Health Workforce Oral Health Background Paper. February 2013

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1 Health Workforce Oral Health Background Paper February 2013

2 Health Workforce Australia This work is Copyright. It may be reproduced in whole or part for study or training purposes. Subject to an acknowledgement of the source, reproduction for purposes other than those indicated above, or not in accordance with the provisions of the Copyright Act 1968, requires the written permission of Health Workforce Australia (HWA). Enquiries concerning this report and its reproduction should be directed to: Health Workforce Australia GPO Box 2098 Adelaide SA 5001 Telephone: Internet: Suggested citation: Health Workforce Australia 2012: HW Oral Health, Background Paper HW 2025 Oral Health, Background Paper

3 Contents Introduction... 1 Why do we need the HW Oral Health project? How do Australians get their oral health care?... 3 Private health insurance... 3 Public services Which population groups have greater oral health needs or face additional barriers to accessing services?... 7 Elderly... 7 Low socioeconomic status... 7 Special needs... 9 Rural & remote What does the oral health workforce look like? Demographics Registered workforce Non-registered workforce Becoming part of the oral health workforce Immigration Recent Commonwealth Government Initiatives Background policy Current schemes closed 1 December Existing schemes Dental Reform Package - Dental Benefits Amendment Bill Appendices HW 2025 Oral Health, Background Paper

4 Appendix A Quarterly dental services, total benefits paid and fees for services, September 1995 to June Appendix B Current adult oral health services provided by the States and Territories Appendix C Current child oral health services provided by the States and Territories References HW 2025 Oral Health, Background Paper

5 Introduction Health Workforce Australia (HWA) was established under the National Partnership Agreement on Hospital and Health Workforce Reform in 2009 to progress health workforce reform and addresses the challenges of providing a skilled, innovative and flexible health workforce in Australia. One of HWA s major tools towards achieving this is workforce planning. Health Workforce 2025 (HW 2025) provided Australia s first major, long-term, national projections for doctors, nurses and midwives and presented the best available planning information on our future health workforce. HWA indicated in these reports that the next steps were to expand the range of workforces covered, develop and improve methods of scenario analysis and undertake economic analysis to quantify the cost to allow an assessment of the relative affordability of the modelled scenarios. The HW 2025 Oral Health (HW 2025 Oral Health) project is the next phase of this series. Why do we need the HW Oral Health project? Having good oral health means being able to eat, speak and socialise without discomfort or embarrassment and without active disease that affects overall wellbeing. Good oral health is an integral part of good general health, and is essential to being able to participate in daily activities without limitation, or without physical or psychological discomfort as a result of poor oral health 1. Efforts to improve oral health are guided by Australia s National Oral Health Plan , prepared by the National Advisory Committee on Oral Health, which aims to help all Australians retain as many of their teeth as possible throughout their lives, have good oral health as part of their general good health, and have access to affordable and quality oral health services 2. Australia had two important achievements in oral health in the 20th century: the first was large gains in child oral health associated with widespread access to fluoride, and the second was the decline in tooth loss in adults. As a result of changes in patient preferences and dental practice, fewer Australians are experiencing edentulism (complete tooth loss) and it is now almost exclusively a condition of old age. In addition, adults who are not edentulous are keeping more teeth than in the past as fewer decayed teeth are extracted and more are treated with restorations (fillings) 1, 3. In recent years, reports from the National Health and Hospitals Reform Commission and the National Advisory Council on Dental Health have focussed on inadequacies in Australia s oral health system, highlighting pressure on the oral health workforce to meet the demand for services in particular groups of the population 4-7. Australia s National Oral Health Plan states that demand for oral health care services will continue to grow, in response to population growth and ageing, increased tooth retention into older age, greater awareness of the importance of oral health, and more advanced restorative procedures and technologies 2. On page 3, the plan describes a population health approach to oral health, in which the programs, services and institutions of public health emphasise the prevention of disease and the health needs of the population as a whole. This approach was HW 2025 Oral Health, Background Paper 1

