Economic burden and economic impact of oral diseases in India: a protocol for a systematic review

Abstract

Introduction

Oral diseases are a major contributor to global disability but remain largely neglected in health policy, especially in low- and middle-income countries. India carries a disproportionately high burden of dental caries and periodontal disease, with limited access to oral healthcare and high reliance on out-of-pocket expenditure (OOPE). Despite this, there is a lack of synthesised economic evidence specific to India, which limits informed policymaking and resource allocation. This systematic review aims to assess the economic burden and financial impact of oral diseases in India—at individual, household, health system and societal levels—focusing on direct and indirect costs, including OOPE and catastrophic health expenditure (CHE).

Methods and analysis

This review will follow the JBI methodology for economic evaluation evidence and adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. A three-step search strategy will be used to identify relevant studies from databases, including MEDLINE (Ovid), Embase, Scopus, CINAHL (Ovid), Dentistry and Oral Sciences Source (EBSCO) and Cochrane CENTRAL, as well as grey literature sources.

We will include studies conducted in India that report on the economic burden or financial impact of oral diseases at the individual, household or population level. Eligible designs include cost-of-illness studies, cost analysis, cost-outcome analysis and health expenditure analysis using cross-sectional (including repeated cross-sectional) or cohort designs, as well as analyses based on secondary datasets. Studies using econometric, statistical or modelling methods, with or without comparators, will be included. Mixed-methods studies will be eligible if they provide extractable quantitative data.

Two reviewers will independently screen and appraise studies using JBI critical appraisal tools suited to each study design. Data extraction will focus on direct and indirect costs, including OOPE and financial impacts, such as CHE, hardship financing and poverty effects. Findings will be presented narratively and, where feasible, pooled in a meta-analysis using MetaXL V.5 software.

Ethics and dissemination

This review does not involve the collection or analysis of individual patient data. Instead, it will use data from publicly available economic research studies. All data sources will be appropriately cited. Extracted data will be systematically curated and managed using version-controlled spreadsheets and reference software. As this is a secondary analysis of published literature, ethical approval is not required. Findings will be disseminated through peer-reviewed publications and scientific presentations, as well as shared with policymakers and community health organisations via policy briefs and stakeholder outreach.

PROSPERO registration number

CRD420251030651.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This systematic review aims to fill gaps in the literature by providing a comprehensive synthesis of the economic burden of oral diseases in India, using standardised cost estimates and exploring key variations by region, gender and oral disease type.

• Our methodology will follow JBI’s systematic review guidelines, including a risk-of-bias assessment, and adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

• We will conduct a meta-analysis using random-effects models, with the latest guidelines and inflation adjustments to ensure accurate cost estimations.

• Our study will pool data from existing studies, but limitations may arise due to inconsistent reporting of cost data, varying definitions of economic metrics and differences in the scope of costs included (eg, direct vs indirect costs).

Introduction

Oral health is integral to overall health and well-being, yet it remains a neglected area of global health priorities.¹ As per the Global Burden of Disease 2019 report, oral disorders affect over 44.5% of the world’s population and are among the leading contributors to disability-adjusted life years (DALYs) worldwide.² This translates to approximately 3.5 billion people suffering from oral diseases, such as dental caries, periodontal disease, oral cancer and edentulism.³ The burden is particularly pronounced in Southeast Asia, where high population density and unique healthcare challenges exacerbate the problem. India, in particular, bears a substantial share of this burden, accounting for nearly 18% of the global cases of caries in permanent and deciduous teeth and over 20% of severe periodontal disease cases.⁴

India’s significant contribution to the global oral health burden is mainly due to systemic issues, such as limited access to quality oral healthcare, inadequate health insurance coverage and insufficient budgetary allocation for oral health programmes.⁵ Financial barriers play a crucial role, as the lack of comprehensive health insurance often forces patients to rely on out-of-pocket expenditures (OOPEs) for public and private dental care.⁶ In India, dental health insurance is still developing, with only a few insurers offering coverage.⁷ Some government schemes reimburse dental treatment costs, but these are limited to government employees and those below the poverty line (PL).⁷ To improve access to comprehensive primary healthcare under Ayushman Bharat, oral health has been included under non-communicable diseases. However, only a limited number of tertiary dental treatments are covered under the specialty package.⁸ Additionally, oral health resources are scarce, and the absence of a dedicated budget for oral health programmes results in limited prioritisation and ineffective policy interventions to address the growing burden.⁹

