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School of Dentistry and Oral Health

Building a Better Oral Health Workforce for Australia and the

Pacific

Prof Newell Johnson

Leonie Short


•Oral diseases common and increasing•Australia producing fewer dentists and professionals complementary to dentistry than in past half century•Griffith playing its part by increasing graduates•Innovative inter-professionalism at Griffith•BUT ONLY 10% IS CONTRIBUTED TO HEALTH OUTCOMES BY WORKFORCE•UPSTREAM SOCIAL DETERMINANTS

MATTER MOST – peace, education,

nutrition, income, safe water, housing,

personal control………..[Janie Dade Smith, 2004]


Outline

•Oral diseases in Australia•Prevention of Oral Diseases•Interactions between oral

and general health

•Common risk factors•Workforce to promote oral health•Griffith University•Workforce mix


Oral diseases in Australia

Tooth and gum disease amongst most common causesof morbidity in Australia, and linked to negative effects on quality of life.[i] Oral diseases THE most common of the chronic diseases: important public health problems because of prevalence, impact on individuals and society, and expense of treatment.[ii] Yet, governments still separate oral health from general health and fund it quite limitedly.

[i] Spencer 1999, NSW Public Health Bulletin[ii] Sheiham 2005, Bulletin of the World Health Organisation 83 (9)


Current oral health trends in AustraliaThe 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

[ii] Armfield et al. 2003. AIHW DSRU


Current oral health trends in Australia

May not hold for all children.

Evidence that most caries present in minority of children:1997 Save Our Kids Smiles programme in NSW showed rural children significantly more likely to have dental caries than metropolitan.[i]

Indigenous Australian children are also have significantly worse dental health than non-Indigenous groups. [1]

[1] This and other ongoing research projects are detailed at: http://www.crroh.uwa.edu.au

[i] AHS Health Status Profiles. NSW Health Dept.

http://www.crroh.uwa.edu.au/








Current oral health trends in Australia Dental health appears to deteriorate after childhood in all populations. 18–24 age group has poorer oral health than might be expected, given the low level of caries in children. This population has, on average, 7 teeth with caries cf 2 at age 12.[i]

[i] Brennan et al. 1997. AIHW DSRU



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.



Oral health in Australia poor among adults, deteriorating among children.

Most recent National Oral Health Survey conducted 1987/88, and results of a second survey not available for a further 3 years.

Current evidence indicates those with worse teeth and gums tend to be public patients, often rural .

School of Dentistry and Oral HealthThe major causes of morbidity and mortality [WHO]

HIVMalariaTuberculosis Malnutrition – under and over!!TobaccoAlcohol and other drugsCancerAccidentsWar and violence

School of Dentistry and Oral HealthImportant “Oral” Diseases

Dental caries is variably active throughout the life span and is the major cause of tooth loss – excluding dentists!!

Periodontal and peri-apical infections cause much morbidity and ?mortality

Oro-pharyngeal cancers

Mucosal diseases

Salivary diseases and dysfunctions

Developmental anomalies

Maxillo-facial trauma




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


83 000

Sub Saharan Africa

3 500 000


250 000 East Asia & Pacific

270 000


700 000


500

Total: 5 million

Estimated number of adults and children newly infected with HIV during 2002

School of Dentistry and Oral HealthEstimated adult and child deaths due HIV/AIDS

during 2002 North America

15 000

Caribbean

42 000

Latin America

60 000

Western Europe

8 000


37 000

Sub Saharan Africa 2 400 000


25 000

East Asia & Pacific

45 000


440 000


<100

Total: 3.1 million

Total: 3.1 million

School of Dentistry and Oral HealthHIV INFECTION:INDIAN SCENARIO

MEAN CD4 COUNTS

315303

270

192 192 190 190 187180

154 148 144133

118

100

150

200

250

300

350

HERPES SIM

PLEX

HERPES ZOSTE

R

DERMATO

PHYTE IN

FECTION

OHL

TOXOPLA

SMOSIS

OP CANDID

IASIS

MOLL

USCUM C

ONTAGIO

SUM

PULMONARY

TB

EXTRAPULM

ONARY TB

RECURRENT BACTE

IAL

RTI

CMV R

ETINITI

SPCP

GASTROENTE

ROPATHY

CRYPTO

COCCAL M

ENINGITI

S

ME

AN

CD

4


Prevention of Oral DiseasesOral diseases are lifestyle diseases – they are nearly all preventable.

Both prevention and cure of dental and periodontal disease are important for overall health.


Interactions between oral and general health

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


Interactions between oral and general health

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


Public Funding 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.


Public Funding While all States and Territories

provide some public dental

health services to individuals

Who cannot afford to see a

dentist privately,

there is great variation

across the country in this public provision of services.


Public Funding 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.


Funding for Oral Health Services

Total spending on dental services in Australia rose from $1.71 billion in 1992/93 to $4.37 billion in 2002/03 (4.9% versus 6.06% of total health expenditure).[i]

[i] ADA submission to HoR Standing Committee

on Health and Ageing 2005 ‘Inquiry into Health Funding’



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.


Commonwealth Gv t

30% rebate

State/territory Gv t

Private insurance

Indiv iduals

Proportional dental services expenditure 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.


Funding for Oral Health ServicesAll 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).