6 developed in response to growing recognition of the importance of the social, economic, cultural and environmental determinants of health. The plan further notes a population health approach offers a way to manage the growing demand for oral health services, utilising both private and public sector resources as effectively as possible, and working across sectors and communities to maximise oral health gains and promote oral health across the community 2. What will the HW Oral Health project do? HW2025 Oral Health will address the central question of what is the right number and mix in the oral health workforce to best meet changing demographic and policy requirements to 2025? This question will be addressed through the process of health workforce planning. In the context of the plan, health workforce planning is the process of estimating the right number in the oral health workforce with the right skills and skill-mix, and in the right place at the right time, to meet future service requirements. This will also reflect the current issues and policy levers that have an effect on the workforce. The National Oral Health plan is also being updated and it will be important that the HW Oral Health project complement this work. HW 2025 Oral Health, Background Paper 2

7 1 How do Australians get their oral health care? Private health insurance With the majority of the oral health workforce in private practice, most services in Australia are provided by the private sector, with or without the assistance of private dental insurance 2, 8. The Australian Institute of Health and Welfare s (AIHW) report Insurance and use of dental services : National Dental Telephone Interview Survey 2010 states insurance may be considered an enabling factor that can assist in access to services, and having dental insurance has been identified as a buffer against the financial burden of dental care 8. For the purpose of this paper, patients with dental insurance refers to patients with general treatment insurance (commonly sold as extras cover ), which usually includes dental insurance 8. As of 30 September 2012, 54.5% of the Australian population have general treatment insurance 9. During the September 2012 quarter there were 7,827,196 services delivered and $460 million in total dental benefits paid 9. Appendix A provides quarterly data on the number of dental services, total benefits paid and fees for services, from September 1995 to June Table 1 provides annual data on the total number of dental services, benefits paid, fees for services, and average benefit per service and fees charged per service Table 1. Annual data: total dental services, benefits paid, fees for service, and average benefit per service and fees charged per service, Year Services Benefits Fees Benefit per Fees charged service per service ,999,526 1,187,205,240 2,414,323,368 $49.47 $ ,071,695 1,283,302,783 2,638,144,068 $51.19 $ ,687,191 1,414,241,884 2,925,375,186 $52.99 $ ,739,510 1,509,763,524 3,118,928,845 $54.43 $ ,829,591 1,605,632,781 3,295,090,696 $55.69 $ ,966,431 1,713,893,281 3,445,141,918 $57.19 $ Source: PHIAC, Data on services, benefits paid and gap payments by MBS Specialty Block Groupings for medical services paid by private health insurers, extracted 10 October The results of the National Dental Telephone Interview Survey 2010, conducted by the Australian Research Centre for Population Oral Health (ARCPOH), show a higher proportion of Australian adults with insurance made a dental visit in the last 12 months (70.9%) than adults without insurance (48.3%). Adults who visited in the last 12 months made 2.3 dental visits on average, and this did not vary between those with and without insurance. This indicates that while insurance may have enabled access to dental care, it did not lead to a greater demand for visits once access had been obtained (but might lead to a greater demand for more expensive services though). A higher proportion of adults with dental insurance visited for a check-up (66.1%) than adults without insurance (50.2%) 8. HW 2025 Oral Health, Background Paper 3

