1. University Department of Rural Health U N I V E R S I T Y O F T A S M A N I A The changing oral health situation in Australia: Will Australia move towards primary oral health care? Dr Len Crocombe Centre for Research Excellence in Primary Oral Health Care

2. 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

3. 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.

4. Overview Where are we now? How did it come to this? Where are we heading? Commonwealth Government policies Does our CRE have a role?

5. 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)

6. Where are we now? % Periodontal (gum) disease19.0 1+ tooth, untreated decay25.5 1+ tooth extracted due to decay61.0 (AIHW 2008)

7. Where are we now? Expenditure on dentistry in Australia was 7.7b in 2009-10 (AIHW, 2012).

8. 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?

9. Expenditure: Coverage of health care expenses (2004/05) (all insurance): Hospitals98.4 Medical 89.1 Pharmaceutical 54.5 Dental33.3 Social cover of dental expenses: Commonwealth government 9.1 (via PHI) State government 9.7 Private Health Insurance14.2 Total33.0 (AIHW Health Expenditure Bulletin)

10. Where are we now? 85% of dental care is provided in the private sector m ale 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)

11. Where are we now?

14. Planning is currently happening on an ad hoc basis (AJ Spencer, 2007)

15. the body is nothing else than a statue or machine René Descartes. Portrait by Frans Hals, 1648. How did this come about?

16. 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)

17. How did this come about? Lisbon, Portugal Venice, Italy 4 th – 7 th Century: Northern India Venice monopoly Lisbon, Portugal White Gold

18. How did this come about? Harvesting Sugar Cane 1870

19. How did this come about? Audubon Park Laboratory 1894

20. How did this come about? 20 th Century: Reduced sugar prices Increased sugar consumption (Porter, 1997) Massive increase in tooth decay More dentists needed

21. 65+ total no. teeth Rx (millions) 19891.8 19992.9 20094.3 20197.0 Teeth potentially in need of treatment Where are we heading?

22. 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

23. Where are we heading? Department of Education, Employment and Workplace Relations, 2012

24. 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).

25. 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).

26. 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 the Commonwealth 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

27. 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

28. Chronic Disease Dental Scheme Government Policies

29. 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

30. 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

31. Ministers 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

32. 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

33. 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

34. 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

35. 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

36. Siloing continues: - Dental care has been largely excluded from the Medicare Local process - From the eHealth innovation - National Health Workforce Reform Workshop. Government Policies

37. 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

38. House of Representatives Standing Committee on Health and Ageing: Inquiry into adult dental services to identify priorities for Commonwealth funding Government Policies

39. 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

40. Centre of Research Excellence Theme 1: Successful aging and oral health Community based trial: Medical GP assessment of need for dental care. Incorporating dental professionals into aged care facilities.

41. 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

42. Centre of Research Excellence Theme 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. ParametersEst.p 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<0.011.22<0.01 Income ($30,000-<$60.000, ref: <$30,000)-0.190.690.660.25 Income ($60,000+, ref: <$30,000)-1.220.020.160.77 Educ. (Trade/Dip/Cert, ref: No post sec)0.580.141.19<0.01 Educ. (Deg/Teach/Nur, ref: No post sec)-0.130.751.54<0.01 Country of birth (Not Aust., ref: Aust.)0.130.71-0.710.05 Eligibility for public care (Yes, ref: No)-0.110.80-0.400.41 FTE dentists/100,000 (<50, ref: 50+)0.000.99-0.120.72 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<0.01-0.380.25 Lifetime fluoride exposure-0.02<0.01 Regional Location (Non-Metro, ref:Metro)1.01<0.01-0.310.38 Centre of Research Excellence

52. 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

53. 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

54. Will Australia move towards Primary oral health care?

55. Where are we heading? Crisis of oral health care for the aged