OOPE constitutes 58.7% of India’s national health expenditure, often leading to catastrophic financial consequences or impoverishment. This heavy reliance on OOPE disproportionately impacts low-income populations, deepening income inequality and trapping many in a cycle of medical poverty.¹⁰ The proportion of OOPE allocated to non-medical expenses, such as travel and accommodation, has also increased—from 7% to 17% over the past two decades. As of 2015, the per capita expenditure on dental diseases in India was USD$0.14, while the estimated productivity loss per capita due to dental diseases amounted to USD$1.8.¹¹

Despite the high burden, economic evidence related to oral health in India remains fragmented and underexplored.¹² While global research increasingly quantifies the financial impact of oral diseases, estimates specific to India have not been systematically compiled. This lack of context-specific data limits the ability of policymakers to prioritise oral health in national planning and budget allocation. Standard economic metrics are inconsistently applied or reported in existing studies, highlighting a need for more robust, India-specific research. Although several studies^{13 14} have examined OOPE and its financial impact on dental care in India, these are isolated in scope and methodology. An initial search confirmed the existence of such studies; however, no pooled data or comprehensive synthesis brings together these findings to offer nationally relevant insights, highlighting a clear gap in consolidated evidence.

A preliminary search of the International Prospective Register of Systematic Reviews (PROSPERO), MEDLINE (Ovid), Epistemonikos, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted, and no current or in-progress systematic reviews on the topic were identified. Considering this evidence vacuum, a systematic synthesis is needed to estimate the direct and indirect economic costs, OOPE and the financial impact of oral diseases at the individual, household and health system levels in India. Such insights are essential for designing targeted, equitable and cost-effective oral health financing and policy strategies. The findings may also inform the development of a comprehensive oral health policy framework and support the integration of oral health into India’s Universal Health Coverage agenda by promoting financial protection and equitable access. The synthesis will also support strategic allocation of resources and elevate the priority of dental care within public health planning. The objective of this review is to identify the economic impact of oral diseases on individuals, households and the healthcare system in India.

Our review questions include: (1) what is the economic burden of oral diseases in India, including direct costs, indirect costs and OOPEs? and (2) what is the financial impact of oral diseases on costs and expenditures for individuals, households and the healthcare system in India?

Methods and analysis

As of July 2025, the systematic review is in the critical appraisal phase. The research team has completed all prior stages, including the development of a comprehensive search strategy, database searches, title and abstract screening and full-text review using predefined inclusion and exclusion criteria. Full-text screening has been completed with consensus from multiple reviewers.

The team is currently appraising the methodological quality of included studies using appropriate JBI critical appraisal tools, which will be followed by data extraction. The synthesis of extracted data will begin on completion of this phase. The review is progressing in accordance with the planned timeline, with finalisation targeted for September 2025. The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of economic evidence.¹⁵ The reporting of this review will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA)-2020 guidelines to promote transparency and reproducibility.^{16 17} The review protocol has been prospectively registered with PROSPERO under the registration number CRD420251030651. Any deviations or amendments to the original protocol will be documented in the final published review.

Patient and public involvement

Patients and the public will not be involved in the design, conduct, reporting or dissemination plans of this research.

Inclusion criteria

Population

The review will include studies focusing on individuals, households and population-level data on oral diseases in India. This includes:

• Individuals: any person regardless of age, gender, socioeconomic status (SES) or demographic group, whether they seek oral healthcare services.

• Household data: studies examining the economic burden or impact of oral diseases at the household level, such as OOPE, financial strain or catastrophic health expenditure (CHE).

• National-level data: studies providing aggregated economic data on oral diseases, including healthcare resource utilisation, national cost estimates or the economic implications for India’s healthcare system.

Outcomes

1. Economic burden: direct and indirect expenses, at the individual, household or population level, will be measured.

   1. Direct costs: include all the medical and non-medical OOPE related to the diagnosis, treatment and management of oral diseases. Medical expenses will include the cost of consultations with healthcare professionals, diagnostic tests, medications, surgeries and dental procedures. These expenses may arise from both in-patient and outpatient care settings. Non-medical expenses will include transportation to and from healthcare facilities, accommodation, food and other expenses for both caregivers and the patient.