8 The results also show a higher proportion of adults with dental insurance had scale and clean services in the previous 12 months (83.5%) than adults without insurance (63.6%). A lower proportion of adults with insurance had fillings (37.2%) than adults without insurance (43.9%). A lower proportion of adults with insurance had extractions (10.4%) than those without insurance (19.0%). Additionally, a lower proportion of adults with insurance received dentures (3.2%) than adults without insurance (6.3%). Insurance was associated with a different reason for dental visits and a different pattern of services that was more oriented to prevention and retention of natural teeth 8. Further to this, the survey results found that dental insurance status was a much stronger predictor of visiting patterns than Australian Government concession cardholder status. The proportions of adults who made a dental visit in the previous 12 months were similar for cardholders and non-cardholders with insurance (68.3% and 73.0%) and without insurance (46.4% and 52.1%). Average numbers of dental visits were similar for cardholders and noncardholders with insurance (2.6 and 2.2 visits) and without insurance (2.4 and 2.3 visits). However, cardholders with insurance were far more likely than cardholders without insurance to have visited for a check-up at their most recent dental visit (61.9% and 40.4%) 8, 10. The results show the proportions of adults who had scale and clean services were similar for cardholders and non-cardholders with insurance (81.2% and 83.4%) and without insurance (57.3% and 67.4%). The proportions of adults who had extractions were also similar for cardholders and non-cardholders with insurance (15.2% and 10.4%) and without insurance (23.8% and 17.5%) 8. AIHW s report Trends in access to dental care among Australian children, based on data collected from , notes in general, children with private health insurance, or those covered by their parents private health insurance, are more likely to have favourable visiting patterns and are at lower risk of experiencing oral disease than those without insurance 11. In general, children with insurance are more likely than uninsured children to make a dental visit at least once a year, and are more likely to visit for the purpose of receiving a check-up rather than treating a problem. Uninsured children are generally more likely than insured children to receive extractions and fillings 11. Public services Australia s National Oral Health Plan states that while the Commonwealth continues to play a direct and indirect role in the financing of dental services, responsibility for the delivery of the major public programs for disadvantaged adults and children is managed by the States and Territories 2. A full overview of services is provided in Appendix B Current adult oral health services provided by the States and Territories, and Appendix C Current child oral health services provided by the States and Territories. For adults, public service access is largely determined by eligibility for concession cards 9. Eligible adults can generally access public dental services from age 18, with the exception of Queensland where eligibility is from above the age and completion of year The type of concession card which allows access to public dental services and the amount of co- HW 2025 Oral Health, Background Paper 4

9 payment varies across the states and territories. However, the type of services available is generally similar across jurisdictions and is limited to emergency dental care and general dental treatment. Services are delivered by public dental clinics mainly located in community health centres or on hospital grounds. Waiting times are significant, with the average exceeding two years in some states 9. For children, eligibility also varies across the jurisdictions. There are also differences in the models of service delivery. Western Australia (WA), Queensland and South Australia (SA) have dedicated school dental programs. The Northern Territory (NT) uses a hybrid model consisting of community-based services and school dental programs. New South Wales (NSW), Victoria, Tasmania and Australian Capital Territory (ACT) rely predominantly on community-based clinics 9. All dental schools throughout Australia provide clinical dental care to the community. The treatment provided by students (around 7%) is performed under the supervision of registered dentists. University-managed clinics include those at the University of Queensland, Griffith University, University of Newcastle, Charles Sturt University and James Cook University. In Victoria, South Australia and NSW public health managed clinics are run from the Royal Dental Hospital (University of Melbourne), Adelaide Dental Hospital (University of Adelaide) as well as the Westmead Centre for Oral Health and the Sydney Dental Hospital (University of Sydney). Students also provide public patient services through some student placements in public clinics. The private sector also contributes to the treatment of patients through publicly funded schemes including the NSW Oral Health Fee for Service Scheme, SA General Dental Scheme, SA Emergency Dental Scheme, SA Pensioner Denture Scheme and WA Government Subsidised Oral Health Care Schemes. The Commonwealth Government directly finances these services to eligible individuals 2 : Medicare Teen Dental Plan Veteran s Affairs programs the Armed Forces and Army Reserve Dental Scheme the Cleft Lip and Cleft Palate Scheme oral health services provided through Community Controlled Aboriginal Medical Services, (managed by the States and Territories, Commonwealth-funded) oral health services in the Christmas and Cocos Islands, and for asylum seekers in community detention some specialist oral surgery and oral radiography through Medicare, and subsidised drugs prescribed by dentists under the Pharmaceutical Benefits Scheme. Table 2 provides a summary of eligibility criteria for these programs. HW 2025 Oral Health, Background Paper 5

