COMMUNITY HEALTH STUDIES VOLUME vm, NUMBER I . 1984

ACCESS TO DENTAL CARE AMONGST THE AGED

D.M. Gibson*, D.H. Broom** and P. Duncan-Jones***

Ageing and the Family Project, Research School of Social Sciences, Australian National University, Canberra, 2600.

** Social Justice Project, Research School of Social Sciences, Australian National University, Canberra, 2600.

*** National University. Canberra, 2600.

National Health and Medical Research Council, Social Psychiatry Research Unit, Australian

Abstract This paper examines access to dental services

amongst older people living in Sydney. The results suggest marked underutilization by large segments of the aged population, and particularly by the poor, the physically disabled, the less educated and the very old. Yet good dental health is essential for nutrition, personal comfort, self-image and oral hygiene. Adequate dental care is as important to the health and well-being of older people as it is to other sections of our population. It is difficult to explain the continued neglect and paucity of government funding which characterize this aspect of public health services.

Introduction The care of the aged is currently the subject of

considerable political interest. Most attention has focussed on domiciliary care and institutional programs. The accessibility of paramedical services to older people, and particularly to those in poor health or on low incomes, has rarely been examined although there are serious problems of access to these systems of care. Poverty and disability constitute barriers to the effective use of a range of services but we know comparatively little about the special difficulties experienced by the aged. This paper addresses how far low income and poor personal mobility limit use of dental servics by older people but the questions could be asked as usefully with reference to such services as physiotherapy, occupational therapy, speech pathology and podiatry.

The discussion presented here should be considered in the light of underutilization of dental services by the general population. Convincing Australian evidence of this is lacking yet, if the

GIBSON, BROOM & DUNCAN-JONES 62

results of overseas studies can be generalized, dental care is one area where client ‘demand‘ is consistently lower than professionally determined ‘need‘.’ This pattern is likely to be particularly marked in the population under study, most of whom grew to adulthood before the advent of preventive dentistry in Australia.

Utilization and Socioeconomic Status The use of dental services by elderly

Australians can be understood better in the context of the international literature relating variation in the utilization of medical services to socioeconomic differences. However, comparison of these findings is complicated by the wide range of methodologies, the numerous assumptions (not always explicit) and the varied objectives of the different studies. For example, patterns of “utilization” vary according to the measure of utilization employed: contact (or delay), volume of service use or patterns within an illness episode.2 The kinds of services can also make a substantial impact on the utilization rates of different groups.

A central objective of publicly-funded medical services is to ensure equal access to health care regardless of ability to pay by reducing financial barriers to service use. Currently, discussion focuses on the effectiveness of public provision in remedying the problem of inequitable access and on accounting for continuing discrepancies. Tudor Hart described the ‘‘inverse care law” whereby medical services are most readily available to those whose social and medical needs are least.’ The Black Report documents persistent unmet need for medical services among lower socioeconomic groups in England.‘ There is evidence that unequal access to primary medical

COMMUNITY HEALTH STUDIES

care was widespread in the United States although such inequalities may have diminished since the 1960s.’ As one study succinctly summarized the matter, “Low income and recent welfare contact were found to be associated with failure to seek care despite self-perception of poor health.- A study of insured households in South Australia found that persons living in higher status areas (measured by income and occupational status) had more general practice surgery and home visits and more specialist consultations.7

However, inequalities in the use of medical services may be changing. In the last two decades use of medical services has grown, and it has apparently grown more among the poor than among other sectors of the population, at least for certain kinds of services. Recent investigations have shown that when financial barriers are removed, some of the differences between the poor and others diminish or disappear: apparently because the net price of the service is more closely related to service use “among the poor than among high income persons“.9 When poor people were enrolled in a prepaid group medical scheme, initially they used more services than other members but after six months this difference in utilization rates disappeared.10

Wilson and White show that the poor in the United States are admitted to hospitals more frequently and for longer stays and that poor adults of economically active ages have more doctor visits per person per year although they also have a higher percentage who have not consulted a doctor at all in the past two years.5 The Black Report (Chapter 4) finds much the same pattern of higher rates of hospital admission, outpatient consu l t a t ion , a n d general p rac t i t ioner consultation in the lower socioeconomic groups: Rein calculates higher rates of consulting and hospital admission and longer hospital stays among lower status persons which he interprets as evidence that the N.H.S. has successfully removed barriers to access.II

