PART 2

INTRODUCTION

THE ORAL HEALTH OF VICTORIANS

2.1 This audit examines Victoria’s public dental health services, with a focus on community dental health services delivered through the Community Dental Program and the School Dental Service. In particular, the audit examined:

• access to community dental services;

• delivery of those services by clinics in rural and metropolitan regions;

• issues relating to the recruitment and retention of the public oral health work force; and

• the framework for planning, managing and monitoring community dental services.

2.2 A complete description of the audit’s objectives, scope and methodology are provided in Appendix A of this report.

2.3 Oral diseases are estimated to be among the most prevalent diseases in the community, with dental caries (decayed teeth), edentulism (loss of all teeth) and advanced periodontal (gum) disease being the 1^st, 3^rd and 5^th most prevalent health conditions in Australians, respectively¹.

2.4 Poor oral health may cause people to avoid social interaction and personal contact, reducing their quality of life. Patterns of oral health and disease also indicate that personal and behavioural factors impact on dental health outcomes, and that particular population groups have a greater vulnerability to poor oral health status². Chart 2A illustrates the impact of oral disease on productivity.

CHART 2A
IMPACTS OF ORAL DISEASE

Source: Victorian Department of Human Services, Promoting Oral Health 2000-2004, Strategic Directions and Framework for Action, 1999.

Oral health status of Victorians

Children

2.5 The oral health of Australian children is relatively good when compared with that of adults. However, data gathered as part of the Child Dental Health Survey, Australia, 1998³ showed that Victorian children:

• Had the highest mean number of deciduous dmft⁴ among 5 to 6 year olds in Australia - 1.47 compared with the national average of 0.97. Victoria was one of only 3 States with a mean dmft greater than one (the other States being Queensland and the Northern Territory); and

• Had the highest mean number of missing teeth among 5 to 6 year olds - 0.12 compared with the national average of 0.06. Victoria was the only State with a mean number greater than 0.10⁵.

2.6 Despite the higher level of dental caries for Victorian children, Chart 2B shows that over the past 25 years there has been a significant decrease in the prevalence of dental decay in Victorian 6 to 12 year olds.

CHART 2B
TEETH AFFECTED BY DENTAL DECAY
VICTORIAN 6 TO 12 YEAR OLDS
(average no. of affected teeth)

Source: Australian School Dental Scheme and the Child Dental Health Survey, Victoria 1999, AIHW Cat. No. DEN 87.

2.7 The Child Dental Health Survey, Victoria, 1999⁶ revealed that:

• there was significant variation in caries experience in both deciduous and permanent teeth across regions⁷;

• clinically-detectable caries in deciduous teeth were lowest in the 4 metropolitan regions of the State, and highest in the Grampians region;

• rural regions had higher mean scores for deciduous missing and filled teeth: Grampians had the highest score (3.20) and Eastern Metropolitan had the lowest (1.45); and

• the rural-urban disparity also existed for permanent caries experience: Loddon Mallee had the highest mean DMFT (1.73) and Northern Metropolitan had the lowest (0.90).

Adults

2.8 The key indicators typically used for adult oral health are the percentage of edentulous (i.e. those without teeth) among 65+ year olds and DMFT among 35 to 44 year olds. Clinical data on oral health of adult Australians and Victorians are sparse, but the oral health of Victorians in these age groups is worse than for the Australian population. For example, the 1999 National Dental Telephone Interview Survey revealed the percentage of edentulous Victorians aged 65 or over as 40.1 per cent compared with 33.4 per cent for Australia.

2.9 Data for 35 to 44 year old public dental patients, collected through the Adult Dental Programs Survey 1995-96, indicated that the mean DMFT among that group was 12.5 for Victoria and 13.4 for Australia, i.e. on this measure the Victorian adult population appears to have slightly better oral health.

