“WHY IS HE NOT SMILING?” DENTAL COSTS STUDY PHASE ONE

Transcription

“WHY IS HE NOT SMILING?”
DENTAL COSTS STUDY PHASE ONE
FINAL
REPORT
August 2008
Health Issues Centre Inc.
Level 5, Health Sciences 2
LA TROBE UNIVERSITY VIC 3086
(03) 9479 5827
Email:
Fax: (03) 9479 5977
[email protected]
Websites:
www.healthissuescentre.org.au
www.participateinhealth.org.au
We suggest that this report be cited as follows:
Horey, D., Naksook, C., McBride, T. and Calache, H., 2008, Why is He not Smiling: the
Dental Costs Study Final Report. Health Issues Centre, Melbourne.
TABLE OF CONTENTS
PAGE NO:
ACKNOWLEDGEMENTS
5
EXECUTIVE SUMMARY
8
PART A:
1.
2.
14
1.1
1.2
1.3
1.4
1.5
1.6
14
14
15
16
20
20
Rationale for the Study
Broader Context
Victoria’s Public Dental Service
Dianella Community Health
Impacts of Oral Health Status
Dental Cost Study
RESEARCH PLAN
22
2.1
2.2
2.3
2.4
2.5
2.6
22
22
23
23
25
26
Aims
Research Method
Sample Size
Data Sources
Recruitment
Reliability
RESULTS
ALL STUDY PARTICIPANTS
Overview
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
4.
14
INTRODUCTION
PART B:
3.
BACKGROUND
Limitations of the Study
Response to Recruitment
Who Took Part?
Use of Dental Services
Oral Health Status
General Health Status
Proposed Treatment and Costs
Key Issues
COMPARISON OF WAITING TIMES
Overview
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
Demographic Profile
Oral Health and General Health
Clinical Outcomes
Oral Health Impact Profile
Costs of Proposed Treatment and the Treatment Plans
Impact of Proposed Treatment on Number of Functional Teeth
Key findings
“Why is He Not Smiling?”
Dental Costs Study Phase One Final Report
Health Issues Centre, August 2008
28
28
28
30
31
32
34
36
43
46
47
48
48
49
49
51
54
59
59
61
62
3
5.
QUALITATIVE DATA FROM THE QUESTIONNAIRE
Overview
5.1
5.2
5.3
5.4
5.5
6.
7.
Oral Health and Quality of Life
Barriers to Public Dental Services
The Consequences
Key Issues
64
64
65
66
68
70
71
NON PARTICIPANT SURVEY
74
6.1
6.2
6.3
6.4
Survey Method
Responses
Why People Did Not Take Part
Key Issues
74
74
75
78
DISCUSSION AND CONCLUSION
80
7.1
80
Key Findings
8.
REFERENCES
88
9.
APPENDICES
92
APPENDIX ONE:
APPENDIX TWO:
APPENDIX THREE:
APPENDIX FOUR:
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
FIVE:
SIX:
SEVEN:
EIGHT:
NINE:
TEN:
APPENDIX ELEVEN:
APPENDIX TWELVE:
STUDY PROTOCAL
COMPLETE LIST OF DATA ITEMS
DIANELLA’S LETTER OF OFFERING ON
AN APPOINTMENT
HEALTH ISSUES CENTRE’S LETTERS
EXPLAINING THE STUDY
PROJECT INFORMATION SHEET
CONSENT FORM
NON PARTICIPANT SURVEY
INTERVIEW QUESTIONNAIRE
RELIABILITY TESTING
PROPOSED TREATMENT ITEM NUMBERS
BY TREATMENT TYPE AND WAITING TIME
ADDITIONAL TABLES FOR CHAPTER 3
MEAN COSTS, NUMBER OF PROPOSED
TREATMENT BY TYPE AND BY GROUP
92
98
100
101
103
107
108
109
117
118
118
127
132
4
ACKNOWLEDGEMENTS
Health Issues Centre, in collaboration with Dental Health Services Victoria and
Dianella Community Health, conducted the study with funding support from the
Department of Human Services Victoria, the Victorian Health Promotion Foundation
and Dental Health Services Victoria.
The Project Reference Group provided advice and support. It comprised:
Mark Sullivan
Dr Sachidanand Raju
Nella Larubina
Dr Hanny Calache
Dr Rodrigo Marino
Frank McNeil
Judith Cassar
Tony McBride
Dell Horey
Charin Naksook
Dental Health Services Victoria
University of Melbourne
Consumer representative
Consumer representative (until August 2006)
Health Issues Centre
Health Issues Centre (until December 2007),
Australian Institute for Primary Care
Health Issues Centre
Additional advice was sought from:
Professor John Spencer Adelaide University
Dr Jane Harford
Adelaide University
Dr Charles Livingstone Monash University
Pauline Brophy, Zahra Lassi and Helen Walls conducted most of the interviews.
Martin Whelan of Dental Health Services Victoria provided technical assistance in
the data collection.
Dr Rodrigo Marino of the University of Melbourne assisted with the reliability testing
analysis.
We would like to acknowledge the invaluable contributions of all staff members at
Dental Practice, Dianella Community Health, especially Nella Larubina and reception
staff who assisted with recruitment of study participants; Dr Rosemary Phillipos, Dr
Thanh Nguyen, Angela Black and clinical staff who conducted dental examinations
for all study participants.
We are especially grateful to the public dental patients at Dianella Community
Health who kindly took part in the study.
Dell Horey, Charin Naksook, Tony McBride and Hanny Calache wrote the report.
5
6
7
EXECUTIVE SUMMARY
The Dental Costs Study (DCS) is the first comprehensive study of the comparative
costs of public dental care in Victoria. It investigated the costs of delayed dental
treatment for users of public dental health clinics1 among two groups of dental
patients. One group was on the waiting list for more than two years (Group A) and
the other group was on the waiting list for two to four months (Group B). The
study also explored the impact of delayed dental treatment on health and social
behaviours.
Health Issues Centre, in collaboration with Dental Health Services Victoria and
Dianella Community Health, conducted the study at Dianella Community Health,
Broadmeadows, between September 2006 and February 2007. Funding for the
study was provided by the Department of Human Services Victoria, the Victorian
Health Promotion Foundation and Dental Health Services Victoria.
Comprehensive data were collected through a mixed method approach combining
clinical data with structured interviews and data from non-participants. The costs
measured in this study are based on proposed treatment plans, and do not include
the costs of emergency dental services or co-payments. This study is by no means
an evaluation of Dianella’s staff performance or the quality of services they provide.
Two hundred and forty-six (246) public dental patients took part in the study. One
hundred and thirty (130) had been on the waiting list for two years or more (Group
A), and 116 on the waiting list for two to four months (Group B).
Key findings
Cost of proposed dental treatment
The costs of proposed dental treatment for people in the study ranged from $46 to
more than $4,000, with an average cost of $924. This average cost is higher than
expected, and almost three and a half times higher than the average cost of
general dental treatment for public patients in Victoria of $271.2 Nearly 80% of
people in the study had proposed treatment costs greater than the state’s average.
This difference raises concerns about whether low income Australians receive all the
dental treatment they require and whether actual treatment differs markedly from
proposed treatment. There are also issues about the variation in need among those
seeking public dental services and how this variation is managed.
The mean costs of proposed dental treatment were slightly lower for people in the
short-waiting Group B compared with those in the longer-waiting Group A ($912
compared with $936). Although this difference of less than 3% is statistically
significant, it is not financially significant (see Section 4.6).
The calculation of the proposed costs of treatment did not include costs associated
with dental treatment from emergency dental services, or private dentists,
undertaken while people were waiting for an offer of treatment from the public
dental clinic.
1
For details about the Dental Costs Study, go to www.healthissuescentre.org.au\projects\index.asp
The 2006-2007 figure from Clinical Analysis and Evaluation, DHSV. As with the study’s average, it does not include dental
voucher and emergency services.
2
8
Distribution of cost and types of treatment
A major finding of the study was the distribution of costs for the proposed
treatment types. Overall, only 8% of all proposed treatment costs were allocated to
preventive care. The smallest proportion of costs (2%) was for the proposed
management of periodontal disease, even though more than a fifth of the study
population (22%) showed evidence of advanced periodontal disease and more than
six in 10 showed evidence of calculus (that indicates a need for scaling and
cleaning; 61%). More than one-third of the proposed costs were for fillings or
restorative treatment (37.7%), and nearly a quarter of proposed costs were for
dentures (see Section 3.7).
Differences in the proposed costs between the two groups were apparent in all
types of treatment apart from preventive care. The average cost for the proposed
treatment among the longer-waiting Group A was higher for diagnostic services and
periodontal, endodontic and restorative treatments, and for dentures. Costs for oral
surgery and other services—mainly interpreter services—were higher for the
shorter-waiting Group B (see Section 4.6).
Oral health
We found strong evidence of continuing inequalities in oral health status. The
majority of study participants had a number of indicators of poor oral health.
Compared with the results of the National Survey of Adult Oral Health (NSAOH)
(2004–2006;Slade, Spencer et al. 2007), more adults in this study had:
•
Inadequate dentition—20 or fewer natural functional teeth (51% DCS
vs 11% NSAOH)
•
High levels of gum disease—advanced gum disease (22.2% vs 2.4%)
and moderate gum disease (53.6% vs 20.5%).
Only nine (3.6%) out of 246 people in the study had at least 20 natural functional
teeth and all associated supporting periodontal tissues (gums) healthy.
More than 40% of people in this study reported they had visited a dentist in the
previous 12 months (42.9%), about two-thirds the rate of dentate Australian adults
(Slade, Spencer et al. 2007). The majority of these visits for people in this study
were for emergency dental treatment (57% [see Table 4.3]), whereas nationally
only 38 percent of dental visits are for emergency care (Slade, Spencer et al.
2007).
Some differences in oral health between the two groups were apparent. Clinical
examination of the two groups found that the longer-waiting Group A presented
with a greater proportion of gum disease (87.7% vs 79.3%, p<0.05) and required
more periodontic, restorative, and endodontic treatments (see Table 4.12).
The treatment plans also suggested different needs, although this picture is
somewhat complicated by the relatively low number of natural teeth present. More
extractions were proposed for the shorter-waiting Group B, and given that it
averaged fewer natural teeth than Group A at examination, these additional
extractions would considerably worsen their oral health status and increase the
probability for future dentures or dietary deficiencies, with subsequent general
health implications.
9
Impact of oral health
The majority of study participants reported social costs associated with their quality
of life from issues related to oral health. For example, in the previous month, over
half reported avoiding cold foods (56%) compared with 17% of Australian adults in
the 2004–06 National Oral Health Survey (NOHS) (Slade, Spencer et al. 2007).