10 Table 2. Eligibility for Commonwealth oral health programs Service Eligibility Criteria Medicare Teen Dental Plan The Child Dental Benefits Schedule will overtake this program on 1 January 2014 and offer a subsidy for basic dental services for eligible 2-17 year olds. Veterans Affairs Armed Forces and Army Reserve Dental Scheme Cleft Lip and Cleft Palate Schemes Community Controlled Aboriginal Medical Services Oral health services in the Christmas and Coco Islands, and asylum seekers in community detention To be eligible for a voucher for a preventative dental check a teenager must be 12 : aged between years, and eligible for Medicare, and: - getting the Family Tax Benefit (Part A), ABSTUDY, Carer Payment, Disability Support Pension, Parenting Payment, Special Benefit or Youth Allowance, or - their family/guardian/carer gets the Family Tax Benefit (Part A), Parenting Payment or the Double Orphan Pension for the teenager, or - their partner gets the Family Tax Benefit (Part A) or Parenting Payment, or - are aged years and getting financial assistance under the Veterans Children Education Scheme or the Military Rehabilitation and Compensation Act Education and Training Scheme from the Department of Veterans Affairs. Important: a teenager may still be eligible if the above conditions are only met for a minimum of one day in the calendar year. Veterans who have served in the Australian Defence Force are eligible for free dental treatment but entitlements vary between Department of Veterans Affairs (DVA) White Card and Gold Card holders 13. The DVA Gold Card is also issued to dependents and widows/widowers who have access to these services 14. Employees of the Army are eligible for free dental treatment 14. If an adult or child have a cleft lip or cleft palate condition, the schemes provide Medicare benefits for a range of dental treatment including: a limited range of orthodontic work, surgical extraction of teeth, some general and prosthodontic services by a private practitioner, and oral and maxillofacial surgery by an oral and maxillofacial surgeon. A person must be registered before the age of 22 to be eligible. An eligible person receives a cleft lip and cleft palate identification card and can claim benefits until the age of 28. Once over the age of 28, card holders can only claim for the repair of previous reconstructive surgery 15. eg. Aboriginal Medical Service Western Sydney, Nganagganawili Aboriginal Health Service 16, 17 Community controlled Aboriginal health and medical services provide culturally appropriate services, including oral health care, to Indigenous persons residing in the area. Detainees on the islands have access to free oral dental care. In 2009 the Human Rights Commission noted that detainees faced long waiting lists as there is only one dentist on Christmas island to meet the needs of both the local community and detainees 18. Medicare ineligible asylum seekers are provided with health services (which normally require a Medicare Card) including public dental services in each state or territory. HW 2025 Oral Health, Background Paper 6

11 2 Which population groups have greater oral health needs or face additional barriers to accessing services? Elderly Australia s National Oral Health Plan highlights the oral health of older people as a priority action area 2. The plan notes that older people generally refers to people aged 65 years and older. On page 23, the plan distinguishes Aboriginal and Torres Strait Islander people, with a life expectancy some 20 years less than the Australian average, and defines the term old as age 45 and above for this group. Findings on the activity of dentists in private general practice from ARCPOH s Longitudinal Study of Dentists' Practice Activity show that between and the percentage of patients 65 years or more increased from 11.3% to 14.1% 19. Edentulism across all age groups decreased (3.1% in to 1.3% in ), and a trend over the period was tooth extraction replaced by measures allowing people to keep their own teeth, as reflected in a reduction in extractions and an increase in restoration work. Reflecting the decline in tooth loss, the percentages of patients visiting for denture problems decreased (30.3% to 15.8%) among patients aged 65 years or more. There were corresponding increases in the percentages of older patients attending for recall/maintenance care (11.4% to 20.9%) 19. The study found that the number of diagnostic services per visit increased among older patients, reflecting increased rates of radiograph services among patients aged 65 years or more. The rates of crown and bridge services per visit increased among older patients while there were significant decreases in rates of full dentures and partial upper dentures, yet an increase in the rate of partial lower dentures. The total number of services per visit increased among patients aged 65 years or more 19. The study concluded that there are increasing numbers of older patients who are retaining their teeth, and these patients may have complex treatment needs that require more services and take longer to complete. Such changes in oral health, demographics and use of services will impact on the practice activity of the workforce 19. Low socioeconomic status Australia s National Oral Health Plan notes that profound disparities exist across socioeconomic groups in Australia in respect to oral and general health. People of lowest socioeconomic status the poor and disadvantaged carry the highest burden of disease and the incidence of caries and periodontal disease increases as socioeconomic status decreases. Socioeconomically disadvantaged groups include low-income earners and their families, some young adults and older people, some people from non-english speaking backgrounds, Indigenous Australians, and a significant proportion of people living in rural and remote areas 2. HW 2025 Oral Health, Background Paper 7