0

20

40

60

80

100

120

140

160

180

Total expenditure($millions)

Per capita expenditure($)

Per concession cardholder ($)

NSW

VIC

QLD

SA

WA

TAS

NT

ACT

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’


Cost of Poor Oral Health

Oral ill-health is not only costly in terms of personal discomfort; it is also expensive in economic terms. Dental decay is the most expensive diet-related disease in the country, costing more that Coronary Heart Disease, hypertension and diabetes,[i] and it may lead to hospitalisation: in 2002/03, 223 patients were hospitalised for dental conditions.[ii] [i] NSW Public Health Bulletin 1999[ii] Steering Committee for the Review of Government Service Provision 2005, cited in ADA submission to HoR Standing Committee on Health and Ageing 2005 ‘Inquiry into Health Funding’


Access to oral health care

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]).

[i] Teusner 2005 Australian Dental Journal 50:2


Waiting Times

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]

[i] AHMAC 2001


Eligible Patients for Public Dental Services

•Over 1million persons in Queensland– Health Care Card

– Pensioner Card

– Seniors Card

– Qld Seniors Card


Dental Inflation

Dental inflation is estimated at 20% - this is greater than the Consumer Price Index as well as greater than for other health services.

(Mihailidis, S., Spencer, A.J. and Brennan, D.S. Perceived busyness and productivity of Australian private general dentists, Paper at IADR Conference, 25-28 September, Queenstown, New Zealand)


Demographics

•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]


Demographics•These people will need, want and demand oral health care•Function •Quality of life•Aesthetics•Demand may not address inequality•Role of technology•Wanting youth•Social marketing •(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


Workforce to promote oral healthOverall numbers of dentists per head of population appear to be increasing (to 46.9 per 100,000 population in 2000 from 43 in 1994). However, compared to other developed countries, Australia still lags behind 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


Workforce to promote oral health

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


0

10

20

30

40

50

60

70

Australia NSW VIC QLD SA WA TAS NT ACT

Rural Metropolitan

Dentists per 100,000 population in 2000


Workforce to promote oral health

Most dentists work in private practice.In 2000, 82.6 of dentists worked privately, with 16.2% in the public sector and 1.2% in other areas.[iii]

[iii] Teusner, Spencer 2003. AIHW DSRU.


Workforce to promote oral healthAt 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


Migration

250 dentists now imported per annum

Approx. equal to Aust. graduates


Suggestions to Workforce Shortages

•Bonded scholarships•Intern year•Remuneration – salary, package, etc. •Right of private practice•Outsourcing

•Mr Andrew McAuliffe, Director, Oral Health Unit, Queensland Health, Future Directions for Oral Health, paper at the DOHTAQ Conference, 1 October 2005.


Teach oral health to ALL members of the health professions

Including doctors


Suggestions for Workforce Changes to Promote Oral Health •Better workforce mix – follow nursing with protocols for dental therapists, dental hygienists and dental technicians•Integration with general health

– Tuckshops, obesity, nutrition, pregnancy, common risk factors

•Oral health promotion activities including water fluoridation


Suggestions for Workforce Changes to Promote Oral Health

•Weighted occasions of service in public sector•Changes to ADA Item Numbers for private health insurance

– dental therapists and dental hygienists– differential rebates

•Changes to Provider Numbers for private health insurance

– dental therapists and dental hygienists


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.


Project One - Community Living Older People in South Australia

•Inclusion of 6 simple questions to the Enhanced Primary Care (EPC) Health Assessment by Medical Practitioner for people 75+ years•Referral of those identified as “at risk” for dental care (for low income adults bypassing the waiting list).



•Is the medical practitioner the best/the right/the only assessor?•What about Domiciliary Care/ Aged Care assessment teams/District Nursing Services? •Advocacy for oral health from

– The Divisions of Medical Practitioners– The Aged Care Sector



•Oral Health for older people and quality of life can be improved by integrating an oral health assessment within a general health assessment and providing timely dental care•The whole process of design, implementation and evaluation is better done with oral health more fully integrated into the general health and aged care system.


Griffith University- Auatralia’s first new dental school in 57 years! •Bachelor of Oral Health in Dental Science•Bachelor of Oral Health in Oral Health Therapy•Bachelor of Oral Health in Dental Technology•Bachelor of Oral Health in Dental Technology

(Post Registration)•Master of Dental Technology in

Prosthetics


Community Research Placement

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


Community Research PlacementLearning Outcomes

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



At the end of Year 2, within the component Community Research Placement 1, students working in groups of 6-8 will have:

Selected a defined community with which their group will interact Described the demography, socio-economic and health profile of that community Conducted, under supervision, a pilot oral health survey of that community Analysed the data obtained and prepared a written report



At the end of Year 3, within the component Community Research Placement 2, students working in groups of 6-8 will have:

Refined the oral health survey instrument from the previous year, based on the experience and data obtained

Extended the oral health survey to improve the generalisability of the results and improve its power to address questions concerning causes of disease levels

observed Devised a health promotion/health education programme for their community Performed basic preventative interventions such as fluoride applications and fissure sealants, under supervision, in a proportion of their population



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


Potential Communities

Kindergartens, primary schools, secondary schools Tertiary teaching institutions Factories and other workplaces with a substantial on-site

workforce Educational establishments for special needs, eg. Deaf, partially

sighted, otherwise disadvantaged…. Hospitals, respite care, hostels and nursing homes Care centres for special groups: eg. HIV positive, alcohol

rehabilitation, drug rehabilitation, tobacco cessation, diabetic, hospices Prison detainees Indigenous communities Refugee and immigrant communities Residential areas of known poor health status Representative residents of small towns, many of which will be underserved by

health personnel


Where to go for information

Australian Dental Association Consumer Information

http://www.ada.org.au/_Consumer_Information.asp


Conclusion

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.


ReferenceNational Rural Health Alliance 2005 Public Dental Services in the States and Territories of Australia, public draft, http://www.ruralhealth.org.au/nrhapublic/

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