   2. Indirect costs: these costs will include productivity losses by the patients and caregivers due to missed workdays (absenteeism) caused by illness or treatment, as well as reduced productivity while at work (presenteeism) because of oral conditions. Indirect costs will also consider the burden of oral disease measured in DALYs.

2. Financial impact: the effect of oral diseases on individuals, households and the healthcare system, such as CHE and financial hardship, will be measured.

   1. CHE: the proportion of households experiencing CHE due to oral diseases will be assessed. CHE occurs when the total cost of oral diseases exceeds a specific threshold of the household’s annual income. Household income will be calculated as the sum of prepayment income from salaries and all other sources for all household members.¹⁸

   2. Financial hardship: we will evaluate the broader economic challenges faced by individuals and households, including financial strain and the long-term implications of oral healthcare costs on their economic stability. This includes instances where oral healthcare costs force individuals or households to depend on informal strategies, such as borrowing or selling assets, to manage treatment expenses. Hardship financing refers to situations in which a household must borrow money with interest or sell property/assets to meet its healthcare expenses.^{19 20}

   3. Poverty impact: the impact of OOPE on poverty will be assessed by determining the proportion of households whose net total expenditure, after accounting for OOPE, falls below the PL. The PL will be based on the most recent available data, such as the latest recommendations from official sources, including government reports or committees.²¹ Households with expenditures below the PL due to OOPE will be quantified using the poverty headcount ratio. The poverty gap will be calculated to measure the extent to which the expenditures of households falling below the PL deviate from it. All expenditures will be adjusted to the most recent inflation-adjusted prices using the consumer price index, including the PL thresholds.¹⁸

Context

The present study/review is conducted within the Indian context, focusing on data derived from studies based on the Indian population. Where appropriate, national-level secondary data and statistics from government datasets or Health Management Information System22,27 will also be incorporated to provide a broader epidemiological and demographic perspective.

Types of studies

Both randomised and non-randomised study types will be included. This review will include quantitative and mixed-methods studies that report on the economic burden or financial impact of oral diseases in India. Eligible study designs comprise cost-of-illness studies, which provide detailed estimates of direct and indirect costs, and cross-sectional studies that present relevant economic data, including household expenditure and healthcare utilisation. Longitudinal or cohort studies that capture changes in economic and/or financial outcomes over time, as well as modelling studies estimating national-level costs or productivity losses, will also be considered. Secondary data analyses using administrative or national health databases are eligible if they present cost-related outcomes. Mixed-methods studies will be included only if they contain extractable quantitative economic data. All included studies must present data specific to the Indian context and involve populations affected by oral disease, including oral cancer.

Search strategy

A limited search of MEDLINE (Ovid) and Embase was performed to identify articles on the topic. The text words in titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a complete search strategy for MEDLINE (Ovid) (see online supplemental file 1). The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference lists of all included sources of evidence will be screened for additional studies. No language restrictions will be applied. Non-English articles will be considered, and DeepL will be used for translation where needed; however, translation validation will not be performed due to resource and time constraints. No date restrictions will be applied, and the search will include all relevant studies published up to the most recent search date.

The databases to be searched include MEDLINE (Ovid), Scopus, Embase, Dentistry and Oral Sciences Source (DOSS), CINAHL (Ovid), Web of Science Core Collection and Cochrane CENTRAL. Unpublished studies and grey literature will be located from ProQuest Dissertations, OAIster and Google Scholar (first 20 pages). In addition to bibliographic databases, relevant economic and health expenditure data sources will be consulted with health economists to supplement the analysis. These include publicly available datasets and statistical reports from the National Sample Survey Organisation (NSSO), National Health Accounts, WHO Global Health Expenditure Database, World Bank Open Data and Institute for Health Metrics and Evaluation.22,27 These sources will be used to support currency conversions, inflation adjustments and contextual interpretation of economic findings. To capture potentially relevant Indian literature, we will also conduct hand-searching of selected Indian journals. Hand-searching will cover all available issues up to the most recent issue at the time of the search, with no date restrictions applied. A detailed list of these sources is provided in table 1.

Table 1. Key data sources for economic burden of oral diseases in India.