12 In 2012, AIHW reported on the shape of the socioeconomic-oral health gradient based on the results of ARCPOH s National Dental Telephone Interview Survey , 8. The report illustrates when the adult population is divided into thirds by household income (adjusted for the size of the household), oral health improves incrementally from the lowest income group through to middle and higher incomes, as illustrated in table 3. The report notes that adults with the lowest one-third of household incomes are more likely to have lost all their teeth, and if they have their own teeth, adults on lower incomes are more likely to have more missing teeth than adults on high incomes. These differences translate to affecting everyday activities for which people rely on well-functioning teeth. Adults on lower incomes are more likely to experience toothache, to avoid certain foods and to feel uncomfortable with their appearance than adults on higher incomes 1, 8. Table 3. Oral health indicators, by household income, 2010 Group Self rated oral health (a)(b) (per cent) Edentulism (c) Missing teeth (a)(c) Experienced toothache (a) (d) (per cent) (average number) (per cent) All Australians Household equivalised incomes: Uncomfortable with appearance (c) (e) Avoided food (f) (per cent) (per cent) Lowest Middle Highest (a) Relates to dentate persons (those with any of their natural teeth). (b) The proportion of people who rate their oral health as good, very good, or excellent. (c) This question asked only for persons aged 18 and over. (d) The proportion of people who experienced toothache sometimes, often or very often in the past 12 months. (e) The proportion of people who felt uncomfortable about the appearance of their teeth, mouth or dentures sometimes, often or very often during the past 12 months. (f) The proportion of people who avoided eating some foods because of problems with their teeth, mouth or dentures sometimes, often or very often during the past 12 months. Source: National Dental Telephone Interview Survey, Oral health care is more difficult to access for those on low incomes, with often years-long waiting lists for public care, while private care can be prohibitively expensive 2. Average waiting times for general care are 27 months and can extend to five years 7. Wait lists for emergency care are significantly shorter. Many patients start on public dental waiting lists seeking preventative or restorative treatment but become emergency cases by the time they receive treatment 20. The significant wait for dental services can lead to a piecemeal approach to care, with people seeking treatment through numerous emergency dental visits 7. HW 2025 Oral Health, Background Paper 8

13 Special needs In its advice to Parliament on priorities for consideration in the budget, the National Advisory Council on Dental Health identified people with special needs, noting that this group experience much higher levels of oral disease and face additional barriers to accessing dental care 7. According to Australia s National Oral Health Plan special needs refers to people with intellectual or physical disability, or medical or psychiatric conditions, that increase their risk of oral health problems or increase the complexity of oral health care 2. Australia s National Oral Health Plan highlights the following points 2 : Approximately 2.4 million people are aged less than 65 years of age in Australia with at least one disability or long-term health condition; 6% of Australians are reported to have severe/profound disabilities; Whilst there is no published data to support accurate estimates of the numbers whose disability would increase the risk of oral health problems or the complexity of oral health care, expert opinion estimates that around 1 million people would be in the special needs category for oral health; People with special needs experience higher levels of oral health disease and poorer access to oral health care than the general population; For many people with special needs, socio-economic disadvantage adds to their risk of oral disease and difficulties in accessing dental care; Access to dental care is difficult for those with special needs, particularly for those in community-based housing; and Treatment can also be more difficult when oral health care is obtained due to complex medical conditions, physical and behavioural barriers. Special needs patients receive predominantly emergency care, rather than general dental care. Their limited access to care may be further aggravated as the treatment required by many patients is beyond the capacity of the private surgery setting. More patients therefore require treatment through hospital admission or under general anaesthesia 21. For special needs patients in supported accommodation, the move from institutions to communitybased housing has meant that some cannot access public dental services which, in the past, cared for residents in institutions 2. HW 2025 Oral Health, Background Paper 9

