The oral health of Australian children is generally good, currently ranking 2nd among Organisation for Economic Co-operation and Development (OECD) countries. [i] Dramatic improvements occurred between the 1970s and the 1990s, but a recent trend reversal has been documented. Overall caries experience rose between 1996 and 1999 among 6-year-old children, and there has been a 21.7% increase in decay among 5-year-olds. [ii]
[i] National Advisory Committee on Oral Health 2004. Healthy Mouths Healthy Lives: Australia’s National Oral Health Plan 2004-2013
This trend continues over time and adult oral health in Australia languishes behind that of many other developed nations. Dental caries represent the most prevalent health problem among Australians, and periodontal disease is the fifth most prevalent: 90% of tooth loss may be attributed to these two factors. [i]
[i] AHMAC 2001, cited in ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’
A monitoring survey of dental health among adult public patients, published in 2004 by the Australian Institute of Health and Welfare (AIHW), showed an overall drop in oral health status since 1995. Trends varied somewhat between patients from metropolitan areas and those from rural and remote locations.
North America 980 000 Caribbean 440 000 Sub Saharan Africa 29 400 000 Western Europe 570 000 North Africa & Middle East 550 000 Latin America 1 500 000 Eastern Europe & Central Asia 1 200 000 East Asia & Pacific 1 200 000 South & South-East Asia 6 000 000 Australia & New Zealand 15 000 Adults and children estimated to be living with HIV/AIDS, end 2002 Total: 42 million
North America 45 000 Caribbean 60 000 Latin America 150 000 Western Europe 30 000 North Africa & Middle East 83 000 Sub Saharan Africa 3 500 000 Eastern Europe & Central Asia 250 000 East Asia & Pacific 270 000 South & South-East Asia 700 000 Australia & New Zealand 500 Total: 5 million Estimated number of adults and children newly infected with HIV during 2002
Estimated adult and child deaths due HIV/AIDS during 2002 North America 15 000 Caribbean 42 000 Latin America 60 000 Western Europe 8 000 North Africa & Middle East 37 000 Sub Saharan Africa 2 400 000 Eastern Europe & Central Asia 25 000 East Asia & Pacific 45 000 South & South-East Asia 440 000 Australia & New Zealand < 100 Total: 3.1 million Total: 3.1 million
There are many studies to prove the link, for example, that periodontal disease is linked to cardiovascular illness. Stroke is more likely to occur with elevated levels of the periodontal pathogens Actinobacillus actinomycetemcomitans or Porphyromonas gingivalis . [i] Periodontal disease and tooth loss are linked to coronary heart disease (CHD) [ ii ] and there is specific evidence of an association between periodontitis and heart attack, even after adjusting for well-known risk factors. [ iii ]
[i] Pussinen et al, Stroke. 2004;35:2020-3
[ii] Elter et al, J Periodontol 2004;75:782-90
[iii] Cueto et al, J Periodontal Res. 2005;40:36-42
There is some evidence that effective dental treatment of individuals with Coronary Heart Disease may result in reductions in levels of inflammatory markers (such as C-reactive protein) and haemostatic factors (such as oxidised low density lipoprotein), providing protection against future deterioration in heart health. [i]
[i] Montebugnoli et al, J Clin Periodontol. 2005;32:188-92
Dental services are, however, almost entirely removed from medical services in Australia and many other parts of the world. Funding is provided separately, and there is a strong history of the Commonwealth Government deeming dental health to be a State/Territory issue. (This is despite the Commonwealth having the same constitutional powers [S. 51, xxiiiA] to fund dental services as it has for medical services.) There may also be an impression that, while medical services should at least in part be provided by Government, dental services are a matter for personal attention.
The Commonwealth Dental Health Program (CDHP) was introduced in January 1994 to improve access and reduce waiting times for public dental services by subsidising patients with concession cards to see private dentists for restorative dental treatment (denture services were not covered). The Commonwealth Dental Health Program drastically reduced waiting times for public dental patients. The Coalition Government discontinued funding for the CDHP at the end of 1996 and responsibility for funding the bulk of public dental services therefore passed to the State and Territory Governments.
