UNIVERSITY OF TASMANIA
University Department of Rural Health
The changing oral
health situation in
Australia: Will
Australia move
towards primary oral
health care?
Dr Len Crocombe
Centre for Research Excellence in
Primary Oral Health Care
Primary health care
Primary health care is essential health care
based on practical, scientifically sound and
socially acceptable methods and
technology made universally accessible to
individuals and families in the community
through their full participation and at a cost
that the community and the country can
afford to maintain at every stage of their
development in the spirit of self-reliance
and self-determination.
WHO 1978
Primary oral health care
Primary oral health care is essential oral
health care based on practical, scientifically
sound and socially acceptable methods and
technology made universally accessible to
individuals and families in the community
through their full participation and at a cost
that the community and the country can
afford to maintain at every stage of their
development in the spirit of self-reliance
and self-determination.
Overview
•
•
•
•
•
Where are we now?
How did it come to this?
Where are we heading?
Commonwealth Government policies
Does our CRE have a role?
Where are we now?
• Avoidance of food due to dental problems
(AIHW 2008)
• Restricted activity and days of work lost
(Reisine 1984; Sternbach 1986; Spencer & Lewis 1988; Gift & Redford 1992)
• Dental caries - second most costly diet
related disease in Australia
(AHMAC 2001)
Where are we now?
• Periodontal (gum) disease
• 1+ tooth, untreated decay
• 1+ tooth extracted due to decay
%
19.0
25.5
61.0
(AIHW 2008)
Where are we now?
• Expenditure on dentistry in Australia
was 7.7b in 2009-10 (AIHW, 2012).
Where are we now?
Those missing out on primary oral health care:
• frail and older people (Chalmers 2002)
• rural residents (Crocombe et al. 2010)
• Indigenous Australians (Slack-Smith 2011)
• Australians with physical and intellectual
disabilities (Pradhan et al. 2009)
• People of low socio-economic status (Sanders et al.
2006)
Where are we now?
Expenditure:
Coverage of health care expenses (2004/05) (all insurance):
• Hospitals
98.4
• Medical
89.1
• Pharmaceutical
54.5
• Dental
33.3
Social cover of dental expenses:
Commonwealth government
State government
Private Health Insurance
Total
9.1 (via PHI)
9.7
14.2
33.0
(AIHW Health Expenditure Bulletin)
Where are we now?
• 85% of dental care is provided in the private
sector
• male dominated
• dominated by baby boomers
• vast majority of clinicians are dentists as
opposed to dental hygienists, dental
therapists or oral health therapists
(Balasubramanian & Teusner, 2011)
Where are we now?
Where are we now?
Where are we now?
Where are we now?
• Planning is currently happening on an ad
hoc basis
(AJ Spencer, 2007)
How did this come about?
“the body is nothing else
than a statue or machine”
René Descartes. Portrait by Frans Hals, 1648.
How did this come about?
• Lay perceptions of health among Canadians
– oral conditions should not constitute a
justification for exemption from work
– oral conditions not regarded as illnesses
because they do not conform with the "sick
role“
(Gerson, 1972)
• Perceptions of health in UK population
– not recognized or accepted as ill health
(Dunnell & Cartwright, 1972)
How did this come about?
•
•
•
•
4th – 7th Century: Northern India
Venice monopoly
Lisbon, Portugal
White Gold
Lisbon, Portugal
Venice, Italy
How did this come about?
Harvesting Sugar Cane 1870
How did this come about?
Audubon Park Laboratory 1894
How did this come about?
20th Century:
• Reduced sugar prices
• Increased sugar consumption (Porter, 1997)
• Massive increase in tooth decay
• More dentists needed
Where are we heading?
Teeth potentially in need of treatment
8
Number of teeth (millions)
7
2019
6
5
2009
4
3
65+ total no. teeth Rx (millions)
1989
1.8
1999
2.9
2009
4.3
2019
7.0
2
1
1999
1989
0
5–14
15–24
25–34
35–44
Age group
45–54
55–64
65+
Where are we heading?