RISK FACTORS AND STRESSORS CURRENTLY FACING PUBLIC DENTAL SERVICES

Children

2.10 Four key risk factors facing public dental care in Australia have been identified. They particularly affect school-based dental services, and have the potential to deteriorate the relatively good oral health of children⁸. These “real or emerging problems” identified for school dental services are:

• existing pockets of children at high risk of dental disease;

• inequalities in access to school-based dental care across States and Territories, with Victorian and NSW children the most affected in Australia;

• capital stock at the end of its working life, with the need for reinvestment to maintain safety and quality of care; and

• resources being thinned and stretched across greater numbers of children, to the extent that quality of care as judged by parents, children, and providers may be diminishing.

Adults

2.11 For a large portion of the adult population, the investment that has been made in school dental services for children’s oral health is not followed by a commensurate investment in maintenance during adulthood. Approximately one-third of adults are eligible to use community dental services but only a small minority of eligible adults do so. We recognise that this could be a matter of choice or the result of resource limitations. The numbers accessing the private sector are not known.

2.12 The problems identified for adult community dental services are:

• low use by the eligible population, raising concerns about lack of any dental services for many adults, or the hardship faced by others in purchasing private dental services;

• the high percentage of users whose use of community dental services is limited to emergency care, and the limited scope of treatment received, especially the high number of extractions performed;

• the lack of emphasis in the community dental services on maintenance of teeth and prevention of oral disease or its recurrence;

• the lack of higher level services for patients with special needs; and

• the lack of continuity of dental care as reflected in the absence of recall or incremental programs.

2.13 An additional risk to the service system relates to characteristics of patients who are eligible for public dental services. Compared with patients accessing private dental care, public patients tend to:

• have poorer levels of oral health and greater rates of complete tooth loss;

• have more recent experience of oral health problems;

• be older, have lower education levels and are more likely to be retired or unemployed; and

• be from a non-English speaking background, particularly those accessing care in community health centres.

2.14 In general, such patient-related factors are likely to make the provision of dental services in the public sector more difficult than in the private sector⁹.

Work force

2.15 The ability to recruit and retain a clinical work force is also a stressor facing public dentistry. Adult community dental services are experiencing a shortage of dentists, while School Dental Services are experiencing a shortage of dental therapists, dentists and dental assistants. This is discussed in Part 5 of this report. Dental service provision in the Australian context is predominantly private practice-based. The public sector is competing with the private sector for a limited supply of clinical staff and traditionally has had difficulty recruiting.

Fluoridation of the water supply

2.16 Water fluoridation was first introduced to Australia in Beaconsfield in Tasmania in 1953, and now covers two-thirds of the Australian population¹⁰. Water is not the only source of fluoride but it is considered beneficial due to its ready ability to be controlled, absence of consumer compliance issues, and the fact that the amount of fluoride received is in constant but very small quantities. All capital cities in Australia, excluding Brisbane, have implemented water fluoridation at varying concentrations depending on climate and geography. Outside metropolitan areas there is often no water fluoridation.

2.17 The Australian Institute of Health and Welfare Dental Statistics and Research Unit cites fluoride as “the keystone to the prevention of caries in Australia”¹¹. Data from the Victorian School Dental Service clearly shows a decline in dental caries from the early 1980s or even late 1970s, particularly in metropolitan Melbourne where water fluoridation was introduced in 1977.

2.18 Table 2C containing data from the Victorian School Dental Service shows that a higher percentage of Victorian children in fluoridated communities are decay-free or have no decay experience across all age groups, than those in non-fluoridated communities. The absolute benefit ranges from 0.95 dmft for 3 to 5 year olds to 0.27 DMFT for 12 to 14 year olds.

TABLE 2C
VICTORIAN CHILDREN’S DECAY EXPERIENCE (a),
DMFT AND dmft (b),
1996-97

(a) Based on children using the School Dental Service: fluoridated communities – sample population 15 775; non-fluoridated communities – sample population 8 064.

(b) DMFT relates to caries experience in the permanent or secondary teeth (usually used for age groups 12 years and older) and dmft relates to the deciduous teeth (used for age groups younger than 12). In this table, the index used for children 3 to 11 years is dmft and for 12 to 14 year olds is DMFT.

