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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?
Where are we now?
Where are we now?
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)
How did this come about?
Lisbon, PortugalVenice, Italy
• 4th – 7th Century: Northern India• Venice monopoly• Lisbon, Portugal• White Gold
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
0
1
2
3
4
5
6
7
8
5–14 15–24 25–34 35–44 45–54 55–64 65+
Age group
Num
ber o
f tee
th (m
illio
ns)
1989
1999
2009
2019
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?
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).
“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
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
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
RE
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.
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 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
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
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
Lifetime fluoride exposure -0.02 <0.01
Regional Location (Non-Metro, ref:Metro) 1.01 <0.01 -0.31 0.38
Centre of Research Excellence
• 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?
Where are we heading?
• Crisis of oral health care for the aged