• Mix of services per year by dentists is
shifting:
- more diagnostic, preventive, root fillings
and crown & bridge
- less restorative, denture and extraction
services
- increased use of dental services by adults
Brennan, 2000
Where are we heading?
Department of Education, Employment and Workplace Relations, 2012
Where are we heading?
The make-up of dental graduates is changing:
– Feminisation
– Cultural background (Burgess , Crocombe et al. 2009).
– X & Y Generation outlook
– Allied dental practitioners
(Balasubramanian & Teusner, 2011).
Where are we heading?
The make-up of dental graduates is changing:
– Feminisation
– Cultural background (Burgess , Crocombe et al. 2009).
– X & Y Generation outlook
– Allied dental practitioners
(Balasubramanian & Teusner, 2011).
Government Policies
“Dental is a State issue”
“51 The Parliament shall, subject to this
Constitution, have power to make laws for the
peace, order, and good government of the
Commonwealth with respect to…..:
(xxiiiA) endowment, unemployment, pharmaceutical,
sickness and hospital benefits, medical and dental services
(but not so as to authorize any form of civil conscription),
benefits to students and family allowances…”
Government Policies
Chronic Disease Dental Scheme
-
“Health measure not dental measure”
Chronic medical condition
Complex care needs
Oral health must be impacting on, or likely to
impact on, general health
Government Policies
Chronic Disease Dental Scheme
Government Policies
Medicare Teen Dental Plan
• Cost of an annual preventative dental check
for teenagers who:
– are aged between 12 to 17 years
– receive (or their family receives) certain
government benefits
– are eligible for Medicare
Government Policies
• National Advisory Council on Dental Health:
- an individual universal capped dental benefit
entitlement for children
- a means-tested individual capped dental benefit
entitlement for adults
- measures targeting specific at-risk groups,
which would be expanded over time to include
the broader population
NACDH, 2012
Government Policies
Minister’s response:
- a dental scheme that targeted the
financially disadvantaged.
- addressed workforce and
infrastructure constraints.
- did not duplicate existing state dental services.
- was fiscally responsible.
Plibersek, Press release 27 Feb 2012
Government Policies
The 2012 Federal Budget:
• $515.3 million, over four years, for dental health.
• $10.5 million for oral health promotion and to develop
a National Oral Health Promotion Plan
• $35.7 million for an expansion of the Voluntary Dental
Graduate Year Program
• $45.2 million for a Graduate Year Program for Oral
Health Therapists
• $77.7 million for a Rural and Remote Infrastructure
and Relocation Grants for Dentists
• $450,000 to a NGO to coordinate further pro-bono
work by dentists.
Government Policies
The 2012 Federal Budget:
– $515.3 million, over four years, for dental health.
– $10.5 million for oral health promotion and to
develop a National Oral Health Promotion Plan
– $35.7 million for an expansion of the Voluntary
Dental Graduate Year Program
– $45.2 million for a Graduate Year Program for Oral
Health Therapists
– $77.7 million for a Rural and Remote Infrastructure
and Relocation Grants for Dentists
– $450,000 to a NGO to coordinate further pro-bono
work by dentists.
Government Policies
The 2012 Federal Budget:
– $515.3 million, over four years, for dental health.
– $10.5 million for oral health promotion and to
develop a National Oral Health Promotion Plan
– $35.7 million for an expansion of the Voluntary
Dental Graduate Year Program
– $45.2 million for a Graduate Year Program for Oral
Health Therapists
– $77.7 million for a Rural and Remote Infrastructure
and Relocation Grants for Dentists
– $450,000 to a NGO to coordinate further pro-bono
work by dentists.
Government Policies
The 2012 Federal Budget:
– $515.3 million, over four years, for dental health.
– $10.5 million for oral health promotion and to
develop a National Oral Health Promotion Plan
– $35.7 million for an expansion of the Voluntary
Dental Graduate Year Program
– $45.2 million for a Graduate Year Program for Oral
Health Therapists
– $77.7 million for a Rural and Remote Infrastructure
and Relocation Grants for Dentists
– $450,000 to a NGO to coordinate further pro-bono
work by dentists.
