Dr Len Crocombe Centre for Research Excellence in Primary Oral Health Care

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The changing oral health situation in

Australia: Will Australia move

towards primary oral health care?

Dr Len CrocombeCentre 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 19.0• 1+ tooth, untreated decay 25.5• 1+ tooth extracted due to decay 61.0

(AIHW 2008)

Where are we now?

• Expenditure on dentistry in Australia was 7.7b in 2009-10 (AIHW, 2012).

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?

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 9.1 (via PHI)

State government 9.7Private Health Insurance 14.2Total 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?

• Planning is currently happening on an ad hoc basis

(AJ Spencer, 2007)

“the body is nothing else than a statue or machine”

René Descartes. Portrait by Frans Hals, 1648.

How did this come about?

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)

Lisbon, PortugalVenice, Italy

• 4th – 7th Century: Northern India• Venice monopoly• Lisbon, Portugal• White Gold

Harvesting Sugar Cane 1870

Audubon Park Laboratory 1894

20th Century:• Reduced sugar prices• Increased sugar consumption (Porter, 1997)

• Massive increase in tooth decay• More dentists needed

5–14 15–24 25–34 35–44 45–54 55–64 65+

Age group

65+ total no. teeth Rx (millions)1989 1.81999 2.92009 4.32019 7.0

Teeth potentially in need of treatment

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

Department of Education, Employment and Workplace Relations, 2012

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).

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).

“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 theCommonwealth 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

work by dentists.

Government Policies

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

Senator Peter Walsh AO

“..dental treatment has the potential to be a

bottomless fiscal pit…”

$7 and $11 billion per annum (NHHRC, 2008))

Government Policies

House of Representatives Standing Committee on Health

and Ageing:Inquiry into adult dental services

to identify priorities for Commonwealth funding

Government Policies

Centre of Research Excellence

• A/Prof David Brennan• Dr Len Crocombe• Prof Kaye Roberts-Thomson• A/Prof Tony Barnett• Prof Linda Slack-Smith• A/Prof Erica Bell

Primary Oral Health Care

Centre of Research ExcellenceTheme 1: Successful aging and oral health

• Community based trial: Medical GP assessment of need for dental care.

• Incorporating dental professionals into aged care facilities.

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 ExcellenceTheme 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

• Community-based Trial: train carers of people with physical and intellectual disabilities then evaluate carers’ knowledge and practices & clinical outcomes for adults with disability

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).

– 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).

– 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).

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

Lifetime fluoride exposure -0.02 <0.01

Regional Location (Non-Metro, ref:Metro) 1.01 <0.01 -0.31 0.38

• 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.

Overview

• 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.

Conclusions

Will Australia move towards Primary oral health care?

• Crisis of oral health care for the aged

Dr Len Crocombe Centre for Research Excellence in Primary Oral Health Care

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