14 Aboriginal and Torres Strait Islanders Australia s National Oral Health Plan highlights the oral health of Aboriginal and Torres Strait Islander peoples as a priority action area 2. Although there have been a number of studies of the oral health of Aboriginal and Torres Strait Islander people, AIHW s report, Australia s Health 2012, suggests that there are a number of gaps in nationally representative data on their oral health 1. AIHW notes that methods used to collect data on adult oral health tend to under-represent Indigenous Australians, especially those living in remote locations, however all comparisons point to poorer oral health among Indigenous Australians than other Australians 1. The results of ARCPOH s National Survey of Adult Oral Health show that the rate of untreated caries was 2.3 times more in the Indigenous than the non Indigenous adult population, with 57% of Indigenous adults having one or more teeth affected compared with 25% of non Indigenous adults, and there was also greater tooth loss 22. The survey results showed Indigenous children experience more caries that non Indigenous children in their deciduous (baby) teeth, with caries rates in Indigenous children aged 4-10 years being significantly higher than for their non Indigenous counterparts in NSW, SA and the NT. The highest overall caries rate was for Indigenous six-year-olds, who experienced 2.4 times the caries rate of non Indigenous children of that age, while four-year-old Indigenous children had more than three times the caries rates of non Indigenous four-year-olds 22. Poorer oral health for Indigenous children continues among those with permanent teeth with the caries rate being 1.5 times greater for Indigenous children aged 6-15 years than for their non Indigenous counterparts 22. The findings also illustrate a significantly higher incidence of periodontal disease in Indigenous Australians (both adult and children) (34.2%) compared to non-indigenous people (26.7%). Of dentate Indigenous Australians, 19.6% have fewer than 21 teeth, compared to 14.2% of non-indigenous Australians 22. Services Currently, public oral health services give priority access to Aboriginal and Torres Straight Islanders. In NT however, Aboriginal and Torres Strait Islanders are not specifically prioritised as these patients are the core patient population. In NSW, 18 Aboriginal Medical Services, funded by NSW Health provide free oral health services to Indigenous residents 23, 24. Across urban, regional and remote Australia, over 150 federally-funded Aboriginal Community Controlled Health Organisations (ACCHOs) primarily service the health needs of Aboriginal and Torres Strait Islander people. Those with dental programs can have varying eligibility criteria, and some charge co-payments or a small contribution fee 25. In 2012, a $719 million funding investment was provided as part of Australian Government s Stronger Futures package. The Government is providing the investment over 10 years to improve the health and wellbeing of 65,000 Aboriginal people in the Northern Territory. More than 12,000 children will also have access to preventive oral HW 2025 Oral Health, Background Paper 10

15 health services through outreach services, to improve oral health practices, and reduce dental problems. The National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people was updated and rereleased in These guidelines developed by the National Aboriginal Community Controlled Health Organisation (NACCHO) for the Royal Australian College of General Practitioners (RACGP), outline screening and appropriate health interventions for Aboriginal and Torres Strait Islander groups. While the guidelines were developed for general practice, they have wider application when considering the oral health treatment of these groups 26. In 2008, the Indigenous Dentists Association of Australia (IDAA) published its Indigenous oral health goals as part of the Closing the Gap Campaign 27. The goals include increased Indigenous participation in the oral health workforce, and the provision of high quality, culturally-appropriate oral health care to Indigenous people that is organised and coordinated regionally. Adding to this, in 2010 the Ministerial Council for Federal Financial Relations published the Implementation plan for national Indigenous mobile dental infrastructure: Alice Springs, Implementation plan for national Indigenous mobile dental infrastructure: Orange, Implementation plan for national Indigenous mobile dental infrastructure: Queensland, highlighting the increased need for indigenous-dedicated services in these areas Rural & remote Following a mid-term review of Australia s National Oral Health Plan , a supplementary action area covering residents of rural and remote areas was developed by the National Oral Health Plan Monitoring Group and subsequently endorsed by the Australian Health Ministers' Advisory Council. Additionally, ARCPOH S 2008 report Improving Oral Health and Dental Care for Australians, prepared for the National Health and Hospitals Reform Commission, highlighted rural residents as among the groups in Australia that are more likely to have unfavourable dental visiting patterns, with a greater likelihood of poor oral health outcomes. According to the report, the rates of untreated caries in rural residents is 31.7% compared with 24.8% in urban residents, and the rate of moderate to severe periodontal disease is 32.8% in rural residents compared to 26.1% in urban residents 31. For children, sixyear-olds in rural areas will have 50% more decayed, missing and filled teeth compared with same-aged children in the major cities, and 12-year-olds will have 30% more decayed, missing and filled teeth compared with their counterparts in the major cities 32. AIHW reported in Australia s Health 2012 that rural and remote adult residents are about 1.7 times as likely to have no natural teeth, and those who do have natural teeth have 25% more missing teeth than adults who live in major cities, as illustrated in table 4 1. However, this increased tooth loss did not translate to higher rates of adverse oral health effects, such as feeling uncomfortable with their appearance, avoiding foods or experiencing toothache, or to worse self-rated oral health. These variations in oral health can be attributed in part to differences in access to the means to prevent dental disease, and to differences in access to HW 2025 Oral Health, Background Paper 11