Source	Relevant data provided	Website
National Sample Survey Organisation (NSSO)/ National Statistics Office (NSO)22	Household-level surveys on health (eg, 75th round), including OOPE, healthcare access, SES and CHE.	http://mospi.gov.in
National Health Accounts (NHA) ((Ministry of Health and Family Welfare (MoHFW) and National Health System Resource Centre (NHSRC))23	National and state-level data on health expenditure by financing source (Govt, household and insurance), including dental care in some categories.	https://nhsrcindia.org and https://main.mohfw.gov.in
Indiastat (subscription-based)24	Aggregated state and national-level statistics on health spending, dental health indicators and poverty.	https://www.indiastat.com
WHO Global Health Expenditure Database (GHED)25	National-level health expenditure by function and financing scheme; may help for general health context and triangulation.	https://apps.who.int/nha/database
Institute for Health Metrics Evaluation (Global Burden of Disease (GBD) Study)27	Burden of oral diseases (Disability Adjusted Life Year (DALY)s and Years Lost to Disability (YLD)s), oral disease prevalence and health loss—useful for linking economic impact to disease burden.	https://www.healthdata.org/gbd
World Bank Open Data (India)26	National-level data on health financing indicators, poverty incidence and PPP-adjusted income—useful for contextualising CHE or economic thresholds.	https://data.worldbank.org/country/india
Indian Journal of Dental Research (IJDR)	Original research on oral health epidemiology, healthcare utilisation and costs in India.	https://journals.lww.com/ijdr/pages/default.aspx
Journal of Indian Association of Public Health Dentistry (JIAPHD)	Public health dentistry studies, oral health programmes and occasionally OOPE-related data.	https://journals.lww.com/APHD/Pages/default.aspx
Indian Journal of Public Health (IJPH)	Articles on healthcare financing, OOPE and access to services.	https://journals.lww.com/IJPH/pages/default.aspx
Indian Journal of Medical Research (IJMR)	Cross-disciplinary studies, including health systems research and oral-systemic conditions.	https://ijmr.org.in/
Journal of Health Management (JHM)	Research on health economics, health policy and healthcare systems in India.	https://journals.sagepub.com/home/jhm

CHE, catastrophic health expenditure; OOPE, out-of-pocket expenditure; PPP, purchasing power parity; SES, socioeconomic status.

Study selection

The search results will be compiled and uploaded into Zotero V.5.0.60 (Corporation for Digital Scholarship and Roy Rosenzweig Centre for History and New Media, Virginia, USA), and duplicates will be removed. Following a pilot test, titles and abstracts will be screened by two or more independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full, and their citation details will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (JBI, Adelaide, Australia).²⁸ Two or more independent reviewers (VK and AR) will thoroughly assess the full text of selected citations against the inclusion criteria. The systematic review will record and report the reasons for excluding full-text papers that do not meet the inclusion criteria. Any disagreements that arise between reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer(s) (DJ/CJ). The search results and the study inclusion process will be reported in full in the final systematic review and presented in a PRISMA flow diagram.¹⁶

Critical appraisal

The methodological quality of all included studies will be assessed using the JBI critical appraisal tools, selected based on the specific study design. The JBI Checklist for Economic Evaluations will assess the transparency and validity of cost estimations and financial modelling for cost-of-illness studies and economic evaluations.²⁹ Cross-sectional studies presenting economic data will be appraised using the JBI Checklist for Analytical Cross-Sectional Studies, with a focus on the clarity of inclusion criteria, measurement of outcomes and control of confounding factors.³⁰ Longitudinal and cohort studies will be assessed using the JBI Checklist for Cohort Studies, which evaluates participant selection, follow-up and statistical analysis.³⁰ Modelling studies, based on secondary data or simulations, will be critically appraised using relevant elements from the Checklist for Economic Evaluations in conjunction with methodological notes adapted for model transparency and assumptions.³¹ Studies using secondary data analysis will be assessed using the appropriate checklist matching the original study design (eg, cohort or cross-sectional), depending on how the data were analysed and reported. For mixed-methods studies, only the quantitative component relevant to cost or economic impact will be appraised using the corresponding JBI checklist for the embedded design. All critical appraisals will be conducted independently by at least two reviewers (VK and AR), with disagreements resolved through discussion or consultation with a third reviewer (DJ/CJ). Studies will not be excluded solely based on methodological quality; however, the critical appraisal results will inform the interpretation of findings and the confidence in the overall evidence.