In view of the suspicion that morbidity is generally higher among the lower classes, several efforts have been made to relate use to some measure of need. Several of these are discussed in the Black Report (pp.94-98): and Le Grand elaborates the strategy in some detail.12 Such calculations must be treated with considerable caution, because they require a number of assumptions which cannot be confirmed, but it

GIBSON, BROOM & DUNCAN-JONES 63

seems that for many kinds of services, people from the higher social classes use more services relative to need than the lower classes. Le Grand suggests that this results from more intensive service use for any given condition among the middle and upper classes and that the high rate of consulting among male manual workers occurs because they must have an official medical exemption’to be excused from work rather than because their conditions are subject to careful medical supervision. Cartwright and O’Brien come to a similar conclusion.lj In one of the few Australian studies to address this question, Najman er al. found a curvilinear relationship between service use and income when controlling for sex, age and number of symptoms.14

Even where overall rates of service use are similar or where poorer people seem to use more services than the middle and upper classes, the patterns of use are distinctive. In both Britain‘and the United States,s working-class patients are apparently more likely to present at hospital outpatient or casualty departments, whereas middle-class patients have more appointments with private practitioners. McKinlay characterizes this difference as a contrast between a buyer’s market for the middle-class patient and a seller’s market for poorer patients.13 When type of service is specified in detail it appears that, despite high rates of hospital admission, the poor still make less use of a range of discretionary medical services, including preventive services.9,20

For services that prevent illness or promote health, considerations of need do not enter. Rates of screening for cervical cancer, early antenatal care and family planning services are all inversely related to socioeconomic group.4 Freeborn ef al. found that socioeconomic status (measured by education and income) was associated with use of preventive services among American women in a prepaid group practiceJ7 and, in Cartwright and O’Brien’s British sample, the middle class made more use of preventive services.~~ If preventive services diminish the need for curative services such as those most often used by the poor, this may help explain the apparently paradoxical findings.

As far as is known, the factors that influence health service use by theelderly are much like those that influence other adults, except that age itself appears to diminish medical consulting despite the fact that morbidity increases.118 Apparently, older persons sometims view symptoms as “the

COMMUNITY HEALTH STUDIES

invevitable consequences of aging” or confuse symptoms of new conditions with an earlier problem and hence do not consult a doctor about them.19 However, this pattern may not apply to all kinds of services. In Snider’s study of use of ancillary health agencies, age cohort (65-70,7 1-80, or 80 and over) was unrelated to rates of consulting.” However, modern medical practice offers few preventive or discretionary services to the aged; consequently, insofar as these kinds of services increase utilization of some services by people of higher socioeconomic status, patterns of use by older persons may be expected to be distinctive. Hence, studying the elderly as a separate group may help to clarify the relationship between socioeconomic status and service use.

Dental Utilization Because various services exhibit different

patterns of utilization, another way of distinguishing several influences on service use is to examine one type of service at a time. Some of the studies discussed above included dental services along with other medical and paramedical services. As with other health care, dental care in fact consists of a range of services from primary prevention to the repair of damage and the care of disease. Thus, simple rates of utilization may mask the same countervailing patterns that we suspect exist in medical care; however in the older population with high proportions edentulous, there is much less scope for preventive dentistry and probably less propensity to seek such services. Hence, studies of dental care of the elderly may be easier to interpret than others.

As was true for medical utilization, dental utilization is apparently influenced by the cost of the service to the user. Insurance is estimated to more than double demand for dental services and surprisingly, this effct is larger for children than adults.2’ Indeed, American data suggest that income is a better predictor of dental utilization than it is of medical and hospital service use.18 Time price as well as service price were important to utilization, leading to the comment that, for some ages, “reduction in waiting times may be as important as price reductions ....( to) the poor*’,22 although waiting time may not be as important to older people unless they are accompanied to dental appointments.