Government Policies
Siloing continues:
- Dental care has been largely
excluded from the Medicare
Local process
- From the eHealth innovation
- National Health Workforce Reform Workshop.
Government Policies
“..dental treatment has
the potential to be a
bottomless fiscal pit…”
$7 and $11 billion
per annum (NHHRC, 2008))
Senator Peter Walsh AO
Government Policies
House of Representatives
Standing Committee on Health
and Ageing:
Inquiry into adult dental services
to identify priorities for
Commonwealth funding
Centre of Research Excellence
RE
Primary
Oral
Health
Care
•
•
•
•
•
•
A/Prof David Brennan
Dr Len Crocombe
Prof Kaye Roberts-Thomson
A/Prof Tony Barnett
Prof Linda Slack-Smith
A/Prof Erica Bell
Centre of Research Excellence
Theme 1: Successful aging and oral health
• Community based trial: Medical
GP assessment of need for
dental care.
• Incorporating dental
professionals into aged care
facilities.
Centre of Research Excellence
Theme 2: Rural oral health
• Dental practitioners: Rural work
movements
• Relationship of dental practitioners
to rural primary care networks
• Oral health policy: International
policy implications for Australia
Centre of Research Excellence
Theme 3: Indigenous oral health
• Why Aboriginal adults who are
referred for priority dental care
do not take up or complete a
course of dental care
• Perceptions and beliefs regarding
oral health of Aboriginal adults in
Perth and key rural centres,
Western Australia
Centre of Research Excellence
• Community-based Trial: train
carers of people with physical
and intellectual disabilities
then evaluate carers’
knowledge and practices &
clinical outcomes for adults
with disability
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (Slade et al. 2013).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (ARCPOH, 2006).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (ARCPOH, 2006).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (ARCPOH, 2006).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (ARCPOH, 2006).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (ARCPOH, 2006).
Centre of Research Excellence
Causes of poor oral health
– Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
– Poor diet (Rugg-Gunn, 1993)
– Lack of access to primary health care (National Oral
Health Plan 2004-2013).
– Social determinants (Sanders et al. 2006).
– Smoking (Do et al. 2008).
– Low fluoride exposure (Slade et al. 2013).
Centre of Research Excellence
Parameters
Est.
p
Est.
p
Age (15-<45 years, ref: 60+ years)
-15.57 <0.01
-5.91
<0.01
Age (45-<60 years, ref: 60+ years)
-3.45
<0.01
1.22
<0.01
Income ($30,000-<$60.000, ref: <$30,000)
-0.19
0.69
0.66
0.25
Income ($60,000+, ref: <$30,000)
-1.22
0.02
0.16
0.77
Educ. (Trade/Dip/Cert, ref: No post sec)
0.58
0.14
1.19
<0.01
Educ. (Deg/Teach/Nur, ref: No post sec)
-0.13
0.75
1.54
<0.01
Country of birth (Not Aust., ref: Aust.)
0.13
0.71
-0.71
0.05
Eligibility for public care (Yes, ref: No)
-0.11
0.80
-0.40
0.41
FTE dentists/100,000 (<50, ref: 50+)
0.00
0.99
-0.12
0.72
Av time visits (<12 mths, ref: 12+ mths)
-2.28
<0.01
-2.08
<0.01
Usual reason visit (Chk-up, ref: Prob.)
-2.10
<0.01
-0.38
0.25
-0.02
<0.01
-0.31
0.38
Lifetime fluoride exposure
Regional Location (Non-Metro, ref:Metro)
1.01
<0.01
Overview
• Oral health is important.
• The prevention of oral diseases has been
largely due to public health measures.
• There is an inequitable access to primary
oral health care.
• Primary oral health care will improve oral
health outcomes.
• The primary oral health care workforce is
going through a process of rapid change.
• CRE role.
Conclusions
• The Federal Government is interested in
oral health.
• Primary oral health care planning is
becoming less ad hoc.
• Siloing of dental care out of primary health
care continues.
• Supplying primary oral health care will be
expensive.
Will Australia move towards
Primary oral health care?
Where are we heading?
• Crisis of oral health care for the aged