The Commonwealth Government’s proportional share of dental expenditure fell from 2.22% in 1992/93 to 1.78% in 2002/03. Indirect Commonwealth expenditure, through the 30% private health insurance rebate, was $298 million in 2002/03, representing 6.81% of total dental expenditure. The number of dental benefits has increased since the introduction of this rebate in 1999 from 14.4 million to 22.7 million in 2004. Costs of private health insurance are growing as a result, however, and benefits are reportedly not keeping up with dental care costs. [i]
[i] Private Health Insurance Administration Council 2005. Cited in ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’
State/Territory and Local Governments spent $342 million on dental services in 2002/03, representing 7.82% of total expenditure ($32 million less than in 1999/2000, when this funding represented 12.94% of total dental expenditure). This expenditure includes payments for public and school dental services.
Over 15.5% of total dental spending was attributed to private health insurance funds in 2002/03, which is half the proportion of funds spent a decade earlier.
Direct out-of-pocket expenses account for the remaining expenditure on dental services. This has risen from $984 million and 57.6% in 1992/93 to $2.96 billion and 67.3% of total expenditure in 2002/03.
The Commonwealth Government contributes a relatively small amount to the provision of dental care (see Figure 3). However, it continues to fund dental care for specific populations, such as the Department of Veterans’ Affairs, Department of Defence, inpatient dental care and outpatient radiological dental services (through Medicare). [i]
[i] ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’
It also provides some indirect funding for dental services through the Aboriginal Health Council. Planned changes to Medicare include the provision of limited subsidised dental care for the first time for referred patients with chronic health conditions that are exacerbated by poor oral health. Up to 23,000 people may be treated over four years.
All States and Territories fund the vast majority of public dental services, but spending varies significantly. According to the AIHW, in 2001/02 Queensland had the greatest expenditure ($111,000,000) and NT and ACT the least ($7,000,000). Per capita dental expenditure was greatest in NT ($35.23) and least in NSW ($11.76). Per concession card holder spend was also greatest in NT ($160.16) and least in NSW ($50.40).
Dental expenditure based on 2001/02 figures [i] [ i] AIHW ‘Health Expenditure Australia’. Cited in ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’
Although supply of dentists in regional/remote areas is substantially lower than for major city areas, this does not automatically mean that people living in these areas access dental services less. Access to services may depend on car ownership, road conditions, and socio-economic issues. Although unmet demand and equity of access should be examined, lower rates of supply in rural and remote areas will indicate lower access. (See Teusner [i] ).
While waiting times in the public sector for emergency dental care are short throughout the country, waiting times for general dental care can be extensive (estimated to be between 10 and 54 months in 2000). [i]
In the next ten years (10), 30% of the population will be over 60 years of age.
A greater proportion of these people will have natural teeth.
The destiny of our demography: from pyramid to … coffin?
[Chairman Gary Banks, Productivity Commission , Policy Implications of an Ageing Australia: an illustrative guide ( http://www.pc.gov.au/speeches/cs20050927/index.html ) - presentation to the Financial Review Ageing Population Summit, held in Sydney on 27 September 2005]
These people will need, want and demand oral health care
Quality of life
Demand may not address inequality
Role of technology
(Steele, J. 2005 Old is the New Young: A Changing world and research priorities , Paper at IADR Conference, 25-28 September, Queenstown, New Zealand)
Poverty Housing Sanitation Leisure Facilities Shopping Facilities Employment Work/educational environment Income Policy - International - National - Local Commercial Advertising Social norms Peer Groups Social Capital Cultural Identity Social networks Self esteem Diet Hygiene Smoking Alcohol Injury Service Sex Age Genes Biology Economic, Political & Environmental Conditions Social & Community Context Oral Health Related Behaviour Individual Oral Health Determinants of oral health
in terms of dental workforce numbers. [i] It is difficult to
project whether the rise will be sustained into the longer-term although there is no doubt that the number of dentists is low by historic levels. Numbers of dental graduates have fallen by one-third since the 1970s. [ii]
[i] Teusner, Spencer 2003. AIHW DSRU.