As far as we know, the pattern in Australia is similar. In a Brisbane sample, having visited a dentist in the last six months (an extremely limited

GIBSON. BROOM & DUNCAN-JONES 64

criterion) was associated with income, occupational and educational level, although the association diminished when standardized for age and sex.14 In the 1973-74 Gosford Wyong health survey, better educated respondents and those from households on higher incomes were more likely than their counterparts to have seen a dentist in the last year, and this was true for the elderly as well as for younger adults (unpublished data). In the United States, access to dental services does not appear to have improved in recent years as much as access to hospital and medical services. Although the proportion with no dental visits in the last two years has fallen for all race and income groups, the gap between the poor and the non-poor was wider in 1973 than in 1964.5

Dental needs are likely to be somewhat different among the elderly than for the rest of the population. As has been suggested, prevention is probably less relevant to older persons, hence the element of discretion is smaller. For one thing, the elderly are less likely to have all their own teeth and edentulous persons do not need to consult a dentist as frequently as people who still have natural teeth. Indeed, older people are typically less likely to have been to the dentist.23 Among respondents to the 1979 Australian survey of dental health, 25 percent had last visited a dentist more than five years ago, but more than twice as many of the respondents over 65 years of age (52 percent) had not been to a dentist in the last five years. Furthermore, 31 percent of the elderly said they have regular check- ups compared to 62 percent of the total sample. The services obtained by older persons are different; as would be expected, many more of them have dentures prepared and maintained and the aged are considerably less likely to have diagnostic, preventive, or restorative work.”

Snider’s research suggests that knowledge of available services, which is closely related to level of education (and to prior use of agencies), is a predictor of service use by the aged.22.25 This factor is probably more relevant to social services and other services less well known to the general public than it is to conventional medicine and dentistry, which are familiar.26 However, people may be unaware of dental services provided or funded by the government and there is evidence that the elderly in Australia are not well informed about the various community services that are available to them.27

Education is also known to be related to dental utilization by old persons.28 Furthermore,

COMMUNITY HEALTH STUDIES

education was strongly related to having a regular dentist and having a dentist was, in turn, more important than any variable except dental need in predicting how recently the last visit occurred. Lack of a regular source of care has also been found to depress service use among the elderly in studies of medical utilization.p,29 However, people who are infrequent attenders may define themselves as not having a regular doctor or dentist because they go so rarely, rather than failing to go because they do not have a regular source of care.

Method The data reported here were collected in a

survey of 1050 people aged 60 and over. Respondents were selected from persons living in private dwellings in Sydney in 1981, using a stratified random sampling technique. Full details of the sampling and interviewing procedures are available elsewhere.30 Information was collected on a wide range of social, demographic, and health variables. In this paper, attention will focus on only seven variables: the dependent variable (dental utilization) and four predictor/in- dependent variables: income, education, disability, and living arrangement. In addition, the analysis includes age and having natural or false teeth.

Education was measured in years of schooling (two year intervals). Income was initially recorded jointly for the respondent and spouse (where appropriate). A personal income variable was created by adjusting for marital status, then collapsed into four categories. The disability measure was derived from seven commonly-used activity of daily living items, such as being able to get up and down stairs and go out alone. For analysis here, the scale was converted to a dichotomous variable; all respondents reporting difficulty with any task were placed in the disabled category. Living arrangement was dichotomized into those living alone and those living with others.

The indicator of dental utilization used in this analysis was the period elapsed since most recent consultation. Although this was recorded as a grouped interval variable, ordinary linear regression analysis was not appropriate. Dental treatment normally consists of short spells of visits, separated by quite long intervals. The appropriate interval between treatment will vary, dependent on a person's dental characteristics. Almost any person in the sample who has seen a dentist in the

GIBSON, BROOM & DUNCAN-JONES 65

last year is probably showing appropriate use of the service. For this reason alone, direct analysis of the length of time since last treatment would be unsatisfactory. Additionally, the elapsed time variable had a skew distribution which could have led to technical difficulties. Finally, an analysis expressing differences in use as differences in elapsed time is somewhat uninformative and not intuitively very meaningful. Instead, analysis focussed on the probability of having had dental treatment in the last year, in the last two years or in the last four years. An extension of logit analysis was used.3' In this analysis, logit regressions were fit simultaneously to predict the three intervals since last consultation. A different intercept term was estimated for each level, with a common slope for all levels. The assumption of a common slope is tested below and shown to be acceptable. The model provides a single interpretable coefficient for each predictor, applicable to the prediction of all levels of utilization. The logit modelling approach also provided appropriate significance tests for different effects and provides smoothed estimates of specific effects, with other variables and chance fluctuations controlled.