Source: National Health and Medical Research Council, Review of Water Fluoridation and Fluoride Intake from Discretionary Fluoride Supplements, 1999, based on data provided by Dental Health Services Victoria.

2.19 The above data show the oral status of children in fluoridated communities to be clearly better than that of children in non-fluoridated communities. Despite this evidence, and a wide body of research that indicates improved oral health outcomes in fluoridated areas, there remain communities within Victoria, inhabited by large populations, where the water supply is unfluoridated. For example, the major regional centres of Geelong, Ballarat and Wodonga remain unfluoridated due to local resistance to the practice in the 1980s. Chart 2D provides an illustration of the distribution of fluoridation throughout the State.

CHART 2D
DISTRIBUTION OF FLUORIDATION IN VICTORIA (a)

(a)Water fluoridation status in Victorian population centres greater than 5 000 people, 2002.

Notes:
* Portland is naturally fluoridated: no fluoride is added to the drinking water supply, fluoride levels are generally lower than optimal fluoridation level.

** Optimally fluoridated water contains approximately 1 milligram of fluoride for every litre of water.

Source: Map prepared by GISCA, Adelaide University, May 2002.

2.20 The Government has encouraged Water Authorities to engage their communities in discussions about fluoridation and, where there is community support, to introduce this key public health measure. Both the Department of Human Services and Dental Health Services Victoria have undertaken initiatives to encourage the uptake of fluoridation throughout the State. However, the failure of some communities to take this proven preventive action means that the burden of the poorer oral health status of people in those communities, who are eligible to use public dental health services, is disproportionately borne by the remainder of the State.

PUBLIC DENTAL SERVICES IN VICTORIA

2.21 A number of oral health studies show that the socially disadvantaged visit dentists less frequently than the rest of the community, are more likely to have teeth extracted rather than filled and are less likely to get preventive care¹². Governments have taken a role in providing public dental care to the poorer sections of the community. In Australia, persons eligible for adult public dental care are generally holders of concession cards, such as the unemployed and aged pensioners. Primary school-aged children, predominantly, are also recipients of public dental services through the School Dental Service.

2.22 In Australia, approximately 15 per cent of dental services for adults are provided publicly. Faced with increasing demand, public adult dental services in Australia see it as desirable to give priority to:

• acute emergency dental needs;

• the socially, physically and psychologically disadvantaged, and disabled; and

• people with combinations of greater needs and propensity for oral health gains¹³.

Delivery framework

2.23 The Rural and Regional Health and Aged Care Services Division of the Department of Human Services has responsibility for the full range of health and aged care services in rural and regional Victoria. The Division also has policy and program responsibility for a range of programs, including public dental health for which the Division’s Dental Health Unit is accountable.

2.24 Dental Health Services Victoria (DHSV) was established in 1996 through the amalgamation of the Royal Dental Hospital of Melbourne, the School Dental Service and the Community Dental Program. The Department funds DHSV under a Health Service Agreement to manage the provision of community and school dental services across the State.

2.25 The Victorian public dental service system aims to provide community dental services to all primary school children, concession card holders and their dependents through:

• the Community Dental Program, including:

• adult dental services and the Youth Dental Program, which are provided in public dental clinics managed by DHSV or contracted to community health centres or hospitals; and

• 3 schemes which provide vouchers for provision of services by private dentists: the Victorian Emergency Dental Scheme, the Victorian General Dental Scheme and the Victorian Denture Scheme;

• the School Dental Service, which is provided through fixed-site and co-located clinics and mobile dental vans; and

• several small programs targeted at special needs groups, including the Gerodontic Program, special needs projects and pre-school dental services.

Adult and youth dental services are provided in public dental clinics.

School Dental Service mobile dental vans visit schools to treat children.

2.26 Chart 2E shows the structure under which community dental care is provided throughout Victoria.

CHART 2E
VICTORIAN COMMUNITY DENTAL SERVICES
DELIVERY FRAMEWORK

Note: The chart details the framework for delivery of community dental services. A range of other public dental services are provided by Dental Health Services Victoria, including specialist and emergency services through the Royal Dental Hospital of Melbourne.