[ii] National Advisory Committee on Oral Health 2004. Healthy Mouths Healthy Lives: Australia’s National Oral Health Plan 2004-2013
Significantly fewer dentists operate in rural compared to metropolitan areas (see Figure 6). Taking Australia as a whole, a comparison by the AIHW between rates of dentists practising in rural and metropolitan areas showed there are 55.7 dentists per 100,000 population in metropolitan areas and only 31.4 in rural areas in 2000. [i] In addition, rural dentists see more patients than their counterparts in the city. [ ii ]
[i] Teusner, Spencer 2003. AIHW DSRU.
[ii] Barnard, White. Australian Dental Association News Bulletin 1999;266:13-21
At the same time, the cost of studying dentistry is rising. [i] Currently, around 250 dentists qualify each year, but Spencer et al project that, in order to meet rising demand, an additional 120 dental graduates per year are needed across the country. [ ii ] Only 70 more Bachelor Degrees in Oral Health (for dentists, dental therapists and oral hygienists) have been funded by the Commonwealth Government from 2005.
[i] ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’
[ii] Spencer et al. The dental labour force in Australia: the position and policy directions. AIHW Population Oral Health series No.2
Suggestions for Workforce Changes to Promote Oral Health
Health Maintenance Organisation type services
Australian Health Management Group with 3 dental practices in Sydney, Parramatta and Wagga Wagga
$60 for risk assessment and lifestyle advice
Reintroduce a Commonwealth Programme
Integration of Geriatric Oral Health into the General Health System Dooland, M. 2005 Integration of Geriatric Oral Health into the General Health System, Paper at IADR Conference, 25-28 September, Queenstown, New Zealand.
This course aims to provide the knowledge base, instil attitudes, and develop skills in research, practical health promotion and in preventative dentistry on a community level.
It seeks to provide a balanced education in these branches of the health sciences whereby students appreciate the primacy of lifestyle and environment in determining population and community health, understand the many common risk factors for oral and general diseases and the importance of primary prevention in achieving both individual and population health
In concert with the community focus of the Griffith University “mission”, this course provides a valuable counterbalance to the intensely interventionist, individual patient-focused components of much of modern dentistry
At the end of Year 1, within the component included in Introduction to
Clinical Oral Health Practice, students will be able to:
Understand basic epidemiological principles
Quantify the roles of common risk factors for oral and general diseases
Know methods and indices for describing the common oral diseases, dental caries and the periodontal diseases, and describe variations in their severity and extent in different populations within Australia and the world
Identify local and regional populations and communities with significant health needs which might be targeted for future community research placements
During Years 4 and 5, within the Community Research Placement 3 & 4 components of the Graduate Diploma in Dentistry, students working in groups of 6-8 will have revisited their communities from the previous years on at least two occasions and:
Refined and extended their epidemiological surveys of oral health
Extended the proportion of the population to which preventive oral health interventions have been applied
Made a contribution, under supervision, to emergency dental interventions and pain relief in their community
Carried out, under supervision, a range of dental treatments for patients in the community
Written a detailed policy for promotion and maintenance of oral and general health for the future of their community
Prepared information derived from their 4 or 5 years experience with their particular community for publication in the international refereed literature
Poor oral health is associated with significant costs in human and economic terms. Yet the main dental problems facing Australians are easily preventable. It is vital that the scale of the problem of dental and gum disease be recognised. The oral health workforce must be expanded and trained to promote oral health in order to reverse the trend in deteriorating oral health and ensure equality of care across the country.
Reference National Rural Health Alliance 2005 Public Dental Services in the States and Territories of Australia , public draft, http://www.ruralhealth.org.au/nrhapublic/