Results In reviewing the utilization patterns of older

people, we observe not only current trends but also the cumulative effects of a lifetime of service use. This is particularly true of dental provision where the proportion of edentulous people is prima facie testimony to the effectiveness of earlier dental services. Overall, 78 per cent of respondents wore either full or partial dentures. This proportion increased steeply with increasing age, from 74 per cent in the 60 to 64 age-group to 87 per cent amongst those over age 75 (significant at the .001 level). Retaining one's own teeth was also significantly related to income and to education. Thus, those on low incomes and with less education seem rather more likely than their better educated and wealthier counterparts to lose their natural teeth prior to or during old age. (These results are summarised in Table 1). However, the effects of income and education are small relative to the age effect.

Of the edentulous elderly, barely half had attended a dentist in the past five years; 25 per cent had used dental services in the preceding 12 months. Amongst the dentate, consultation rates were higher; 40 per cent had seen a dentist in the past 12 months and ony 26 per cent had not attended within a five year period. It is not possible

COMMUNITY HEALTH STUDIES

TABLE 1

Proportions With Dentures By Age, Education and Income (Summary Table)

Proportion with dentures

Total (n)

Age+* 60-64 65-74 75+

Education++ 14 yrs 15 yrs - 16 yrs 17 yrs

Income+ to $4,000 54,000 - $6,000 $6,000 and over

74% 77% 89%

83% 82% 68%

82% 86% 73%

I72 472 402

544 359 I36

540 195 189

+ Significant at the .01 level ++ Significant at the .001 level

t o p r o v i d e de f in i t i ve s t a t e m e n t s o n underutilization from this type of survey data. The recommended interval between dental visits varies with individual dental health status and there is some controversy as to what are the appropriate guidelines for the general community. If the recommended interval between dental visits is taken as annual for the dentate and 5 yearly for the edentulous, considerable underutilization of dental services is observed. When these results are examined as a function of the recommended consultation interval, 40 per cent of the edentulous elderly and 60 per cent of the dentate had not

attended within the appropriate period (Table 2). These figures are conservative estimates of underutilization since those with a combination of natural and false teeth are included in the edentulous group, whereas the care of their remaining natural teeth would require the more frequent consultation intervals of the dentate.

Factors Influencing Utilization The combined effect of a number of variables

on dental service use was examined using logit analysis. Variables were included in the equation in stages: age and education, false versus natural

TABLE 2

Interval Since Last Consultation For The Edentulous and Dentate Aged (Column Percentages)

Edentulous Dentate

Up to 5 months 6 months to I 1 months 1 to 2 years 3 to 4 years 5 years or more Total (n)

GIBSON, BROOM & DUNCAN-JONES

15% 10% 16% 10% 48%

100% (804)

66

23% 17% 26% 8% 26%

100% (221)

C O M M U N I T Y HEALTH STUDIES

teeth, handicap and living arrangement, and income. The effect of these variables was examined simultaneously for three utilization levels: within the last year, the last two years and the last four years. Overall, 25 per cent of respondents had consulted within the last year, 42 per cent in the last two years, and 52 per cent in the last five years.

Age and education were the first predictors entered into the question. Older respondents and

40 $2 $4 $6 6k :O ;2 /4 :6 /8 S'O d2 d4 sb s's 910

0.9

0.8

0.7

0 C .- +- 0.6 - 3 v)

C 0 0 0.5

C 0 .- +-

0.4 0 a. 2 II

0.3

0.2

0.1

those with less education make less use of dental services than others. For each utilization level, the odds that the respondent will have consulted a dentist decrease by 5 per cent for each additional year of age and increase by 17 per cent for each additional year of schooling. These results are illustrated separately for the edentulous and dentate elderly in Figure I . In terms of dental service use, each additional year of schooling is thus equivalent to being about three years younger.

. . . .-.

1 -. , . . . . . . . Natural teeth

education - high

Natural teeth education - low

False teeth education - high

False teeth education - low

GIBSON, BROOM & DUNCAN-JONES 67 COMMUNITY HEALTH STUDIES

TABLE 3

Chi Square Values lor Each Increase in Predictive Power as Additional Variables were Added to the Equation

(All significant t the ,001 level)

X* D. F.

Age and Schooling 107 2 + Teeth (False/Natural) 57 1 + (Teeth Living Arrangement *Disability) 55 6 + Income 22 1

Note: "*" symbolises an interactive effect, multiplicative in the logit scale.

When the edentulous/dentate variable was included, the predictive power of the equation was significantly increased; having false teeth reduces the likelihood of consulting a dentist (See Table 3). At the same time, the effect of age is somewhat reduced due to the greater likelihood that older persons will have dentures. The effect ofeducation is also slightly reduced.