16 timely dental treatment for dental disease when it is needed. For Australians living in nonmetropolitan areas, both can be a problem 1. Table 4. Oral health indicators, by household income, by location, 2010 Group All Australians Location: Self rated oral health (a)(b) (per cent) Edentulism (c) (per cent) Missing teeth (a)(c) (average number) Experienced toothache (a) (d) (per cent) Uncomfortable with appearance (c) (e) (per cent) Avoided food (f) (per cent) Major cities Other areas (a) Relates to dentate persons (those with any of their natural teeth). (b) The proportion of people who rate their oral health as good, very good, or excellent. (c) This question asked only for persons aged 18 and over. (d) The proportion of people who experienced toothache sometimes, often or very often in the past 12 months. (e) The proportion of people who felt uncomfortable about the appearance of their teeth, mouth or dentures sometimes, often or very often during the past 12 months. (f) The proportion of people who avoided eating some foods because of problems with their teeth, mouth or dentures sometimes, often or very often during the past 12 months. Source: National Dental Telephone Interview Survey, The Royal Flying Doctor Services 2012 Dental Discussion Paper, supplied to HWA but not publically release, summarises some of the major factors impacting on oral health in rural and remote communities 25 : Poor access to dental services and care often with a history of irregular dental visits and programs which can affect continuity of patient care; Limited access to oral health advice and information; An expectation in some areas that dental care is for emergency and relief of pain, hence there can be difficulty in getting patients to return for routine care when available; People have to travel long distances for dental care and there is no financial support for transport for routine dental care, or dental emergencies; In areas of no/low dental workforce, GPs and other health staff are often the first to be consulted for dental pain and infection, leading to a higher use of antibiotics and analgesics; and Varying levels of dental infrastructure in place across the country, with no standardisation of equipment. HW 2025 Oral Health, Background Paper 12

17 Dental school clinics make a significant contribution in sustaining a rural presence. The Australian Government Department of Health and Ageing funds a Dental Training - Expanding Rural Placements (DTERP) Program. This program aims to improve the availability of rural dental care and strengthen the rural dental workforce. The DTERP program supports six Australian dental faculties to develop extended rural training programs. These faculties are the University of Adelaide, University of Melbourne, University of Sydney, University of Queensland, University of Western Australia and Griffith University. The program is designed to encourage dental students to take up a career in rural practice by providing positive, high quality clinical education and training experiences for dental students in rural areas. Capital and operational funding is provided to support at least 30 fulltime equivalent clinical placements annually (five per university) for dentistry students in established rural training settings. HW 2025 Oral Health, Background Paper 13

18 3 What does the oral health workforce look like? Demographics The oral health workforce is made up primarily of those registered with the Dental Board of Australia through the Australian Health Practitioner Regulation Agency (AHPRA). Prior to the 2010 introduction of the National Accreditation and Registration Scheme, registration was with state and territory dental boards and data from this period reflects collated state data. A majority of the data presented in this section has been sourced from AIHW s National Dental Labour Force Collections (previously administered by ARCPOH). Data from 2011 has been sourced from AIHW National Health Workforce Dataset: dental practitioners There is no systematic collection of workforce data for the non-registered - the data presented in regard to these support roles has been sourced from the ABS Census of Population and Housing. Table 5 shows the total number registered in Australia and the total number practicing in Australia from 2000 to For example, in 2011 there were 14,179 dentists registered with the Dental Board of Australia (the Board) and of these 12,734 were working in dentistry 33. Table 5. Oral health workforce headcount, 2000 to 2011 Registered Oral Health Workforce Oral Health Workforce Dentists 10,109 10,922 11,160 12,271 14,179 Oral health therapists Dental therapists (a) 698 1,559 1,364 1,383 1,165 Dental hygienists (b) ,206 Dental prosthetists 1,028 1,034 1,039 1,137 1,145 Total registered (c) 12,214 14,201 14,732 16,416 18,803 Practicing Oral Health Workforce Dentists 8,992 9,678 10,404 11,882 12,734 Oral health therapists Dental therapists 1,317 1,242 1,171 1,234 1,044 Dental hygienists ,065 Dental prosthetists ,013 1,088 Total non-registered 11,596 12,375 13,541 15,652 16,925 Dental Assistant N/A N/A 15,380 N/A 18,822 Dental Technician N/A N/A 2,556 N/A (d) 2192 Grand Total N/A N/A 31,477 N/A 37,939 Source: dentists, oral health therapists, dental therapists, dental hygienists and prosthetists sourced from the AIHW AIHW Dental labour force collection (Cat. no. DEN 218) 35 and AIHW Dental workforce 2011 (Cat. no. HWL 50) 33. Dental Assistants and dental technicians sourced from ABS Census data. HW 2025 Oral Health, Background Paper 14