Over half reported experiencing pain because of problems with mouth or teeth
(56% compared with 15% in the NOHS). More than a quarter reported feeling selfconscious often or very often because of their oral health (28%) and more than
20%reported experiencing interrupted or unsatisfactory meals often or very often
in the previous four weeks (See Tables 3.7 and 3.8).
One in four people said they felt embarrassed or tense fairly often or more
frequently because of problems with their mouth or teeth, and one in six people in
the study reported using over-the-counter medication to manage dental pain fairly
often or more frequently (17%). One in 10 people reported that problems with their
oral health affected intimacy with others and with sleeping. Of those for whom it
was relevant, more than one in seven felt their job prospects were affected by
problems with their teeth, mouth or dentures (See Tables 3.7 and 3.8).
General health
Despite a large majority (86%) rating their health as good or better, people in the
study reported a high level of health-seeking behaviour. Most had seen their GP in
the last six months (87%), with more than half of these reporting three or more
visits in that time (see Table 3.10).
People in the study generally rated their general health more highly than their oral
health (see Table 4.5 and Figures 4.2 and 4.3). Self-ratings of general health were
generally lower than other Australian adults, For example, 50.8% of the study
population rated their health as excellent or very good, compared with 56% of
Australian adults (Australian Bureau of Statistics 2007b).
Response to offer of treatment
There was a relatively low response to offers of treatment experienced in this study
even when incentives were offered, which was comparable to the usual response to
offers of treatment at the community health centre. However, the response
improved with the addition of a follow-up telephone call to the recruitment process.
Our experience raised concern about issues affecting people’s decisions about their
use of public dental care, specifically the high prevalence of poor literacy.
10
Recommendations
The study revealed that this group of public dental patients had significant dental
needs. Apart from the often repeated but still very important recommendation to
significantly increase funding for public dental care, we make the following
recommendations across the areas of policy development, public dental service
practice, and further research.
Policy development
Public dental policy needs to promote a population health focus aimed at preventing
avoidable tooth loss. It should include the following elements: early identification of
need, early intervention, prevention and appropriate treatment.
Specific issues need immediate short-term strategies:
•
Greater capacity to reduce the waiting list
•
Action to maximise oral health as people wait for dental treatment.
•
Develop and implement
preventive care.
•
Promotion of health literacy in regard to dental care.
workforce
structures
to
provide
effective
Funding mechanisms are needed that facilitate effective triage, a population health
approach, and that remove disadvantages to providing preventive care.
Public dental service practice
Public dental clinics need to create supportive environments that enable oral health
practitioners to provide effective dental treatment and preventive care.
Increase promotion of good dental health as part of good general health. To be
relevant and effective, targeted strategies for disadvantaged communities need to
be developed in partnership with those communities.
There is an urgent need for the introduction and evaluation of interventions to help
people preserve their teeth while waiting for dental treatment. This may include a
preventive care appointment with dental hygienists.
Strategies to improve the uptake of offers of dental treatment such as telephone
calls need to be trialled and evaluated to find ways of improving responses to
treatment offers.
Further research
More research is needed to investigate the costs related to public dental programs
and the needs and experiences of clients to help reduce inequalities in access to
dental care. This research could include:
•
An economic evaluation of the impact of oral health on other health
outcomes.
11
•
An economic evaluation of the costs of public dental care, which
includes the costs of emergency and private dental care, should be
conducted.
•
The Dental Cost Study should be repeated in other public dental clinic
populations to compare findings across population and service
groups.
•
A longitudinal study of Australian adults registered for public dental
care, to explore motivating factors and barriers to attend services and
other dental health-seeking behaviours.
•
A descriptive assessment of the socio-demographic characteristics,
oral health literacy, attitudes and health behaviour knowledge and
practices of people waiting for public dental care in Victoria. This
should include an investigation of consumer attitudes and opinions
towards public oral health services.
•
An investigation of the knowledge and use of dental vouchers among
public dental patients, to determine how to improve the use and
efficiency of vouchers in public dental care.
•
Comparison of actual dental treatment with the proposed treatment
plan in Victorian public dental services, to determine differences in
treatment and assess the usefulness of proposed treatment plans in
estimating treatment costs.
12
13
PART A: BACKGROUND
1.
INTRODUCTION
This study investigated the impacts of delayed dental treatment on the direct costs
of treatment to government and the indirect health costs and social costs for those
consumers who await public dental care in Victoria.
1.1
Rationale for the Study
A search of the literature, including a hand search of relevant Australian journals,3
was unable to locate any study that has investigated the impact of delayed dental
treatment for public dental patients; although a number of studies indicate that
failure to seek timely dental care is an important contributor to poor oral health.
This study appears to be the first Australian study that looks at the effect of
delaying treatment, in terms of its costs, both financial and social.
1.2
Broader Context
The World Health Organization (WHO 1964) defines health as ‘a state of complete
physical, social and mental well being and not merely the absence of disease or
infirmity’. Consistent with this definition, it follows that being ‘orally healthy’
means that ‘people can eat, speak and socialize without discomfort or
embarrassment, and without active disease in their mouth which affects their
overall well being’ (Oral Health Strategy Group 1994). Good oral health is more
than just having good teeth and healthy gums. Dental professionals aim to achieve
oral health by ensuring that ‘people’s lives are not affected by oral mucosal disease,
oral cancer, jaw joint problems, malocclusion, malformation or trauma to the jaw
and middle of the face’ (AHMAC 2001).
Access to dental care is important to good oral health. Healthy gums, teeth and
mouth comprise good oral health and are important to good overall health and
quality of life. Timely treatment of dental problems helps prevent oral disease and
tooth loss. The condition and number of natural teeth present have implications for
a person’s capacity to chew and eat well. People with fewer than 20 natural
functional teeth are at increased nutritional risk of an inadequate diet (Sheiham &
Steele 2001).
Despite population trends of improved oral health, Australian adults eligible for
public dental care have consistently shown lower levels of oral health compared to
other Australian adults in studies based on self-report (AIHW 2001, 2005, 2006a).
They also are more likely to rate their oral health as poor and to be dissatisfied with
life (Sanders & Spencer 2005). These self-perceptions of poor oral health are
confirmed by clinical assessments of public dental patients, which reveal a higher
rate of extractions and emergency dental treatment compared to the Australian
population (Brennan, Spencer et al. 1997; AIHW 1999; Brennan, Spencer et al.
2001; AIHW 2002a, 2002b).
3
Australian Dental Journal and Australian and New Zealand Journal of Public Health
14
One of the main reasons attributed to poor oral health among low income
Australians is their pattern of dental attendance. They are less likely to attend
dentists regularly than people from higher income groups (Chen & Hunter 1996;
Harford, Ellershaw et al. 2004; Sanders, Slade et al. 2004). This is the only known
dental self-care behaviour that differs between people with different socio-economic
status (Chen & Hunter 1996; Sanders, Spencer et al. 2006).
While there is no evidence to support the practice of annual dental visits, access to
timely clinical examination is likely to be beneficial because it enables early
detection or diagnosis, and the use of preventive interventions (Wright & Satur
2000). However, organisational barriers, such as extended waiting times, may limit
the effectiveness of dental health services to provide timely care. Limited resources
in the public sector have led to waiting times exceeding five years in some parts of
Victoria (Scopelianos 2006). In 2006, the average waiting time for all public
patients in Victoria was 26 months, although patients at the Royal Dental Hospital
in Melbourne waited less than a month for dental care (DHS 2007a).
Extended waiting times for dental visits could have a number of important
consequences for both the dental service and those receiving care. First, oral health
is likely to deteriorate, leading to a need for more extensive restorative treatment
or increased risk of tooth loss. Delayed treatment is likely to increase demand for
emergency dental services, which generally results in tooth extraction rather than
tooth preservation. This pattern of care shifts costs from preventive to emergency
treatments. Finally, there are likely to be increased costs to those waiting for
dental treatment as they seek alternative ways to manage oral conditions.
1.3
Victoria’s Public Dental Service
Dental Health Services Victoria (DHSV) is responsible for the delivery and purchase
of public dental care for children and disadvantaged adults in Victoria. The major
service is located at the Royal Dental Hospital in Melbourne. DHSV subcontracts
community health services to provide community-based dental care under
conditions set by the Victorian Department of Human Services (DHS), which funds
the system. While the average waiting time for general dental care across the state
in 2006 was 26 months (DHS 2007a) waiting times varied at different public clinics,
from less than one month to 68 months. In one-third of the clinics, waiting times
were 10 months or more above the state average (DHS 2007a).
There are two major constraints to the provision of public dental services. One is
the total funding allocated to oral health services by the Victorian Government in its
annual Budget. The second constraint is the number of oral health practitioners
available to provide care (DHS 2007b). Workforce shortages are reported in both
public and private practices.
To be eligible for public dental services, adults must be health care or pensioner
concession cardholders or their dependants. Co-payment fees apply. Currently,
the maximum service cost for eligible adults is $88 for a complete course of care, 4
excluding dentures, which generally cost the consumer around $105 (DHS 2007b).
Generally there is no provision for check-up visits.
4
A course of care begins when an assessment or examination is conducted. A course of care is deemed to be closed or completed
when all planned treatments have been provided and no further visits are scheduled.
15
Government funding for public dental services varies among agencies in Victoria. It
has been calculated based on service throughput but a new oral health service
framework is proposed that is population-catchment based (DHS 2007b). Currently,
the schedule of dental services and costing in the Community Dental Program is
based on the rates for dental services used by the Department of Veterans’ Affairs.
In 2006–2007 the average cost per course of care (Whelan 2008) for public dental
patients in Victoria was:
•
$272 for general dental care, including restorative and prosthetic
treatment
•
$190 for emergency care and general care combined
•
$97 for emergency dental care only.
These costs do not include the Victoria Denture Scheme, which involves dental
vouchers given to public patients for use in private dental services. The average
treatment cost per course of care for patients using dental vouchers in 2006–07
was $406.21 (Whelan 2008).
1.4
The study involved public dental patients in Victoria, at Dianella Community Health,
Broadmeadows campus. It was carried out between September 2006 and February
2007.
Dianella Community Health (DCH) has a large catchment area, covering most of the
City of Hume on Melbourne’s northern urban-rural fringe. It provides primary and
community health services to one of the poorest and most diverse communities in
the state.