Physical disability and living arrangements were then added to the equation. Considered independently, living arrangement had no effect and physical disability only a small effect. Those with personal mobility problems were only slightly less frequent users of dental services. The existence of co-residents who could potentially provide assistance or support did not make any appreciable diffference in service use for the sample as a whole.

There is a significant interaction between living arrangement and disability and between these and the dentate/edentulous variable. This unexpected interaction is shown in Table 4. The table shows probabilities calculated from the final model. It gives the probabilities of consulting in the last two years for a person aged 70, who left school at 15 or 16 and who has an income of between $4,000 and $6,000. Amongst the dentate elderly who lived alone, those with no physical disability had a much higher probability of consulting during the specified time interval (probability = .85) than did those who were physically disabled (.31). For those who lived with others, the handicapped were again less likely to consult ( 3 1 ) than those living alone (.31). Thus, while personal mobility problems are a significant barrier for the elderly who live alone, the problem is considerably

TABLE 4

Probabilities of Consulting by Disability, Living Arrangement 8nd natural versus False Teeth*

TEETH PHYSICAL DISABILJTY PROBABIITY OF CONSULTING IN LAST TWO YEARS

Natural No Yes

.65 3 1

.85

.31

False No .4 1 .40 Yes .35 .56

*Model estimates, calculated for consultation in the preceeding 2 year period, having left school at IS- 16, and with income between $4,OOO and $6,000.

GIBSON, BROOM & DUNCAN-JONES 68 COMMUNITY HEALTH STUDIES

TABLE 5

Model Estimates Predicting Dental Utilization

Age Education Income Teeth (2) Living Arrangement (2) Disability (2) Teeth (2), Living Arrangement (2) Teeth (2), Disability (2) L i h g Arrangement (21, Disability (2) Living Arrangement (2), Teeth (2), Disability(2)

For Utilization In:

Last Year Last 2 Years Last 4 Years

- .03961 + .2303

‘+].I31

+ .3326

+2.850

+ .I528 - .9684

- .5699 -1.161

-1.989

1.077 1.920 2.382

Equation Logit (Probability of dental treatment) = Utilization leveli

+ Agei + Educationk + Incomer

+ (Teeth* Living Arrangement* Disability),,,

Note: This linear equation provides estimates in the logit scale; for any given set of values of the predictor variables the logit can be calculated from the above and then transformed to a probability of utilization. Code (2) for teeth = false; for disability disabled; for living arrangement = alone.

diminished where co-residents are available to provide or arrange assistance in getting to the dental surgery. The effect of living arrangenlent is reversed for the aged who are not in need of assistance; those living alone (.85) are more frequent attenders than those living with others (.65). These results lend some support to the conjecture that professional consultations provide a valued social contact for the lonely but physically able elderly.

For the edentulous respondents living with others, the disabled were again somewhat less likely to consult (.35) than those with no mobility problems (.41). A contradictory pattern emerges, however, for the edentulous aged living alone; the disabled were more likely to have used dental services than those with no disability, the opposite of the pattern for the dentate and for the

GIBSON, BROOM & DUNCAN-JONES 69

edentulous elderly living with others. This last, counter-intuitive, finding corresponds to a second order interaction effect which is highly statistically significant. We have no compelling explanation for it. One possible interpretation relates to thc greater likelihood that disabled persons living alone are recipients of formal services of some sort. Once an initial contact is made, recipients may be more likely to be drawn into contact with other medical and social services, including dental consultations for those having easily observed difficulty with poorly fitting dentures.

Among the edentulous able aged living arrangement did not influence service use. Persons living alone were neither more nor less likely to consume dental services. These results do not support the ‘valued social contact’ hypothesis for the edentulous aged.

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TABLE 6

Effects of Income on Utilization

Income Level Probability of Consulting in a 2 year period

.61

.65

.68

.71

Note: natural; disability = none; living arrangement = with others.

Probabilities calculated for age 70; education = having left school at 15 or 16; teeth

With income added to the equation, there was a significant increase in predictive power (see Table 3). In the final model, shown in Table 5, the influence of both age and education is somewhat diminished because of the relationships between age and the edentulous/dentate variable and between income and education. Even so, the effects of age and education remain strong. To illustrate the effect of income, probabilities were calculated for those who consulted in the past two years, living alone, with a school-leaving age of IS or 16 and with natural teeth. The probabilities are shown in Table 6. Examining only the influence of income, the probability of consultation increases from .61 at income level 1 (less than $4,000) to .71 at income level 4 (greater than $6,000). These results suggest that current income, quite apart from the effects of education and dental status, has a significant effect on use of dental services.