Source: Victorian Auditor-General’s Office.

Funding

Commonwealth

2.27 In the past, the Commonwealth Government played a direct role in the provision of public dental care through:

• The Australian School Dental Scheme, introduced in 1973 to maximise the oral health of children irrespective of their family’s social circumstances and recognising the dependency children have on others to enable them to access dental services. (Public dental health services for Australian children began after World War One, but were limited until the late 1960s, when school-based dental programs began.); and

• The Commonwealth Dental Health Program introduced initially as an emergency scheme in January 1994 and expanded to include general care in July 1994.

2.28 In 1981, the Commonwealth rolled funding for school dental services into block funding for community health provided to State Governments. Widespread Commonwealth funding of dental health was withdrawn in 1997 with the cessation of the Commonwealth Dental Health Program. However, the Commonwealth Government has continued to play a direct role in the provision of dental care for veterans, indigenous persons, the armed services, some in-patient services under Medicare and dental care related to a cleft lip/palate scheme. These groups make up 3 per cent of all public dental care¹⁴.

State

2.29 Chart 2F shows that Victoria’s public dental health budget has incrementally increased since the withdrawal of Commonwealth funding in 1997 and that now, with the inclusion of funds generated from co-payments¹⁵, i.e. patient contributions to the cost of their dental treatment, is (in unadjusted terms) slightly above the level reached in 1995-96.

CHART 2F
TRENDS IN VICTORIAN PUBLIC DENTAL HEALTH FUNDING,
BY SOURCE
($million)

Source: Department of Human Services.

2.30 In 2001-02, $83.1 million was budgeted by Parliament for the Dental Health Output Group ($84 million 2002-03). Of that amount, $63.5 million was provided by the Department of Human Services to DHSV, of which $55.9 million funds clinics or private providers for the direct provision of community dental services under the Community Dental Program and the School Dental Service. Chart 2G shows the distribution of the funds for community dental services.

CHART 2G
COMMUNITY DENTAL SERVICES,
FUNDS PER PROGRAM,
2001-02
(per cent)

Note: Co-payments relating to the 3 voucher schemes are included in the public Community Dental Program component, as they were not separately identified in the data provided.

Source: Department of Human Services.

2.31 In 2001-02, community dental clinics treated 171 934 patients representing a 13 per cent participation of eligible adults, youth and pre-school children, while 110 072 children were treated under the School Dental Service. The overall participation rate at 30 June 2002 for the School Dental Service was 52 per cent including an 80 per cent participation rate among children of concession card holders.

Oral health promotion

2.32 In 1999, the Government introduced its strategy for oral health, Promoting Oral Health 2000-2004: Strategic Directions and Framework for Action. The goal of the strategy is to “prevent and control oral disease and [to] promote oral health amongst the Victorian population”¹⁶.

2.33 The oral health promotion strategy was made up of several “action plans” that identified key interventions, organisations and partnerships that would help develop effective oral health promotions. The action plans covered the following areas:

• “community education and skills development in oral health promotion to develop improved oral health knowledge, attitudes and behaviours of all Victorians;

• development of environments which are supportive of good oral health;

• facilitation of adequate and appropriate access to fluoride;

• facilitation of, and support for, the continued development of oral health research and surveillance; and

• development of the oral health promotion capacity of the oral health and community workforce, to enhance oral health promotion practice in the mainstream primary health care and community support system”¹⁷.

2.34 The strategy lists a number of desired oral health outcomes, namely:

• reduced incidence of dental caries (decay);

• reduced incidence of oral cancers;

• reduced incidence of periodontal diseases;

• reduced incidence of oral trauma; and

• the realisation of social and emotional health and wellbeing associated with improved oral health.

2.35 A key component of this strategy is the provision of dental services to those individuals unable to access such services from private dentistry and seen to be at risk.