Broadmeadows is ranked as third most disadvantaged suburb in
Melbourne (Hume City Council, Dianella Community Health et al. 2007). More than
130,000 people live in the area. The average age is 32.5 years, making it one of
the youngest municipalities in Victoria. The population is expected to grow by
about 40% over the next 10 years, especially among those aged 65 years and
more. It is a culturally diverse community, with over one-third of the population
born outside Australia. In the last seven years, people from Iraq, Turkey and
Lebanon have moved to the area. Other than English, the major languages for
residents include Turkish, Italian and Arabic. Hume has the highest proportion of
Catholic and Muslim residents compared to other local government areas in
Melbourne. The unemployment rate in Hume is above the Victorian average and
individual and household incomes are below average (Hume City Council, Dianella
Community Health et al. 2007). In 2006, less than two-thirds of the population
were in the paid workforce and nearly one in 10 was unemployed. Most people in
the workforce are employed in: manufacturing; the retail trade as clerical, sales
and service workers; or as tradespersons and related workers.
1.4.1
Dental Services at Dianella
The community dental program is offered to eligible clients by Dianella Community
Health’s Broadmeadows clinic. In the financial year 2006–2007, the dental team
treated 4829 clients and provided 42,188 treatments. These included services for
2532 patients who received emergency dental care (Dianella Community Health
2006). In 2006 and 2007 there were 4.06 effective full-time (EFT) dentists and
4.32 EFT dental nurses at Dianella for the adult dental programs. It has six dental
chairs, two of which are for school dental services. On most days dentists receive
13 to 14 dental visits each (Raju 2006). Dianella dental service operates at capacity
16
for both adult and school dental services. It has a stable dental workforce, which
allows it to maximise its resources (Dianella Community Health 2007a).
The dental service at DCH receives between 30 and 40 telephone calls every
working day—about half of these are for emergency care. Calls are assessed over
the phone by the dental receptionist and allocated to either the general waiting list
or the denture waiting list. On average, 170 patients are added to the waiting lists
each month—137 for general dental services and 33 for prosthetic services (Raju
2006).
People who report pain are transferred to a computerised triage system that
assesses the urgency of their treatment needs. Some emergency patients will be
given an appointment on the same day while others may wait up to five weeks
(Raju 2006), depending on the urgency category level that is assigned to them
through the triage system.
In February 2006, there were 5116 patients waiting for dental treatment on the
electronic dental database at Dianella. These comprised 4381 people waiting for
general services and 735 people waiting for prosthetic or denture services. The
estimated waiting time was 30.9 months for general patients (Victorian Minister for
Health 2006). This was higher than the state-wide average waiting time for
general care in March 2006 of 26 months (DHS 2007a).
It is usual practice at Dianella to mail out offers of dental appointments in batches.
Letters are sent to the 150 to 200 people at the top of the waiting list. They are
given about four weeks to make an appointment. About 30% of those offered
appointments for general services, and 60–70% of those offered appointments for
denture services make appointments. The waiting time for appointments is about 3
to 4 weeks (Raju 2006).
Dianella is estimated to require an additional 10 dental chairs. These chairs are
planned to be located in Craigieburn, but not until 2011 (Dianella Community
Health 2007b).
1.4.2
Management of waiting lists at Dianella
Agencies providing public dental care are required to manage waiting lists in
accordance with DHS policies.
The average waiting time has been a key
performance measure in the dental program and DHS has recently reviewed the
drivers and possible solutions of waiting list management (DHS 2007a).
The effectiveness of managing a dental waiting list is a function of the number of
dental chairs and dental staff available at the service (the supply), and the number
of public dental patients in the catchment areas, their needs and the complexity of
needs (the demand).
These factors can have a considerable effect on the waiting time for services. For
example, Dianella Community Health has six dental chairs (four adult and two
school dental service chairs). In this catchment area the number of eligible people
per chair is 7610 and the waiting time for general treatment is 30.9 months
(Victorian Minister for Health 2006; DHS 2007b). The nearby Darebin Community
Health Service (PANCH), which provides services in the north central metropolitan
area, has seven adult dental chairs. The number of eligible people in its catchment
area is 4095 per chair and the waiting time for general dental care is 6.3 months
(Victorian Minister for Health 2006; DHS 2007b). This is significantly higher
capacity than Dianella, and hence waiting times are very much lower.
17
Table 1.1 presents the catchment areas for public dental services in the north and
west metropolitan region. The eligible population per chair, the dental services in
the catchment area, the number of dental chairs, and the waiting time for general
treatment at each service are reported in the table. Please note that figures on the
number of dental chairs include school dental services, which are not a focus of this
study.
18
Table 1.1
Reported number of dental chairs and waiting times in
North and West metropolitan region
Catchment
area
Moonee
Valley
-
4360
Melbourne
West Bay
BanyuleNillumbik
Number of
6
dental chairs
Waiting time for
general dental
7
treatment (mths)
Doutta Galla CH Kensington
4
14.5
Doutta Galla CH Niddrie
7
14.5
Eligible
population
5
per chair
4812
5155
Dental clinics in
catchment area
Ozanam Day Centre
1
n.a.
Altona SDS
2
n.a.
Footscray SDS
5
n.a.
Isis Primary Care Wyndham
8
n.a.
Western Region Health Centre
6
41.7
Banyule Community HS
8
16.0
Nillumbik Community HS
3
38.0
4
9.3
2
6.3
7 (all adults)
7.5
2
36.9
7
11.8
9
35.7
6 (only 4 for
adults)
30.9
Moreland Community HS
3
30.0
Moomba Park SDS
2
n.a.
Sunbury Community HC
5
15.5
Isis Primary Care Brimbank
10
29.3
Melton Latrobe Site
12
n.a.
2
n.a.
114
23.51
Darebin Community HS East
Preston
Darebin Community HS
Northcote
North
Central
4095
Darebin Community HS
PANCH
North Richmond Community HC
North Yarra
North Richmond Community HC
Richmond
Plenty Valley Community HS
HumeMoreland
MeltonBrimbank
TOTAL
7610
4425
Melton Mobile Dental Van
4915
5
DHS (2007b). Improving Victoria's Oral Health July 2007. Melbourne, Victorian Government Department of Human Services.
Ibid.
7
Victorian Minister for Health (2006). Dental waiting list cut by more than 150,000. Media Release from the Minister for Health.
6
19
1.5
Impacts of Oral Health Status
Oral health can affect general health as it is closely linked to the selection and
preparation of food (Walls & Steele 2001), which in turn influences whether there is
an adequate diet, nutritional status and general health status. Adults with reduced
chewing capacity are at increased risk of cardiovascular disease, possibly due to
reduced chewing capacity, which leads to diets low in fibre and Vitamin C (Krall &
Hayes 1998; Steele, Sheiham et al. 1998; Walls & Steele 2001). Reduced dietary
fibre and Vitamin C intake has been associated with an increased risk of
cardiovascular disease, stroke and cataract formation (Khaw & Woodhouse 1995;
Ness, Powles et al. 1996; Joshipura, Douglas et al. 1998; Joshipura, Ascherio et al.
1999; Walls & Steele 2001). Reduced intake of fruit, vegetables and dietary fibre is
also associated with an increased risk of cancers in the digestive system such as
colorectal cancer (COMA 1998; Walls & Steele 2001).
Recent studies also show close links between gum disease and general health. A
meta-analysis found that the incidence of coronary heart disease significantly
increased among people with gum disease (Bahekar, Singh et al. 2007).
Heart
disease, pneumonia and the risk of preterm, low birthweight babies have also been
linked to gum disease as its causative agent can migrate to other systems in the
body (Irwin, Mullally et al. 2008). Oral disease shares risk factors with other
diseases and complicates their management (Mason 2004; Spencer & Harford
2007b).
Poor oral health also reduces quality of life in many ways. The quality of life of an
estimated one in six Australian adults is adversely affected by oral health problems
(AIHW 2006b). About one in 10 respondents in a national health survey reported
frequently experiencing painful aching, uncomfortable eating, poor sense of taste
and trouble pronouncing words; and one in 12 reported frequently feeling tense,
embarrassed or self-conscious because of problems with their mouth or teeth
(AIHW 2006b). People who suffered dental problems have been found to lack the
social confidence for successful job interviews. Dental treatment has been effective
way to help people on welfare benefits gain employment in the USA (Heffernan
2004).
1.6
Dental Cost Study
The impetus for the Dental Cost Study was the belief that delayed dental treatment
was harmful to consumers and, in the long run, more expensive to the system. We
wanted to find out if providing dental care in a more timely way (i.e. within a few
months of seeking care, rather than years) was less costly to funders and to
consumers in terms of its impact on them.
20
21
2.
RESEARCH PLAN
2.1
Aims
The primary aims of the study were to:
(a)
Investigate the costs to the health system associated with a public dental
care when dental treatment is delayed for two years.
(b)
Investigate the health and social impacts on consumers of delayed dental
treatment.
(c)
Identify potential measures to monitor the effective use of public dental
health care.
(d)
Identify areas of data required for further improvement of public dental
health services.
2.2
Research Method
The study involved two groups of users of public dental services—people who had
joined the waiting list for two or more years before their initial dental appointment
(Group A), and those who just joined; that is, only two to four months prior to their
initial appointment (Group B). See Appendix 1 for the study protocol.
The study was designed in two phases. This report covers the initial phase.
Phase One
Undertaken from September 2006 to February 2007, Phase One involved the
following tasks:
(a)
Comparison of system costs of proposed dental treatment and
study of impacts on health and social behaviours on consumers
All study participants underwent a clinical dental health assessment and had a
dental treatment plan developed as part of the usual care at the dental health
service. Data were also gathered from the dental record, and through a structured
face-to-face interview.
The proposed dental treatment plan in the form of the item numbers (the identifiers
used for specific dental treatments) was recorded by the dentist at the time of the
initial consultation. The costs to the funder of the care of proposed dental
treatment (the Victorian Department of Human Services) were calculated from the
item numbers.
Phase Two
Phase Two of the study has yet to be funded. It comprises two parts:
(b)
Assessment of use of emergency dental services among people on
waiting list
De-identified data from all eligible participants in the long wait group (Group A) will
be used to assess the use of emergency dental services and the potential impact to
subsequently accept an offer of a dental appointment.
22
(c)
Comparison of actual costs incurred against estimated costs of
original plan
This will involve a comparison of the actual treatment and the proposed treatment,
and use of emergency dental services between the two groups. Dental records of
study participants will be reviewed after 12 months to determine the actual dental
treatment and its costs. Analyses will include assessment of the pattern of
attendance, influences on adherence to treatment plans, and the use of emergency
dental services at the health centre; it will evaluate the usefulness of an initial
dental treatment plan as an economic assessment tool.
2.3
Sample Size
The estimated minimum sample size for the study was 100 people in each group.
This was based on a statistical power of 0.80, which would give an effect size of
0.40 (i.e. there would be an 80% probability of detecting changes of 0.40 standard
deviations in variables with a bidirectional test and alpha of 0.05).
Based on the value of the private dental voucher of $620, a sample size of 100 in
each group, using a statistical power of 0.80 and alpha of 0.5 would detect a 12%
reduction in dental costs.