Public Provision To consider the implications of these findings

for health policy, it is essential to understand the existing system of public provision.32 Dental services are the responsibility of State governments; hence we are concerned with the programs of the New South Wales government. In principle, the Health Department is committed to the idea that all persons in New South Wales should have access to adequate dental care. In practice, the resources and facilities of the dental care section are grossly inadequate to that task; it has been aptly tagged the ‘Cinderella service’ of the Department.

There are two components in the New South Wales government dental care package. One is the provision of a full range of free dental services in

GIBSON, BROOM & DUNCAN-JONES 70

clinics attached to public hospitals and in the Sydney Dental Hospital. The second is a denture rebate scheme under which eligible persons in rural areas and some outer metropolitan areas may obtain dentures from private dentists who receive a standard fee from the government. Eligibility for both schemes is determined according to Federal government requirements for free medical care. Thus, all recipients of Pensioner Medical Benefits and Health Care Card holders are eligible for these services.

The adequacy of the free dental service is qualified by geographic distribution and waiting lists. Of about 270 hospitals in New South Wales, only 13 are equipped with dental clinics. All of these, and the State Dental Hospital, are situated in the Sydney-Newcastle area; the single exception is one part-time clinic at Taree. The free dental service is thus of limited value to people living outside the Sydney-Newcastle area.

The waiting lists at these clinics are substantial and they have increased considerably as a result of the broadening of eligibility criteria to include Health Care Card holders. A priority system has been instituted, giving preference to those requiring their first set of dentures, or those with Medical Certificates stating an urgent need for new dentures. For these groups, the waiting time for an appointment is from 4 to 6 weeks. The waiting period is 12 months for persons without Medical Certificates. The dentate elderly can expect to wait up to six months for extractions and fillings. For periodontal or general preventive work, the waiting list is even longer. Clearly, the facilities are not adequate to the dental care needs of lower income groups, especially in view of the fact that

COMMUNITY HEALTH STUDIES

expressed demand for dental services is generally lower than need. In brief, despite marked under- utilization of services, there remains a shortage of SUPPIY.

The second component of State government provision is the pensioner denture scheme, based on the reimbursement of private dentists. It originated in the 193Os, when rural people complained of difficulty attending the free dental clinics. The standard fee paid is negotiated between the Department and the Australian Dental Association. It is currently 3309 for a full denture (upper and lower), compared -with the minimum recommended fee by the Australian Dental Association of $440.

The gap between minimum recommended and standard fees is substantial, even without considering the further complication that the aged are generally more difficult to fit accurately and often require numerous adjustments. The minimum recommended fee is thus not regarded as appropriate by many dentists. To quote the Executive Director of the Australian Dental Association:

.... the making of a really good denture for an elderly person is a most demanding task, yet the fees paid by pensioner denture services operated by the States are heavily discounted. Most dentists who treat pensioner patients are resigned to the fact that they will normally make a loss on each one, and regard it as a form of community service. Obviously any one practitioner cannot afford to have too many pensioner patients.33

While the extent of financial loss may be questioned, the fact remains that for many dentists, pensioners are less desirable clients than full paying customers. The pensioner denture scheme was recently extended to include the housebound aged in the Sydney metropolitan area. As was the case for those in rural areas, there is no provision for those who retain their natural teeth. Even those wishing to acquire new dentures may have difficulty availing themselves of the scheme. In order to receive this assistance, the patient must find a private dentist prepared to come to the house for the various fittings and adjustments in return for the limited standard fee.

In sum, there are two limitations of the pensioner denture scheme. First, there is no

GIBSON, BROOM & DUNCAN-JONES 71

provision whatsoever for dental services to eligible persons in rural areas who retain their natural teeth. Second, the low level of remuneration paid to private dentists makes the indigent patient a less desirable patient and, thus, hardly facilitates the provision of good quality dental care.