Special needs programs

2.36 In Promoting Oral Health 2000-2004: Strategic Directions and Framework for Action the Department of Human Services identified facilitating access to dental services for vulnerable and disadvantaged groups as a priority. These groups include:

• people with a mental illness;

• people living in supported residences;

• the homeless;

• people using drug and alcohol treatment programs and those on methadone programs;

• people with disabilities;

• Aboriginals and Torres Strait Islanders;

• people who are home-bound, including those in residential aged care facilities;

• people with HIV/AIDS;

• new arrivals to Victoria under refugee or special humanitarian programs; and

• young people.

2.37 A relatively small but increasing number of individuals participate in special needs programs. Individuals with special needs may also access dental services through the Community Dental Program.

¹ Australian Institute of Health and Welfare, Australia’s Health 2000, Canberra, pp. 46-7, 2000.

² Australian Health Ministers’ Conference, Steering Committee for Oral Health Planning, Oral Health of Australians, National planning for oral health improvement, South Australian Department of Human Services, August 2001.

³ JM Armfield, KF Roberts-Thomson and AJ Spencer, The Child Dental Health Survey, Australia, 1998, AIHW Cat. No. DEN 88, Australian Institute of Health and Welfare Dental Statistics and Research Series No. 24, 2001.

⁴ The number of permanent teeth with dental decay experience (decayed, missing and filled teeth) is represented by the acronym “DMFT”, while the number of deciduous teeth with dental decay experience is represented by the acronym “dmft”. The dmft score of 5 to 6 year olds is an internationally accepted indicator of oral health.

⁵ Care should be taken in interpretation of this information, however, as these data are derived from users of school dental services and could be biased by differences in the way services are delivered between States. For example, the 52 per cent of Victorian children who use the School Dental Service are likely to be at higher risk of caries than those who do not use the Service.

⁶ Australian Institute of Health and Welfare Dental Statistics and Research Unit, The Child Dental Health Survey, Victoria 1999, AIHW Cat. No. DEN 87, 2001.

⁷ For administrative and program management purposes, the Victorian Department of Human Services divides the State into 9 operational regions, comprising 4 metropolitan regions (Western Metropolitan, Northern Metropolitan, Southern Metropolitan and Eastern Metropolitan) and 5 rural regions (Loddon Mallee, Hume, Grampians, Gippsland and Barwon).

⁸ AJ Spencer, What options do we have for organising, providing, and funding better public dental care? Australian Health Policy Institute at The University of Sydney, Commissioned Paper Series 2001/02, 2001.

⁹ JM AC Campain and FAC Wright, Adult dental services in Melbourne: accessibility and client satisfaction, Community Dental Monograph Series No. 9.

¹⁰ AJ Spencer, Time trends in exposure to optimally fluoridated water supplies among Australian adolescents, Community Dental Oral Epidemiol 12:1-4, 1984.

¹¹ Australian Institute of Health and Welfare Dental Statistics and Research Unit, Australia’s Oral Health and Dental Services, AIHW Cat. No. DEN 13, 1998.

¹² S Ziguras and C Moore, Improving the dental health of people on low incomes, Brotherhood of St Laurence and the Australian Council of Social Service, April 2001.

¹³ AJ Spencer, op. cit., 2001.

¹⁴ AJ Spencer, op. cit., 2001.

¹⁵ Co-payments were introduced in Victoria in April 1997 and apply to all adult concession card holders, i.e. Pensioner Concession Card holders or their adult dependents, and Health Care Card holders and their adult dependents. Co-payments do not apply to emergency and general care provided to concession card holders under 18 years of age, or card holder dependents under 18, or to care provided to patients by undergraduate students in any community clinic including the Royal Dental Hospital of Melbourne. People from special needs groups, and individuals with a mental illness or intellectual disability, are also exempt from co-payments. The co-payments range from 9 to 25 per cent of the scheduled fee.

¹⁶ Victorian Department of Human Services, Promoting Oral Health 2000-2004: Strategic Directions and Framework for Action, December 1999.

¹⁷ Victorian Department of Human Services, Promoting Oral Health 2000-2004: Strategic Directions and Framework for Action, December 1999.