19 (a) There was no registration process for dental therapists in NSW, Qld, SA, Tasmania and the ACT in 2000, Dental Labour force, Australia 2000 (AIHW cat. no. DEN 116) (b) There was no registration process for dental hygienists in NSW and Qld in 2000, Dental Labour force, Australia 2000 (AIHW cat. no. DEN 116) (c) Total registered excludes registered therapists and hygienists in states with no registration process in 2000 (d) The number of dental technician for 2011 (2,192) is a projected figure based on the growth rate from 2001 to 2006 Registered workforce Definitions for the registered workforce will be provided by the Dental Board of Australia once approved. Dentists and dental specialists Dentists who wish to become dental specialists undertake additional training and qualifications. The Dental Board of Australia recognises 13 specialist fields: Dento-maxillofacial radiology Endodontics Oral and maxillofacial surgery Oral medicine Oral pathology Oral surgery Orthodontics Paediatric dentistry Periodontics Prosthodontics Public health or community dentistry Special needs dentistry Number of dentists and dental specialists Of the practicing dentists in 2011(12,734), the vast majority (12,154) were working in clinical practice as either in general practice or as a specialist. The proportion of all practicing dentists that are specialists has remained fairly stable since 2000 (11.4%). Working dentists also includes the small proportion of dentists who identified that their main area of work is in nonclinical practice; including administration (177, 1.4%), teaching and education (244, 1.9%), research (48, 0.4%) or other areas of dentistry (111, 0.9%). About three quarters of specialists are consistently concentrated in a small number of specialties. The most popular specialties in 2011 were orthodontics (40%, 567), oral and maxillofacial surgery (11.5%, 164), prosthodontics (11.2%, 161) and periodontics (13.7%, 196). These are the same top four specialties as in 2000 with little change to the proportions, although the slight reduction in the proportion of orthodontists (44% in 2000) and oral and maxillofacial surgeons (16.8% in 2000) has been shared among the other specialties. A group of other niche specialties, including ones like public health dentistry and special needs dentistry remains a small group but grew between 2000 and 2009 (0.9% to 5.9%). HW 2025 Oral Health, Background Paper 15

20 Table 6. Registered practicing dentists (including specialists), selected characteristics by alternative data sources Total number 8,992 9,678 10,404 11,882 12,734 Average age Average hours per week (a) % female % aged 50 and over TBA Source: AIHW Dental labour force, Australia 2000 (Cat. no. DEN 116) 34 AIHW Dental workforce 2011 (Cat. no. HWL 50) AIHW Dental labour force collection (Cat. no. DEN 218) Age and gender profile As shown in table 6, the average age of a practicing dentist in 2011 was 43.5 years. This represents a departure in the trend of gradually increasing average age over the past decade (45.2 years in 2009 compared to 44.3 in 2000). The 2011 data shows a consistent growth (4.2% approx.) in the proportion of female dentists (35.6%) over the past decade (22.7% in 2000). Even though the proportion of female dentists has increased gradually over the past decade, dentistry remains male dominated (64.4% male dentists in 2011). Figure 1 highlights the age pattern of women and men with substantially more men in the older age groups and slightly more women in the youngest age group (20-34 years). Figure 1: Number of registered dentists, by age group and sex, 2011 Age group (years) Males Females ,000 2,000 1,000 1,000 2,000 3,000 Number Source: AIHW Dental workforce 2011 (Cat. no. HWL 50) HW 2025 Oral Health, Background Paper 16

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