2.4
Data Sources
There were three main data sources for the study: face-to-face interviews; a clinical
assessment; and the clinical records. Phase One data were collected at the initial
appointment for a dental examination. Prior to the examination face-to-face
interviews were conducted with consenting participants. The clinical assessment
would provide data to a clinical data sheet and the electronic dental record (see
Figure 2.1). Additional data were also collected from non-participants about their
reasons for not taking part.
All data for Phase Two will be taken from the electronic dental record. Appendix 2
contains a complete list of data items.
Figure 2.1
Initial appointment
for dental check
Face-to-face
interviews
Clinical assessment
Clinical data sheet
Electronic dental
record
23
2.4.1
Face-to-face Interviews
Structured interviews conducted at the initial dental visit collected the following
information:
Consumer demographic information
These included: gender; level of education attained; main life occupation (either
current or previous); country of birth; year of arrival in Australia (if relevant); and
language spoken at home.
Impact Profile: OHIP–14
Oral Health Impact Profile (OHIP) is a validated 14-item measure developed to rate
the perceptions of social impact relating to oral health over the preceding four
weeks (Slade 1997).
It is a shortened form of the original 49-item OHIP
instrument (Slade & Spencer 1994). It includes the dimensions of functional
limitation, physical pain, psychological discomfort, physical disability, psychological
disability, social disability and handicap. It uses a five-point Likert-type scale with
the response categories: never; hardly ever; occasionally; fairly often; and very
often, to assess the frequency of symptoms.
Impact on health and social behaviour
A 16-item scale was developed to assess behaviour relating to factors identified in
the literature as important to people’s experience of poor oral health. The
dimensions included: nutrition; pain management; productivity and employment;
and social relationships.
The scale uses a five-point Likert-type scale with response categories similar to the
OHIP-14 scale for the frequency of self-reported behaviour over the past four
weeks.
Self-assessments of oral and general health
Two items were concerned with self-assessments of health status using a five-point
scale for responses. Perception of oral health was asked as a comparative measure;
that is, oral health compared to others of a similar age. The scale used was: much
better; better; about the same; worse; and much worse. General health selfassessments also used a five-scale: excellent; very good; good; fair; and poor.
Use of dental and medical services:
Four items included in the structured interview at the initial dental visit relate to the
use of dental and medical services in the last six months, including the use of
emergency services.
Additional and clarifying comments were recorded in the structured interview,
either verbatim or as a narrative summary.
2.4.2
Clinical Data Sheet
Clinical data sheets prepared for the study were used during the initial clinical
assessment to collect the following clinical outcomes:
24
•
Periodontal assessment using the Community Periodontal Index
(CPI). 8
•
Determination of the number of functional natural teeth present.
•
Dentate status.
•
Dental treatment needs.
See Appendix 2 for details.9
As part of the clinical assessment, the dental treatment plan was recorded in the
clinical data sheet in the form of item numbers. The cost of all item numbers was
calculated for each patient using the schedule of dental services and costing in the
Community Dental Program 2006–2007. These are based on the Department of
Veterans’ Affairs rates for dental services. The average cost was also calculated for
specific dental services: diagnostic services; preventive services; periodontics (gum
disease); oral surgery (extractions); endodontics (root canal treatment);
restorative services (fillings); removable prosthodontics (dentures); and other, such
as interpreter costs.
2.4.3
Electronic Dental Records
Electronic clinical records are routinely used in community dental clinics in Victoria.
Patient records provide information about: their length of time on the waiting list;
clinical data; use of emergency dental services; types of treatment received; costs
of treatments; and co-payments paid. In Phase One of the study only limited
information from electronic dental records (i.e. length of time on the waiting list)
was accessed.
2.5
Recruitment
2.5.1
Recruitment Process
The study involved people on the dental waiting list at Dianella Community Health
Centre.
They were recruited between 31 July 2006 and 7 February 2007.
Information about the study was sent to 511 people in six batches, comprising 60
to 100 letters and included a letter offering a dental appointment from Dianella
Community Health (see Appendix 3).
The information about the study comprised: a letter explaining the study and how
to take part (Appendix 4); a detailed project information sheet (Appendix 5);
consent form (Appendix 6); and a single-page questionnaire with a reply-paid
envelope for those who did not want to participate (Appendix 7).
The information was sent to 265 consecutive patients at the top of the waiting list
who at that stage had been waiting at least two years. They were told that their
initial co-payment of $22 would be waived if they agreed to participate to
compensate for any additional time spent.
8
A method of ranking or rating a severity of periodontal (gum) disease.
The original study design included calculation of the ratio of the number of teeth decayed, missing or filled teeth compared with
the total number of teeth (DMFT or DMFS Index), but these data could not be accessed during field work.
9
25
The information about the study was also sent to 246 consecutive patients who
joined the waiting list in the previous two to four months. They were offered a
dental appointment if they agreed to take part. This group would not have their
first co-payment waived, as they did not have to wait for their examination and
treatment.
2.5.2
Non-participant Survey
As noted above, the information package sent at time of recruitment included a
single-page questionnaire and a reply-paid envelope. The questionnaire asked
people who did not want to take part in the study to give their reasons for nonparticipation (and not to reveal their identities).
2.5.3
Participation
All potential study participants were asked to attend one hour prior to their dental
appointment to participate in the interview; they were given a telephone reminder
the day before their appointment.
The study was explained to potential participants, including its purpose and
requirements. People were asked to sign a consent form indicating their permission
to access their dental records. Everyone was assured that participation was entirely
voluntary and would not affect their treatment. All potential participants who
attended the clinic received dental treatment regardless of their decision to
participate.
A face-to-face structured interview was then conducted with consenting
participants. It involved the administration of a questionnaire (see Appendix 8).
Additional comments were recorded either verbatim or as a narrative summary. An
interpreter was used when necessary. At the conclusion of the interview,
participants were given an acknowledgement for their contribution to the study.
Following the interview, study participants attended their initial dental appointment
with dentists trained for participation in the study.
2.6
Reliability
2.6.1
Minimising Bias
It was not feasible, or ethical, to randomly allocate people to different waiting
times, which is the ideal way to minimise bias in a study comparing two groups.
However, we made every effort to minimise bias where possible. We approached
people listed consecutively on the waiting list. Dentists were not told how long
patients had been on the dental waiting list for a dental appointment; that is, the
clinicians were blind as to whether the patients belonged to Group A or Group B.
2.6.2
Reliability of Dental Assessment
Two dentists were nominated by Dianella Community Health to examine
participants in the study. The two dentists and dental nurses who worked with
them were trained according to the study protocol provided by Professor Hanny
Calache (one of the study collaborators). Information about participants’ time on
the waiting list was removed from the electronic dental records to ensure that
participating dentists were blind as to which groups the patient belonged.
Administrative staff members involved in recruitment were informed about
recruitment procedures by Health Issues Centre’s project staff.
26
A random sub-sample comprising 19.5% of the study population number was reassessed at their subsequent dental visit to provide an estimate of reliability in the
clinical assessments between the two dentists who took part in the study. An extra
time of fifteen minutes was added to the second visit to allow for re-assessment
prior to the treatment.
A total of 48 people participated in the reliability testing, including 28 study
participants and 20 general dental patients. Inter-examiner re-assessment was
conducted with the 28 participants.
They were re-examined in their second
appointment by a dentist other than the one consulted in the initial appointment.
The remaining 20 underwent intra-examiner reassessment. Each of the dentists
who took part in the study repeated their clinical examination on 10 patients in
their subsequent appointments.
Data on proposed treatment plans were recorded manually as item numbers on a
clinical data sheet. Costs of proposed treatment were calculated using the schedule
of dental services and costing in the Community Dental Program 2006–2007.
Analysis was made by comparing the costs proposed by each dentist on the same
patients (inter-examiner testing) and the costs of two assessments by the same
dentist on the same patient (intra-examiner testing).
27
PART B: RESULTS
3.
ALL STUDY PARTICIPANTS
Overview
Two hundred and forty-six (246) public dental patients took part in the dental costs
study. Over 70% were born overseas, coming from more than 25 countries.
Arabic, Italian and Turkish were the most common languages used at home other
than English. Over half the people in the study were aged less than 65 years.
Women were over-represented overall, but made up less than half those aged 65
years and older. Most people had limited education; most had not completed high
school. One in five identified as a tradesperson and a similar number worked, or
had worked, in transport and production as their main job.
More than 40% had visited a dentist in the previous 12 months; lower than the
normal dental attendance rate of 62.5% among Australian dentate adults (Slade,
Spencer et al. 2007); and 57% of these visits were for emergency dental
treatment; higher than the 38% norm among public dental patients (Brennan,
Spencer et al. 1977). Nearly half the dental visits in the past 12 months were at
Dianella Community Health and about one-third were to private dental practices.
The two major reasons people had not seen dentists were costs and the waiting
time for an appointment.
Overall, the oral health status of participants was poor across several measures in
the study. Study participants had poorer outcomes compared with adults in the
National Survey of Adult Oral Health 2004–2006 (NSAOH; Slade, Spencer et al.
2007), in terms of the proportion with fewer than 21 natural teeth (51% vs 11%),
severe gum disease (19.6% vs 2.4%), and moderate gum disease (53.6% vs
20.5%).
Only 9% of study participants had at least 20 natural functional teeth present and
healthy supporting periodontal tissue (gums). The majority of participants showed
evidence of gingival or periodontal disease (71.9%).
In terms of social impacts from problems with their mouth or teeth in the previous
four weeks, 56% of study participants reported frequently avoiding cold foods
compared with 17.4% reported in the NSAOH. More than half reported experiencing
pain frequently (55.5% compared with 15% in NSAOH). In addition, 28% reported
feeling self-conscious often or very often and more than 20% reported interrupted
or unsatisfactory meals often or very often. One in four people in the study
reported feeling embarrassed or tense fairly often or more frequently because of
problems with their mouth or teeth; 17% used over-the-counter medication to
manage dental pain and one in 10 people said problems with their oral health
affected intimacy with others and with sleeping. Of those for whom it was relevant,
more than one in seven felt their job prospects had been affected by problems with
their teeth, mouth or dentures.
Most people rated their oral health as about the same as other people of similar
age, although people under 65 years tended to rate their oral health about the
same or worse than their peers. Overall, nearly one-third of all study participants
rated their oral health as fair or poorer than others (32.6%).
28
Despite a large majority (86%) rating their health as good or better than others of
the same age, people in the study reported a high level of health-seeking
behaviour. Most had seen their GP in the last six months (87%) with more than half
of these reporting three or more visits in that time (see Table 3.10).
