories:

  • costs that are indispensable and for which payment cannot be postponed
  • costs for which payment can be deferred
  • non-essential costs that can be eliminated during this phase.

Costs do not include investments, which are essential for improving a practice’s effectiveness and efficiency, which will eventually play a strategic role in the coming months of recovery.

With regard to revenue, another important operation during the resistance phase is to create a prevision of the treatments, considering those suspended, those that could be fulfilled from proposals that had been made to patients and are pending a response, and new visits planned, not to mention all the patients to be re-contacted for hygiene visits and check-ups, children under orthodontic monitoring, patients for whom implants have been fabricated and who require prostheses, and so on.

A prevision must be updated every month, but allows one to know in advance, net of all variable and fixed costs, the probable financial requirements. These are requirements to be met by resorting to bank loans and/or personal assets. Non-financing during this phase of the crisis means heading towards a possible closure, an eventuality declared in 14% of the sample of dentists interviewed in recent Key-Stone research (in Italy and Spain), a percentage that rises proportionally with the increasing age of the practice owner.

In addition to securing the dental practice from a financial point of view, it is essential to guarantee safety and health security to patients and collaborators, but this will certainly become an obligation and, therefore, a prerequisite. What will make the difference is a practice’s ability to organise the workflows and processes to avoid mishaps, such as overcrowding, but also excessive downtime resulting from an excess of caution without proper planning.


Returning to the issue of the great patrimony of the practice, represented by patients treated in recent years, it is essential to look after it through an organised system of direct communication. It is very important to have a well-managed patient database, allowing segmentation of patients by age and treatments carried out, among others. It is just as essential that the management of this database complies with the requirements of the new European General Data Protection Regulation.

In this phase, it is important to maintain relationships through WhatsApp, email, videos, calls, and social networks. But what is important is the content of this communication aimed at informing patients, reassuring them about everything that is being carried out regarding their health and safety, and giving practical suggestions for oral and general health and for living a healthy lifestyle. While it is absolutely not recommended to generate communications aimed at selling services or treatments—it is not the opportune time for sales—it is the time, the opportunity, to strengthen your relationship of trust with patients. Similarly, it would be useless to produce information aimed at promoting services which, during this emergency phase, could appear anachronistic or not suited to the current priorities of the population.

Another important time is reopening. When a dental practice is ready to assist new patients, it would be opportune to communicate this and, in this case, even encourage visits. In this regard, in addition to revenue suspended during the lockdown phase, a very serious aspect to consider is that, during this period, new patients have not been acquired and new treatment plans and new treatment plan proposals have not been realized. This is a problem that will be felt in the coming months, even in this autumn season. For this reason, practices must absolutely maintain a space for the creation of new visits, although they may possibly find themselves in a crowded situation due to treatments that were left uncompleted or suspended.

Similarly, during the relaunch phase, once a practice has reopened, it becomes a priority to return to pending treatment plan proposals, for which is essential to obtain the highest possible acceptance rate. While considering possible demotivation by some patients, we suggest not soliciting responses to suspended proposed treatment plans with simple phone calls but inviting the patients to come back, to carry out a new motivational visit that serves the purpose of renewing awareness of the need and the reduction of any prejudices in order to favor the acceptance of the treatment plan.


New organizational protocols will deeply change the organizational model of the practice, and this is precisely the time to collect data and information, consider your practice’s strengths and weaknesses, and evaluate opportunities and threats. It is also time to consider what emotional, organizational, and financial resources are available and which may be necessary with the goal of structuring a virtuous business model for dentistry to come.

Asking questions about changing the competitive system, re-evaluating the positioning and pricing policy, and deciding what your practice should look like in the future are fundamental steps and must be thought through calmly, reasonably, and creatively.

The dental practice owners need to consider for reopening the following factors:

  • Treatment demand
  • Regulatory compliance
  • Personal Protective Equipment (PPE) procurement
  • Workflow organization
  • Staff: commitment, motivation, conflicts
  • Impact on timeline
  • Saturation and productive potential
  • Functional investments
  • New composition of the revenue account
  • Pricing and cost policies

We believe that the truly great problem in the coming months, or perhaps years, will not be so much that of demand for treatment, nor the purchasing power of families, but that of the objective capacity of dental practices because there is no doubt that fewer patients will be able to be accommodated within the same number of work hours.

Planning the future

In order to survive this first stage unharmed, we must start to think about 2022. While the present year is economically lost, we can use it to plan for the future. Next year will also be difficult because we will most likely still be bound by physical distancing and rigid protocols in patient management. Even the economic and social crisis may continue to have a long and clearly visible tail. However, there is a great opportunity to return to performing excellent and successful dentistry in a new competitive context and with the payback of the trusting relationship. Everyone must have his or her own vision of the future and commit to fulfilling it with confidence and trust.

We would like to offer just one suggestion: do not make hasty decisions. Use the next few months, at least until the end of the summer, to collect information, taking note of problems, flaws, and areas of improvement. Use this period as if it was a beta phase for the practice. First, we need to fully understand, then design, and then build. If we change the order of these factors, the risk of failure increases.

During this time, we have come to realize that the key is not hope but trust. The first refers to something that should come to us from the outside, while trust derives from that intimate feeling that whatever happens it will be faced in the best possible manner, for we believe in ourselves and we have used a rigorous method of strategy development.

The article has been published on Dental Tribune in Italian and English.

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