Data extraction

Two reviewers (VK and AR) will independently extract data into a modified data extraction form (using economic evaluation guidance from JBI SUMARI; table 2). For each included study, the data extracted will include specific details about the populations, gender, location, study design, age, sex, year of publication, costs of interventions, direct medical, direct non-medical and indirect costs, OOPE, CHE, hardship financing, distress financing, impoverishment and any other relevant characteristics reported in the study. If multiple publications of the same research are identified (eg, a conference abstract and a full paper), then the most recent publication with comprehensive data on the most significant sample will be included in the review. Authors of papers will be contacted via email in the event of missing or incomplete data, and two reminders will be sent. Any disagreements between the two reviewers will be resolved through discussion or, if necessary, with a third reviewer (DJ/CJ).

Table 2. Data extraction instrument.

Category	Details to be extracted
Study details	Author(s). Year of publication. Country and setting. Study design. Data collection source (eg, survey and administrative database).
Population characteristics	Age range or mean age. Gender distribution. SES (eg, income, education and occupation). Special population groups (if any).
Health condition	Type of dental/oral condition (eg, caries, periodontal disease, oral cancer or edentulism).
Type of economic evaluation	Cost-of-illness, cost-effectiveness, cost-utility, cost-benefit or hybrid. Perspective used (eg, individual, household and societal).
Level of data reporting	Individual-level. Household-level. National-level.
Cost components	Direct costs: Medical (treatment, diagnostics and drugs). Non-medical (travel, lodging and caregiving). Indirect costs: Productivity losses. Time costs. OOPE: Total individual/household spending. CHE: Definition/threshold used. Percentage of households affected. Distress financing: Definition used. Percentage of households affected. Hardship financing: Definition used. Percentage of households affected. Poverty impact: Definition used. Percentage of households affected.
Currency and costing year	Original currency. Year of cost data collection. Inflation adjustments. PPP conversions (if any).
Key findings and cost drivers	Main cost outcomes. Significant cost drivers (eg, treatment type, disease severity and access).
Comments/notes	Methodological notes. Contextual information. Limitations. Data gaps or missing values.

CHE, catastrophic health expenditure; OOPE, out-of-pocket expenditure; PPP, purchasing power parity; SES, socioeconomic status.

Data synthesis

Data from included studies will be synthesised using qualitative and quantitative approaches, depending on the nature and availability of the data. A narrative synthesis will be conducted for studies reporting heterogeneous or context-specific outcomes that cannot be statistically pooled. This will involve grouping studies based on key outcomes, such as direct costs, indirect costs, OOPE, financial strain and healthcare utilisation. For comparison across studies, all costs will be converted into a single currency (USD) and reference year (2023) using the Campbell and Cochrane Economics Methods Group and the Evidence for Policy and Practice Information cost calculator.³² Studies will also be categorised by population level (individual, household or national) and disease type (eg, dental caries, periodontal diseases or oral cancer). The synthesis will describe ranges, averages, cost drivers and relevant contextual factors, and present results in summary tables and figures.

If sufficient homogeneous data are available (for resource utilisation outcomes, such as healthcare visits, hospitalisations or time lost from work), a quantitative synthesis will be conducted using a random-effects model to account for between-study variability. Heterogeneity will be assessed using the I² statistic, and subgroup analyses will be performed to explore sources of variation, such as state/region, sex and oral disease type. Subgroup analyses will also consider SES where data permits, given its influence on OOPE and financial hardship related to oral diseases. If quantitative pooling is not feasible, descriptive statistics will be used to summarise the findings, with results presented in narrative form and supported by tables and figures, as appropriate. Statistical analyses will be conducted using MetaXL V.5 software (EpiGear International, Australia), an add-in for meta-analysis in Microsoft Excel for Windows (Redmond, Washington, USA).^{33 34}

Ethics and dissemination

This review does not involve the collection or analysis of individual patient data. Instead, it will use data from publicly available economic research studies. All data sources will be appropriately cited. Extracted data will be systematically curated and managed using version-controlled spreadsheets and reference software. As this is a secondary analysis of published literature, ethical approval is not required. Findings will be disseminated through peer-reviewed publications and scientific presentations and will be shared with policymakers and community health organisations via policy briefs and stakeholder outreach.