People in the study rated their general health more highly than their oral health
(see Table 4.5 and Figures 4.2 and 4.3). Self-ratings of general health were
generally lower than other Australian adults; for example, 50.8% of the study
population rated their health as excellent or very good, compared with 56% of
Australian adults (Australian Bureau of Statistics 2007).
The study estimated the likely cost of treatment of the dentist’s plan for treatment
for each patient based on the current DHS funding formula, which uses the
Department of Veterans’ Affairs schedule. The estimated costs ranged from $46 to
$4,267. The mean proposed cost was $924.31 per person (more than three times
the average cost of care for Victorian public dental patients; $272)—the largest
proportion of which were for restorative treatments followed by dentures. The
average proposed cost for preventive treatment was $75 (8% of total proposed
costs). The management of periodontal disease was allocated the least costs, only
2%, despite the high evidence of advanced gum disease among study participants.
A more detailed analysis and key findings are presented in the rest of this chapter.
29
3.1
Limitations of the Study
This study has a number of limitations that need to be considered when its results
are interpreted. Some of these relate to the study design; others arose during the
study.
3.1.1
Costs
The costs used in this study were based on the proposed treatment plans, not the
actual treatment. Further, the costs do not include emergency dental services
sought elsewhere or co-payments by clients. The former will be addressed in the
next phase of the study. Note that there has been no attempt in this study to
quantitatively assess the financial costs borne by consumers who buy medications
and other products to manage pain while they wait for dental treatment, although
these are reflected in the qualitative data.
3.1.2
During the study it was found that the response to recruitment was much slower
than expected. We can identify two possible reasons for this. First, contrary to
arrangements agreed prior to the study, the dental clinic had to confine study
appointments to one or two days each week, and often during these weeks, only
one dentist instead of two worked for the study. The second reason may have
contributed to this decision being made. Response to the recruitment letter was
much slower than anticipated, especially among those who had recently joined the
waiting list. We expected that many more of these people would take the
opportunity to have an earlier dental appointment (within 2 to 4 months of
registering) and that the response rate would have been higher than the 30%
usually experienced by the clinic when it offers dental appointments to people at
the top of the waiting list. However, this was not so.
3.1.3
Electronic Dental Record
Prior to the commencement of the study it appeared that the proposed treatment
plan could be recorded on the electronic dental record. This was ideal as the
treatment costs could then be retrieved with minimal effort. Unfortunately,
although the data could be recorded, it was discovered that the inclusion of the
proposed treatment item numbers caused unforeseen problems with the billing
system. This made it necessary to revert to manual recording of the proposed
treatment, with additional data entry and data analysis. These activities also
extended the study timeline and increased potential for errors at each stage of the
process—recording, data entry and analysis—requiring additional data checking.
3.1.4
Reliability of Clinical Examination
Reliability of clinical examination in the study was assessed, as described in Chapter
Two. Assessment of the reliability testing shows that inter-examiner reliability for
treatment planning is moderate, with Intraclass Correlation Coefficient (ICC) of
0.30 on single measures and 0.46 on average measures. This can be interpreted
as moderate agreement between the assessment of both dentists (Landis & Koch
1977).
30
3.2
Two hundred and forty-six people volunteered to take part in the study. Of the 511
letters sent, five were returned to sender, and 350 responses were received
(response rate = 69%). Appointments were made by 288 people (56% of those
approached) and 62 returned completed non-participant questionnaires (12%). Two
days per week in the clinic were allocated to appointments for the study.
Of the 288 people who made appointments, 42 did not participate for the following
reasons: they refused (8); cancelled or rebooked their appointment time outside
the recruitment time (12); did not attend the clinic at the time for their
appointment (18); they were overlooked (2); or their appointment was made for a
non-study day (2). The response is depicted in Figure 3.1.
Two hundred and forty-six (246) patients participated in interviews and dental
examinations; 85.4% of those who initially made study appointments and 48.7% of
those approached to take part in the study (excluding those whose letters were
returned).
The response rate improved when a follow-up telephone call was added to the
recruitment protocol.
Figure 3.1: Response to letter asking people to take part in study
511
letters mailed
156
No response
5 letters
Returned to sender
62
Non-participant survey
288
Made study appointment
42
Did not take part
8 Refused
18
Did not attend
12 Cancelled appointment
2 Missed
2 Appointment error
246 took part in study
31
3.3
Who Took Part?
3.3.1
Age and Gender
Nearly half the people in the study (49.4%) were aged between 35 and 64 years.
People over 64 years made up 40% and 10.6% were aged 35 years or less. The
age range of participants was 21 to 84 years (See Table 3.1).
Women comprised almost 60% of study participants (p=0.001 [see Table A in
Appendix 11 and Figure 3.2 below]). This is higher than the usual proportion of
female of 52.3% among Australian population aged 20–84 years (Australian Bureau
of Statistics 2007). In this study, the proportion of women compared with men was
highest in the group aged under 35 years (84.6% compared with 15.4%) and was
lowest in the group aged over 64 years (48.0% compared with 52.0% [see Table B
in Appendix 11 and Figure 3.3]). Compared with the 2006 Census, the proportion
of females in the study in the younger aged groups (84.6%) is much higher than
the norm of 50.3% among Australian population aged 20–34 years (Australian
Bureau of Statistics 2007a).
Table 3.1: Age range
Age range
Total
n (%)
Less than 35 years
26 (10.6)
35-64 years
121 (49.4)
More than 64 years
98 (40.0)
Total
245 (100.0)
Figure 3.2: Gender of study participants
Male
40%
Female
60%
Male
Female
32
Figure 3.3: Proportion of study participants by gender and age group
90
80
70
60
% 50
40
Male
Female
30
20
10
0
<35yrs
3.3.2
35-64yrs
>64 years
Total
Country of Birth
Most people in the study were born outside Australia, although Australian-born
made up the single largest group of people (27.3%, [see Figure 3.4]). Overall,
people from (born in) more than 25 countries took part in the study. The second
largest groups in the study were born in the Middle East (16.7%) and Italy (16.3%
[see Table C in Appendix 11]).
Figure 3.4: Proportion of participants by country of birth
Australia
27%
Other
40%
Middle East
17%
Italy
16%
Of the 178 people who were born overseas, 163 told us when they arrived in
Australia (91.6% of those born outside Australia). Nearly 75% of these have lived
in Australia for 20 years or longer and just less than 10% arrived in the last five
years (see Table D in Appendix 11).
English is spoken at home by the majority of study participants (55.7%); Arabic is
the second most common language at home (11.8%), followed by Italian (7.7%)
and Turkish (7.3%, [see Table E in Appendix 11]).
33
3.3.3
Education and Employment
Nearly two-thirds of people in the study reported that they did not complete high
school (65.8%), including seven people (2.8%) with no formal education. The
highest level of education was the completion of high school for 15.9%, and tertiary
education of some form for 18.3% (see Table F in Appendix 11).
The five main occupation areas10 in which study participants worked or had worked
were: tradespersons (19.7%); production and transport (19.3); labourers (16.8%);
clerical or sales work (13.1%); and no paid work (12.7%). The rest worked in basic
sales (6.6%), professional areas (5.7%) or associate professional areas (2.5%).
Two people reported that their main occupation had been as managers or
administrators (0.8%, [see Table G in Appendix 11]).
3.4
Use of Dental Services
3.4.1
Last Dental Visit
Over two-fifths (40%) of people in the study had visited a dentist during the 12
months preceding the study, compared with 59.4% in the 2004–2006 National
Survey of Adult Oral Health (NSAOH; Spencer and Harford 2007a). One-fifth of
study participants had been to a dentist in the previous one to two years and
another fifth had been two to five years previously. One in eight had seen a dentist
more than five years prior and two people had never been to a dentist before (see
Figure 3.5 and Table H in Appendix 11; Spencer & Harford 2007a).
For most participants the last dental visit was an emergency visit (57.2% [see
Figure 3.6 below and Table I in Appendix 11]). The rate of emergency visits among
the study population was higher than in the NSAOH where 43.4% of people who
attended a dentists in the previous 12 months did so for a dental problem (Spencer
& Harford 2007a; Brennan, Luzzi et al. 2008).
Figure 3.5: Time since last dental visit
More than 5
years
13%
No dental visit
1%
Less than 12
months
2-5 years
21%
43%
1-2 years
22%
10
Based on the ABS Australian Standard Classification of Occupations (ASCO) 2nd edition 1997
34
Figure 3.6: Type of last dental visit
Unsure
2.4%
Not emergency
40.4%
Not emergency
Emergency
Emergency
Unsure
57.2%
Nearly half the study participants attended the Dianella Community Health Centre
for their last dental visit (48.4%); nearly one-third attended a private dental
practice (32.9%); and about one in 10 attended the dental hospital (9.8%). The
others include two people who had never previously been to a dentist and six
people whose last dental visit was in another country (see Table 3.2).
Table 3.2: Place of last dental visit
Last dental visit
Total
Dianella CHS
119 (48.4)
Private practice
81 (32.9)
Dental hospital
24 (9.8)
Other CHS
13 (5.3)
Dental technician
1 (0.4)
Other
8 (3.3)
Total
3.4.2
246 (100.0)
Reason for Not Seeking Oral Health Services
Table 3.3 shows the reasons people gave for not seeking oral health services. The
question asking people what stopped them from doing so did not specify type of
dentist—public or private. More than one of the prompted 12 reasons could be
selected. The most common reason for not seeing a dentist was the cost (77.2%),
followed by waiting time for dentist (54.9%), availability of dentist (37.4%), and
fear of dentist (26.4%).
35
Table 3.3: Reasons for not seeing dentist
All
Reason
n=246
(% group)
Cost
190 (77.2)
Waiting time for appointment
135 (54.9)
Availability of dentist
92 (37.4)
Fear of dentist
65 (26.4)
Waiting time at surgery
42 (17.1)
Location
24 (9.8)
Health problems
22 (8.9)
Communication problem
21 (8.5)
Mental health issue
12 (4.9)
Rude non-clinical staff
12 (4.9)
Rude dentist
9 (3.7)
Accessibility
8 (3.3)
*
Multiple responses were possible
3.5
3.5.1
Oral Health Status
Rating of Oral Health
A number of different ways were used to rate oral health. These included: study
participants self-rating of oral health compared to others of the same age; clinical
assessment that included the Community Periodontal Index (CPI); the number of
natural functional teeth and the proposed treatment plan; and use of the 14-item
Oral Health Impact Profile (OHIP)—a validated scale that assesses the
consequences of oral health on functional limitation, physical disability,
psychological disability, social disability and handicap.
3.5.2
Self-rating of Oral Health
More people in the study rated their oral health as “about the same” as others
(42.8%), almost one-quarter of study participants rated their oral health as better
or much better than others of the same age (24.5%); a similar proportion rated it
as worse (23.7%), and fewer than one in 10 rated it as “much worse” (8.9%, [see
Figure 3.7 below and Table J in Appendix 11]).
