School of Dentistry and Oral Health

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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

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• 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

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• Oral diseases in Australia
• Tooth and gum disease amongst most common causes
• of 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)

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• Current oral health trends in Australia
• The 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 Australias
  National Oral Health Plan 2004-2013
• ii Armfield et al. 2003. AIHW DSRU

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• 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.

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• Current oral health trends in Australia
• Dental health appears to deteriorate after
  childhood in all populations.
• 1824 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

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• Current oral health trends in Australia
• 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

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• Current oral health trends in Australia
• 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.

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• Current oral health trends in Australia
• 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 .

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The major causes of morbidity and mortality WHO

• HIV
• Malaria
• Tuberculosis
• Malnutrition under and over!!
• Tobacco
• Alcohol and other drugs
• Cancer
• Accidents
• War and violence

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Important 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

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Adults and children estimated to be living with
HIV/AIDS, end 2002
Western Europe 570 000
Eastern Europe Central \Asia 1 200 000
North America 980 000
East Asia Pacific 1 200 000
North Africa Middle East 550 000
Caribbean 440 000
South South-East Asia 6 000 000
Sub Saharan Africa 29 400 000
Latin America 1 500 000
Australia New Zealand 15 000
Total 42 million
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Estimated number of adults and children newly
infected with HIV during 2002
Eastern Europe Central \Asia 250 000
Western Europe 30 000
North America 45 000
East Asia Pacific 270 000
North Africa Middle East 83 000
South South-East Asia 700 000
Caribbean 60 000
Latin America 150 000
Sub Saharan Africa 3 500 000
Australia New Zealand 500
Total 5 million
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Estimated adult and child deaths due HIV/AIDS
during 2002
North America 15 000
Eastern Europe Central \Asia 25 000
Western Europe 8 000
North Africa Middle East 37 000
East Asia Pacific 45 000
Caribbean 42 000
Total 3.1 million
South South-East Asia 440 000
Sub Saharan Africa 2 400 000
Latin America 60 000
Australia New Zealand lt100
Total 3.1 million
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• Prevention of Oral Diseases
• Oral diseases are lifestyle diseases they are
  nearly all preventable.
• Both prevention and cure of dental and
  periodontal disease are important for overall
  health.

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• 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. 2004352020-3
• ii Elter et al, J Periodontol 200475782-90
• iii Cueto et al, J Periodontal Res.
  20054036-42

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• 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.
  200532188-92

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• 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.

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• 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.

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• 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.

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• 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

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• Funding for Oral Health Services
• The Commonwealth Governments 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

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• Funding for Oral Health Services
• 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.

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• Funding for Oral Health 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.

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Proportional dental services expenditure 2002/03
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• Funding for Oral Health Services
• 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

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• Funding for Oral Health Services
• 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.

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• Funding for Oral Health Services
• All 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).

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Dental expenditure based on 2001/02 figuresi
i AIHW Health Expenditure Australia. Cited in
ADA submission to HoR Standing Committee on
Health and Ageing 2005 Inquiry into Health
Funding
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• 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

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• 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 502

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• 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

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• Eligible Patients for Public Dental Services
• Over 1million persons in Queensland
• Health Care Card
• Pensioner Card
• Seniors Card
• Qld Seniors Card

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• 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)

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• 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

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• 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)

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Economic, Political Environmental Conditions
Determinants of oral health
Social Community Context
Poverty Housing Sanitation Leisure
Facilities Shopping Facilities Employment Work/edu
cational environment Income Policy -
International - National -
Local Commercial Advertising
Oral Health Related Behaviour
Social norms Peer Groups Social Capital Cultural
Identity Social networks Self esteem
Individual
Sex Age Genes Biology
Diet Hygiene Smoking Alcohol Injury Service
Oral Health
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• Workforce to promote oral health
• Overall 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 Australias
  National Oral Health Plan 2004-2013

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• 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 199926613-21

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Dentists per 100,000 population in 2000
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• 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.

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• Workforce to promote oral health
• At 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

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• Migration
• 250 dentists now imported per annum
• Approx. equal to Aust. graduates

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• 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.

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• Teach oral health to ALL members of the health
  professions
• Including doctors

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• 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

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• 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

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• 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

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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.

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• 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).

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• Project One - Community Living Older People in
  South Australia
• 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

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• Project One - Community Living Older People in
  South Australia
• 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.

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• Griffith University- Auatralias 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

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• 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
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• Community Research Placement
• Learning 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

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• Community Research Placement
• Learning Outcomes
• 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

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• Community Research Placement
• Learning Outcomes
• 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

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• Community Research Placement
• Learning Outcomes
• 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

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• 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

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• Where to go for information
• Australian Dental Association
• Consumer Information
• http//www.ada.org.au/_Consumer_Information.asp

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• 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.

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