The shortcomings of the current system of public provision are obvious. For low income groups in general, the limited geographic accessibility and long waiting lists make adequate dental care impractical. For the edentulous elderly dependent on the pensioner dental scheme, there is reason to doubt the quality of care which some will receive in return for the limited government benefit available. For the dentate elderly who cannot get to a free dental clinic (for either geographic or personal mobility reasons), no State assistance is forthcoming. Those who can get to the clinics face formidable waiting lists. The implications of these factors for the quality of care received by the aged are of some concern, particularly for the edentulous elderly (65 per cent of the population aged 65 and over) who are typically more difficult and hence more costly to treat.

Conclusions The results presented in this paper point to the

underutilization of dental services by large segments of the aged population, particularly the poor, the physically disabled, the less educated and the very old. These findings suggest that there is a relationship between low socioeconomic status and failure to use needed health services and that some of the conflicting findings of earlier studies may result from the research methodology. When we focus on a specific group in the population who are less oriented toward prevention (the aged) the socioeconomic gradient is quite pronounced.

The findings from this study must be a cause for concern among those involved in the health care of older Australians. Adequate dental care and good dental health are essential for nutrition, personal comfort. good self-image and oral hygiene. Such factors are no less important to older people than any other section of the population.

It is in old age, moreover, that there are increasing problems with dentition and problems with the provision of good quality dental care. The factors most frequently complicating dental treatment are related to cardiovascular and cerebrovascular disease (and the medications

COMMUNITY HEALTH STUDIES

involved); both groups may require hospitalization in order to provide adequate monitoring during dental treatment.

Despite a lack of information on the problems of preventive dentistry for the aged, there are suggestions that disease patterns differ from those encountered in the young. In particular, many older people have chronic, progressive periodontal disease; even an elderly person who is apparently dentally sound may need regular preventive treatment. For the edentulous aged, the deterioration of gums and supporting tissue results in a gradual worsening of denture fit, requiring modifications to the prosthesis which are frequently accompanied by problems of adaptability in the aged person. If these adjustments a re unsuccessful, impaired masticatory efficiency can contribute to the nutritional deficiencies which influence both the physical and mental health of older people.

If good dental care is important to the health and well-being of the aged, it is difficult to explain the lack of interest shown in this area and the paucity of government funds devoted to it. The inadequacy of existing New South Wales government provisions was illustrated earlier in this paper: the services available in other States are not markedly superior. Our findings relate to Sydney residents who presumably, are better off than their country counterparts given the urban locations of free dental clinics. Moreovaer, this paper described only the diffkulties faced by older people living in the community; the problems of the institutionalised aged and particularly those with severe mental or physical disabilities remain unexplored. Even in our comparatively avantaged sample the lower levels of service use by the poor and persons with mobility problems show that existing programs have not removed these access barriers. The long waiting lists are likely to diminish demand for dental services still further. Taken together, these factors suggest that the elderly can probably rarely avail themselves of regular and adequate dental care.

GIBSON, BROOM & DUNCAN-JONES 72

The emphasis on the edentulous rather than the dentate elderly may be attributed largely to the traditional neglect of preventive care which is clear in both paramedical and medical provisions for the aged. At present, the rural elderly eligible for government assistance receive no help if they have natural teeth; if cost is a problem the cheapest option may well appear to be to have the natural teeth replaced by dentures. The more likely option is that continued neglect will render such an action essential.

Two avenues of action in this area are suggested by our findings. First, government programs should be restructured to extend coverage (particularly to the dentate and homebound) and expand facilities and resources. Waiting periods of six and twelve months are totally unacceptable for people in need of dental treatment, whether they need filling, extractions or a new denture. A choice may have to be made between the extension of free dental clinicsand the expansion of general benefits payable to private dentists along the lines of the present system of medical care provision.

Secondly, the elderly and their dental practitioners need health promotion activities to educate them about the importance of adequate dental care during later life. There is evidence of a cohort effect in utilization patterns which is commonly associated with the lack of preventive dental techniques and dental education when this age group were children and young adults. The strong influence of education suggests that such programs might be usefully targeted toward those with lower levels of education. While little research or attention has been directed to this subject in Australia, it has become commonplace to point with some satisfaction to the generally higher levels of dental health enjoyed by younger age cohorts in our society. There is no doubt that this is a welcome and desirable trend. It is unlikely, however, to be to much consolation to those who are already old.

Acknowledgements We are grateful to C. Wall. R . Woods and N. Wright who provided us with valuable information concerningdental practice and policy issues. and to S. Halton, S . Freeman and S. Wells for their assistance in the preparation of this paper. The Commonwealth Department of Health contributed partisl funding for collection of the data.

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