Nearly one-third of people in the study (32.6%) self-rated their oral health as fair
or poor. This is almost double the proportion in the NSAOH, who rated their oral
health this way (16.4%; Harford & Spencer 2007a).
36
Figure 3.7: Proportion of participants by self-rating of oral health compared
with others of the same age
%
45
40
35
30
25
20
15
10
5
0
Much better
3.5.3
Better
About the
same
Worse
Much worse
Factors influencing oral health rating
Table 3.4 shows that age was a significant factor influencing people’s self-rating of
oral health status (p=0.027), and, although the number of natural functional teeth
does appear to affect how people rate their oral health compared to others, it does
not reach statistical significance.
37
Table 3.4: Self-rating of oral health status for all participants by age range, gender and number of natural functional teeth
Much better
n (%)
Better
n (%)
About the same
n (%)
Worse
n (%)
Much worse
n (%)
Total
n (%)
Pearson’s
chi square
Age range
<35yrs
35-64yrs
65 yrs & older
2 (7.7)
5 (19.2)
7 (26.9)
8 (30.8)
4 (15.4)
26 (100.0)
4 (3.4)
19 (16.0)
48 (40.3)
36 (30.3)
12 (10.1)
119 (100.0)
4 (4.4)
24 (26.7)
46 (51.1)
11 (12.2)
5 (5.6)
90 (100.0)
10 (4.3)
48 (20.4)
101 (43.0)
55 (23.4)
21 (8.9)
235 (100.0)
Male
3 (3.2)
24 (25.3)
38 (40.0)
23 (24.2)
7 (7.4)
95 (100.0)
Female
7 (5.0)
24 (17.0)
63 (44.7)
33 (23.4)
14 (9.9)
141 (100.0)
10 (4.2)
48 (20.3)
101 (42.8)
56 (23.7)
21 (8.9)
236 (100.0)
0 (0.0)
2 (10.0)
9 (45.0)
5 (25.0)
4 (20.0)
20 (100.0)
0 (0.0)
4 (13.8)
11 (37.9)
8 (27.6)
6 (20.7)
29 (100.0)
13-20 teeth
1 (1.5)
18 (27.3)
33 (50.0)
13 (19.7)
1 (1.5)
66 (100.0)
>20 teeth
9 (7.6)
24 (20.3)
46 (39.0)
29 (24.6)
10 (8.5)
118 (100.0)
Total
Gender
Total
17.315(a)
df=8
p= 0.027
3.057(b)
df=4
p=0.548
Natural functional teeth
No functional
teeth
1-12 teeth
8.872(c)
df=4
p=0.064
a 5 cells (33.3%) have expected count less than 5. The minimum expected count is 0.76.
b 1 cells (10.0%) have expected count less than 5. The minimum expected count is 4.03.
c 1 cells (10.0%) have expected count less than 5. The minimum expected count is 4.70.
38
3.5.4 Clinical Assessment
Number of natural functional teeth
Twenty natural functional teeth are considered sufficient for effective chewing and
important for good oral health in adults (AIHW 2006). Just over half of all study
participants had fewer than 21 natural teeth (51%) compared with 11.4% of
Australian adults in the NSAOH (Roberts-Thomson & Do 2007).
In this study, 29% had between 13 and 20 natural functional teeth, 13% had fewer
than 12 natural teeth, and 9% had no natural functional teeth. The average
number of natural functional teeth among people in the study was 18.8. Details
are reported in Figure 3.8 and Table K in Appendix 11.
Figure 3.8: Natural functional teeth
None
9%
1-12 teeth
13%
More than 20 teeth
49%
13-20 teeth
29%
Periodontal Assessment
The periodontal assessment was performed on 235 study participants (97% of the
study population); 11 people were excluded because of pre-existing medical
conditions. The following data are for those people who underwent periodontal
assessment.
More than one in five people showed evidence of advanced gum disease
(periodontitis; 22.2%). This is shown in Table 3.4 where the proportion with
periodontal status in one or more sextant rated was severe (19.6%) or showing
mobility (2.6%). More than half (53.6%) had moderate gum disease and over sixty
per cent (61.1%) had evidence of calculus (indicating the need for scaling and
cleaning).
By comparison, the NSAOH in 2004–2006 found the prevalence of moderate or
severe gum disease to be 22.9% (Roberts-Thomson & Do 2007).
39
Table 3.5: Periodontal status based on community periodontal index (CPI)
Number
with at
least one
sextant
affected
n (%)
CPI
HEALTHY
(CPI = 0)
GINGIVITIS
(CPI = 1)
CALCULUS
CPI = 2)
MODERATE
(CPI = 3)
SEVERE
(CPI = 4)
MOBILITY
(CPI = 4)
EXCLUDED
a
Number of sextants affected
Mean
(s.e.)
Range of
sextants
affected
Median
Mode
Skewness
(s.e.)
63 (28.1)
0.85 (0.110)
0.35
0
0-6
1.965 (0.163)
48 (21.4)
0.45 (0.070)
0.24
0
0-6
2.846 (0.163)
138 (61.6)
2.09 (0.143)
1.56
0
0-6
0.557 (0.163)
120 (53.6)
1.24 (0.100)
0.85a
0
0-6
1.123 (0.163)
44 (19.6)
0.41 (0.065)
0.22a
0
0-5
2.598 (0.163)
6 (2.6)
0.03 (0.013)
0.03 a
0
0-2
7.047 (0.163)
77 (34.40)
0.92 (0.103)
0.46 a
0
0-5
1.581 (0.163)
calculated from grouped data
Table 3.6 shows that the large majority of people in the study had no healthy
sextants (71.9%) and fewer than one in 20 people had no evidence of gingival or
periodontal disease (4.0%).
Table 3.6: Sextants* with healthy community periodontal index (CPI=0)
Number of participants
n (%)
No healthy sextants
161 (71.9)
1 healthy sextant
17 (7.6)
2 healthy sextants
12 (5.4)
3 healthy sextants
11 (4.9)
4 healthy sextants
8 (3.6)
5 healthy sextants
6 (2.7)
All healthy sextants
Total
9 (4.0)
224 (100.0)
* The mouth is divided into six sextants defined by tooth numbers (WHO Global InfoBase)
40
3.5.5
Oral Health Impact Profile (OHIP)
Table 3.7 shows the distribution of responses to questions about the frequency of
troubles over the previous four weeks related to problems with teeth, mouth or
dentures. People who answered ‘fairly often’ or ‘very often’ were interpreted as
having the corresponding problem.
More than 40% of people in the study found eating uncomfortable fairly often or
very often because of problems with their teeth or mouth. This was the most
common problem among study participants.
Twenty-eight per cent—about two in seven—felt self-conscious because of their oral
health fairly often or very often in the previous month. Painful aching (26.0%),
feeling embarrassed (24.2%) or feeling tense (24.0%) was experienced by about a
quarter of study participants fairly often or very often. Over one-fifth of participants
reported that their meals were interrupted fairly often or very often (21.5%) or that
their diet was unsatisfactory (21.1%).
Table 3.7: Distribution of responses to oral health impact profile (OHIP) (%)
During the PAST FOUR
WEEKS, how often have
you
had trouble
pronouncing any
words
Felt that your sense of
taste has worsened
had painful aching in
your mouth
found it uncomfortable
to eat any foods
Never
(0)
Hardly
ever
(1)
Occasionally
(2)
Fairly
Often
(3)
Very
Often
(4)
Mean (SE)
80.2
2.1
9.1
3.7
5.0
72.2
2.1
14.5
5.0
6.2
0.71 (0.080)
40.4
4.1
28.6
11.0
15.9
1.58 (0.096)
28.2
4.1
26.9
8.2
32.7
2.13 (0.102)
been self-conscious
47.8
3.3
20.8
6.9
21.2
1.5 (0.104)
felt tense
46.5
5.3
24.1
7.3
16.7
1.42 (0.098)
thought your diet has
been unsatisfactory
57.0
5.8
16.1
7.9
13.2
1.14 (0.096)
had to interrupt meals
55.2
4.1
19.1
9.1
12.4
1.2 (0.096)
found it difficult to
relax
57.0
6.6
18.6
7.4
10.3
1.07 (0.091)
been a bit embarrassed
51.2
2.9
21.7
4.5
19.7
1.39 (0.102)
69.3
2.0
18.4
4.5
5.7
0.75 (0.079)
75.3
4.9
12.8
3.7
2.5
0.56 (0.070)
55.8
5.0
24.0
6.2
9.1
1.08 (0.088)
80.2
3.7
13.2
1.6
1.2
0.40 (0.056)
been a bit irritable with
other people
had difficulty doing
your usual jobs
felt that life in general
was less satisfying
been totally unable to
function
3.5.6
0.51 (0.072)
Impact on Health and Social Behaviour
The scale to assess impact of oral health problems on health behaviour is not
validated and was developed for this project based on the OHIP scale. As with the
OHIP, people who answered ‘fairly often’ or ‘very often’ were classified as having
the corresponding problem.
41
Table 3.8 shows behaviours related to the previous four weeks. Over one-third of
all people in the study reported avoiding cold foods fairly often or very often
(34.8%) and more than half avoided cold food at least occasionally during that
time. About one-sixth reported avoiding hot foods fairly often or very often
(17.9%); more than 30 per cent avoided hot foods at least occasionally (31.7%).
About one in six study participants reported using over-the-counter medications to
manage dental pain fairly often or very often (17.4%).
Table 3.8 also shows that approximately one in 10 people reported that concerns
about their oral health affected intimacy with others (11.6%), affected sleeping
(9.9%), or caused them to buy special foods (8.1%) either fairly often or very often
in the previous four weeks (see Table 3.19).
Among those to whom employment was relevant (n=103), more than one in seven
were concerned that their job prospects were affected by problems with their teeth,
mouth or dentures occasionally or more often in the past four weeks (15.6%).
Of those who smoked (n=164), 6.7% claimed they used smoking to manage dental
pain at least occasionally or more often, and, of the 191 people in the study who
drank alcohol, two (1.0%) reported using alcohol for pain very often and 14
reported using alcohol for pain either occasionally (3.7%) or hardly ever (3.7% [see
Table 3.8]).
Table 3.8: Distribution of responses to impact on health behaviour (%)
Avoided cold foods
(n=236)
Avoided hot foods
(n=244)
Used OTC painkillers
(n=244)
Medication from
doctor (n=244)
Used nutrition
supplements
(n=238)
Bought special foods
(n=242)
Found sleep difficult
(n=238)
Used traditional
remedy (n=240)
Affected social
activities (n=232)
Caused problems with
intimacy (n=232)
Stopped from
important function
(n=238)
Used alcohol for pain
(n=191)
Smoked tobacco to
manage pain
(n=164)
Missed work
(n=98)
Affected job prospects
(n=103)
Never
(0)
Hardly
ever
(1)
Occasionally
(2)
Fairly
Often
(3)
Very
Often
(4)
Mean (SE)
80.2
3.3
19.8
7.9
26.9
1.74 (0.108)
63.8
4.5
13.8
5.3
12.6
0.98 (0.093)
54.9
2.4
25.2
8.1
9.3
1.15 (0.089)
89.8
2.0
6.5
1.2
0.4
0.20 (0.041)
92.6
0.0
2.1
1.6
3.7
0.24 (0.056)
90.6
1.2
5.7
1.2
1.2
0.21 (0.045)
60.9
3.3
25.5
4.1
5.8
0.92 (0.081)
91.8
1.2
5.7
0.4
0.8
0.17 (0.040)
74.6
3.7
12.3
4.5
4.9
0.61 (0.074)
71.3
2.1
15.0
3.3
8.3
0.75 (0.084)
84.4
1.2
11.9
1.2
1.2
0.34 (0.053)
91.6
3.7
3.7
0
1.0
0.15 (0.042)
92.7
0.6
3.7
0.6
2.4
0.20 (0.059)
93.9
2.0
3.1
0
1.0
0.12 (0.055)
84.5
0
4.9
4.9
5.8
0.48 (0.114)
42
3.6
General Health Status
3.6.1
Self-rating of General Health
Self-rating of general health is a common indicator of health status. While it may
not reflect the actual health status of the person, it does show how people perceive
their own health and may provide understanding about perceived general health in
relation to oral health problems.
About half of study participants (50.8%) rated their general health compared to
others of the same age as excellent (10.4%) or very good (41.3%). A further third
described their health as good (34.2%). About one in 10 rated their health as ’fair’
(11.0%) while seven people said their health was very poor (2.9%, [see Table
3.9]).
Compared with the self-ratings of general health in the 2004–05 ABS National
Health Survey (NHS), people in this study were less likely to rate their health as
excellent (10.4% compared with 21% ABS 2007) or poor (2.9% vs 4%), and more
likely to rate their health as very good (41.3% vs 35%) or good (34.2% vs 28%)
(Australian Bureau of Statistics 2007b).
Table 3.9: Self-rating of general health compared to others by age,
gender and number of natural functional teeth
Excellent
n (%)
All
Age range
<35yrs
35-64yrs
65 yrs & older
Total
Very good
n (%)
Good
n (%)
Fair
n (%)
Poor
n (%)
Total
n (%)
25 (10.4)
99 (41.3)
82 (34.2)
27 (11.3)
7 (2.9)
240 (100.0)
4(15.4)
14 (53.8)
7 (26.9)
1 (3.8)
0 (0.0)
26 (100.0)
14 (12.1)
41 (35.3)
39 (33.6)
20 (17.2)
2 (1.7)
116 (100.0)
7 (7.2)
43 (44.3)
36 (37.1)
6 (6.2)
5 (5.2)
97 (100.0)
25 (10.5)
98 (41.0)
82 (34.3)
27 (11.3)
7 (2.9)
25 (100.0)
10 (10.4)
42 (43.8)
31 (32.3)
11 (11.5)
2 (2.1)
96 (100.0)
15 (10.4)
57 (39.6)
51 (35.4)
16 (11.1)
5 (3.5)
144 (100.0)
25 (10.4)
99 (41.3)
82 (34.2)
27 (11.3)
7 (2.9)
240 (100.0)
0 (0.0)
6 (28.6)
11 (52.4)
2 (9.5)
2 (9.5)
21 (100.0)
1 (3.4)
11 (37.9)
12 (41.4)
4 (13.4)
1 (3.4)
29 (100.0)
5 (7.1)
32 (45.7)
20 (28.6)
11 (15.7)
2 (2.9)
70 (100.0)
19 (16.2)
48 (41.0)
39 (33.3)
9 (7.7)
2 (1.7)
117 (100.0)
Pearson’s
chi square
NS
Gender
Male
Female
ALL
NS
Functional teeth
No functional
teeth
1-12 teeth
13-20 teeth
>20 teeth
3.6.2
NS
Use of Other Health Services
Table 3.10 shows the reported use of dental and other health services by people in
the study population in the previous six months.
Nearly 30% had emergency dental treatment, largely at the Dianella dental clinic. A
smaller proportion had non-emergency dental treatments (13.9%), mostly with a
43
private dentist. No further analysis of the use of emergency dental services and the
costs incurred has been done at this stage.
A large majority (87.4%) had seen a general practitioner in the last six months and
more than half of these people had three or more visits.
Hospital-based services were used by fewer people and were used less frequently.
Just under a third reported attending hospital outpatient departments (32.9%),
with the majority using them one to three times in the last six months. Eleven per
cent had attended an emergency department, with more than half of this group
doing so more than once.
44
Table 3.10: Reported use of health services in the last six months
No
n (%)
Use emergency dental service
173 (71.2)
Dianella CHS
Yes
n (%)
69 (28.4)*
Unsure
n (%)
Total
n (%)
1 (0.4)
243 (100.0)
2 (0.8)
244 (100.0)
43 (62.3)
Other public CHS
11 (15.9)
Private dentist
19 (27.5)
Used non-emergency dental service
208 (85.2)
Dianella CHS
5 (14.7)
Other public DHS
6 (17.6)
Private dentist
Saw GP
34 (13.9)
23 (67.6)
n
31 (12.6)
215 (87.4)
246 (100.0)
Frequency
Once only
24 (11.4)
2-3 times
55 (26.1)
4-6 times
63 (29.9)
> 6 times
69 (32.7)
Total
211 (100.0)
Outpatient
165 (67.1)
81 (32.9)
246 (100.0)
Frequency
Once only
34 (43.6)
2-3 times
22 (28.2)
4-6 times
12 (15.4)
> 6 times
10 (12.8)
Total
78 (100.0)
Emergency
department
214 (87.3)
27 (11.0)
4 (1.6)
241 (100.0)
Frequency
Once only
2-3 times
4-6 times
Total
14 (51.9)
10 (37.0)
2 (7.4)
27 (100.0)
* Four people attended both Dianella CHS and a private dentist for emergency dental treatment in the previous six
months.
45
3.7
Proposed Treatment and Costs
3.7.1
Mean Estimated Costs of Proposed Dental Treatment
The average estimated cost to the Victorian Government of proposed dental
treatment was $924.31 per person in the study. This is more than three times the
state average cost—$271.68—actually delivered per course of care for general
dental treatment in 2006–07; and is about twice higher than the state average
cost—$406.21—per course of care for public patients using private services through
dental vouchers. (It is planned to compare the cost of actual care against the
original treatment plan in the next stage of this project.)
Figure 3.9 shows the proportions of the types of treatment in the proposed
treatment plans (see also Table L in Appendix 11). The largest estimated average
costs are for proposed restorative treatments (37.7%) followed by dentures
(24.7%). Eight per cent were allocated to proposed preventive treatments. The
lowest average cost was for proposed management of periodontal conditions (2%).
Figure 3.9: Mean estimated costs of proposed types of treatment
Other $3
Dentures $229
Diagnostic $104
Preventive $75
Periodontal $18
Oral surgery $97
Endodontic $50
Restorative $349
3.7.2
Diagnostic
Preventive 8%
Periodontal 2%
Oral surgery 10.5%
Endodontic 5.4%
Restorative 37.7%
Dentures 24.7%
Other 0.4%
Ranges of Proposed Costs for Dental Treatment
The estimated costs of proposed dental treatment for people in the study ranged
from $46 to more than $4,000. The costs of the proposed treatment for over onequarter of all participants were between $1,001 and $2,000 (see Figure 3.10 below
and Table M in Appendix 11).
Figure 3.10: Distribution of proposed treatment costs
More than $2001
7%
$0-$300
19%
$1,001-$2,000
26%
$301-$600
24%
$601-$1000
24%
46
3.8
Key Issues
•
Most people in the study were born overseas and have lived in
Australia 20 years or more.
•
The rate of dental visits in the 12 months preceding the study is
lower than that of Australian adults in general (40% vs 60%).
•
Cost is the most common inhibitor to accessing dental services,
followed by the waiting time for an appointment.
•
The use of emergency dental care among people on, or joining,
public dental waiting lists was more common compared with
National Survey of Adult Oral Health 2004–2006 (57.2% vs
43.4%).
•
Overall, several oral health indicators of study participants were
poor. Compared with Australian adults in the NSAOH study,
participants:
o
Had lower self-rating of their own oral health
o
Had a higher proportion of inadequate natural dentition
o
Had higher prevalence of severe and moderate gum disease.
•
Fewer than one in 10 had at least 20 natural functional teeth with
associated healthy gums.
•
More than one in five had 12 or fewer natural teeth and more than
one in 10 had no natural functional teeth.
•
The average estimated cost of proposed dental treatment for
people in the study was more than $900; three times higher than
the average cost for general dental care for Victorian public dental
patients (twice as high as public patients using private services
through dental vouchers).
•
Over one-third of all proposed treatment costs were for restorative
treatments (fillings; 37.7%) and nearly one-quarter were for
dentures (24.7%).
•
Less than 10% of proposed treatment costs were for preventive
care (8.1%). Only 2% was for the management of periodontal
disease despite the high prevalence of the condition in this
population group.
47
4.
COMPARISON OF WAITING TIMES
Overview
Of the 246 study participants, 130 had been on the dental waiting list for more than
two years (Group A); 116 joined the waiting list for two to four months previously
(Group B). There were some differences in the characteristics between the two
groups, although age was the only statistically significant difference. Overall, Group
B was significantly younger than Group A.
People in Group B had joined the waiting list more recently and also tended to have
seen a dentist more recently than people in Group A. People in Group A were more
likely to identify the availability of dentists and the waiting time for an appointment
as reasons for not visiting dentists. As these differences were not statistically
significant, they could be due to chance.
Despite the lack of statistical difference there was a common trend; across a
number of indicators of oral health status Group B fared worse than Group A,
despite having joined the waiting list more recently. These indicators included the
average number of natural functional teeth (17.8 in Group B compared with 19.6 in
Group A) and self-ratings of oral health. People in Group B reported more frequent
feelings of uncomfortable eating and reported feeling that life was less satisfying
more often than those in Group A. However, clinical assessment revealed more
people in Group B had no evidence of periodontal disease compared with those in
Group A.
There were significant differences in the proposed dental treatment planned for
people who joined the waiting list more recently (Group B) compared with those
who waited two years or more (Group A). These differences included more complex
fillings, more extractions, and more dentures. Proposed restorative treatment—
treatments for management of periodontal disease, root canal therapy and
dentures—were more common among Group A. Proposed oral surgery procedures
(extractions) were more common in Group B.
If proposed treatments proceed as intended, the average number of natural teeth
will be further reduced in the two groups. The mean number of natural teeth in
Group B will reduce from 17.8 to 12.8, and in Group A it will reduce from 19.6 to
14.6.
The overall estimated dollar costs for the proposed treatment plans were lower for
Group B compared with Group A; although statistically significant, the financial
difference is slight. Apart from preventive services, estimated costs for Group B
were significantly lower for all treatment types except for oral surgery (extractions),
which was significantly higher.
Detailed analysis and more findings on the comparison of the two groups are
presented in the rest of this chapter.
48
4.1
The 246 study participants comprised 130 people who had been on the dental
waiting list for more than two years (Group A) and 116 people who had been on the
waiting list for two to four months (Group B). Figure 4.1 shows the recruitment
steps and responses given by people in both groups.
Figure 4.1: Comparison of waiting times and response to recruitment
511 letters sent
265
Waiting >2 yrs
154
made appointment
2
return to sender
246
Waiting 2-4 months
134
made appointment
3
return to sender
24
did not participate
18
did not participate
GROUP A
130
Waiting > 2 years
GROUP B
116
Waiting 2-4 months
Among the 265 people who had been waiting for a dental appointment for two
years or more and were approached to take part in the study, 58% (154) made
appointments, and 49% (130) kept the appointments and participated (Group A).
Of 246 people who had waiting two to four months and were approached to take
part in the study, 54% (134) made appointments and 47% (116) kept the
appointment and took part (Group B).
There was little difference in response rate, despite one group having only recently
joined the waiting list—less than four months. This is an unexpected result.
4.2
Demographic Profile
There was no significant difference between the two groups in terms of: gender;
whether they were born in Australia or overseas; level of education and main
occupation (see Tables 4.1 and 4.2). However, people in shorter-waiting group
(Group B) were younger than the longer-waiting group (Group A [see Table 4.1]).
A larger proportion of Group B was aged less than 35 years (15.7% compared with
6.2% in Group A), and a smaller proportion was aged 65 years or more (33%
compared with 42.6%).
49
Table 4.1: Age range, gender, born in Australia or overseas, level of education and
main occupation by group
Age range
Group A
Group B
Waiting > 2 years
Waiting 2-4 months
<35yrs
n (%)
8 (6.2)
Total
n (%)
Pearson’s
Chi
Square
n (%)
18 (15.7)
26 (10.6)
35-64yrs
62 (47.7)
59 (51.3)
121
(49.4)
7.971
65 yrs & older
60 (42.6)
38 (33.0)
98 (40.0)
130 (100.0)
115 (100.0)
245
(100.0)
p=0.01
9
Male
53 (40.8)
46 (39.7)
99 (40.2)
Female
77 (59.2)
70 (60.3)
130 (100.0)
116 (100.0)
31 (23.0)
36 (32.4)
67 (27.4)
All
df=2
Gender
All
147
(59.8)
NS
246
(100.0)
Country of birth
Australia
Italy
24 ((19.0)
15 (13.9)
39 (16.7)
Middle East
19 (15.1)
20 (18.5)
39 (16.7)
Other
54 (42.9)
38 (35.2)
92 (39.3)
126 (100.0)
108 (100.0)
234
(100.0)
All
NS
Education level
No formal education
3 (2.3)
4 (3.4)
7 (2.8)
Primary incomplete
7 (5.4)
10 (8.6)
17 (6.9)
Primary complete
30 (23.1)
14 (12.1)
44 (17.9)
Secondary incomplete
51 (39.2)
43 (37.1)
94 (38.2)
Secondary complete
21 (16.2)
18 (15.5)
39 (15.9)
Tertiary education
18 (13.8)
27 (23.3)
45 (18.3)
130 (100.0)
116 (100.0)
246
(100.0)
31 (12.7)
All
NS
Main occupation
No paid work
21 (16.4)
10 (8.6)
Managers/administrators
1 (0.8)
1 (0.9)
2 (0.8)
Professionals
5 (3.9)
9 (7.8)
14 (5.7)
Associate professionals
4 (3.1)
2 (1.7)
6 (2.5)
Tradespersons
22 (17.2)
26 (22.4)
48 (19.7)
Adv clerical & service
3 (2.3)
4 (3.4)
7 (2.9)
Clerical sales service
17 (13.3)
15 (12.9)
32 (13.1)
Production & transport
28 (21.9)
19 (16.4)
47 (19.3)
7 (5.5)
9 (7.8)
16 (6.6)
20 (15.6)
21 (18.1)
41 (16.8)
Basic clerical sales
Labourers & related
NS
50
Table 4.2: Year arrived in Australia and language at home by group
Group B
Year arrived
Australia
Group A
Waiting > 2 years
Waiting 2-4
months
n (%)
n (%)
Pearson’s chi
square
Total
n (%)
>50 yrs ago
20 (23.0)
8 (10.5)
28 (17.2)
20-50yrs ago
51 (58.6)
43 (56.6)
94 (57.7)
10-20 yrs ago
7 (8.0)
7 (9.2)
14 (8.6)
5-10 yrs ago
4 (4.6)
8 (10.5)
12 (7.4)
< 5 yrs
5 (5.7)
10 (13.2)
15 (9.2)
87(100.0)
76 (100.0)
163 (100.0)
English
74 (56.9)
63 (54.3)
137 (55.7)
Turkish
13 (10.0)
5 (4.3)
18 (7.3)
Italian
11 (8.5)
8 (6.9)
19 (7.7)
Arabic
12 (9.2)
17 (14.7)
29 (11.8)
All
NS
Language at home
Greek
2 (1.5)
5 (4.3)
7 (2.8)
Other
18 (13.8)
18 (15.5)
36 (14.6)
130 (100.0)
116 (100.0)
246 (100.0)
All
4.3
4.3.1
Use of Dental Health Services
NS
As described previously, nearly two-thirds of all study participants had seen a
dentist within the previous two years (65.3%, [see Table H Appendix 11]) and for
more than half of those in the study (57.1%) their last dental visit was an
emergency (see Table 4.3). Comparison of the length of time since a dental visit for
the two groups shows no significant difference; however, the trend suggests that
people in Group B who have been waiting a shorter time had seen a dentist more
recently. Two people in this group had not previously seen a dentist. Further
analysis of the use of emergency dental services and the costs incurred is planned
for the next stage of the study.
Table 4.3: Time of last dental visit
A Waiting
B Waiting
All
2 years
2-4 months
n (%)
How long ago?
n (%)
n (%)
<12mths
48 (37.2)
57 (49.1)
105 (42.9)
1-2 yrs
29 (22.5)
26 (22.4)
55 (22.4)
2-5yrs
35 (27.1)
17 (14.7)
52 (21.2)
>5yrs
17 (13.2)
14 (12.1)
31 (12.7)
0 (0.0)
2 (1.7)
2 (0.8)
129 (100.0)
116 (100.0)
245 (100.0)
No
49 (38.0)
50 (43.1)
99 (40.4)
Yes
77 (55.0)
63 (54.3)
140 (57.1)
No dental visit
Total
Pearson’s Chi
square
p=0.067
Last visit emergency?
Unsure
Total
3 (2.3)
3 (2.6)
6 (2.4)
129 (52.7)
116 (47.3)
245 (100.0)
NS
51
4.3.2
Reasons for Not Seeing a Dentist
Table 4.4 shows that people in the longer waiting Group A are more likely to
identify the availability of dentists [Odd Ratio (OR) = 4.3 95%CI 2.3-8.2] and the
waiting time for an appointment (OR= 1.9, 95%CI = 1.1-3.3) as reasons for not
seeing a dentist compared with those in Group B. There were no other significantly
different reasons between the two groups.
Table 4.4: Reasons for not seeing dentist by waiting time*
Reasons for not seeing dentist
Group A
Group B
Waiting > 2
years
Waiting 2-4
months
n (%)
n (%)
All
190 (77.2)
Odds Ratio
(95% CI)
Cost
98 (75.4)
92 (79.3)
NS
Availability of dentist
58 (44.6)
34 (29.3)
92 (37.4)
4.3 (2.3-8.2)
Waiting time for appointment
81 (62.3)
54(46.6)
135 (54.9)
1.9 (1.1-3.3)
Rude dentist
3 (2.3)
6 (5.1)
9 (3.7)
NS
Rude non-clinical staff
8 (6.2)
4 (3.4)
12 (4.9)
NS
Location
15 (11.5)
9 (7.8)
24 (9.8)
NS
Waiting time at surgery
20 (15.4)
22 (19.0)
42 (17.1)
NS
Fear of dentist
28 (21.5)
37 (31.9)
65 (26.4)
NS
Access
4 (3.1)
4 (3.4)
8 (3.3)
NS
Health problems
10 (7.7)
12 (10.3)
22 (8.9)
NS
Communication problem
10 (7.7)
11 (9.5)
21 (8.5)
NS
5 (3.8)
7 (6.0)
12 (4.9)
NS
Mental health issue
*multiple answers possible
4.3.3
Self-assessments of Oral and General Health
Table 4.5 shows that people in Group B were more likely to rate their dental health
as worse than others, compared to the self-rating of people in Group A who waited
longer for dental treatment, but this difference was not significant (p=0.064, [see
Figure 4.2]). However, this trend was not apparent in the self-ratings of general
health, which was similar between the two groups (see Figure 4.3).
52
Table 4.5: Self-rating of oral health compared to others by waiting time
Group B
Group A
Oral health status
Waiting > 2
years
Waiting 2-4
months
n (%)
n (%)
Much better
Total
n (%)
6 (4.8)
4 (3.6)
10 (4.2)
Better
25 (20.0)
23 (20.7)
48 (20.3)
About the same
63 (50.4)
38 (34.2)
101 (42.8)
Worse
22 (17.6)
34 (30.6)
56 (23.7)
Much worse
All
9 (7.2)
12 (10.8)
21 (8.9)
125 (100.0)
111 (100.0)
236 (100.0)
Pearson’s Chi
Square
8.872(a)
df=4
p=0.064
General health status
Excellent
14 (10.9)
11 (9.5)
25 (10.2)
Very good
56 (43.4)
43 (37.1)
99 (40.4)
Good
39 (30.2)
43 (37.1)
82 (33.5)
Fair
17 (13.2)
10 (8.6)
27 (11.0)
Poor
2 (1.6)
5 (4.3)
7 (2.9)
Total
129 (100.0)
116 (100.0)
245 (100.0)
NS
Figure 4.2: Self-rating of oral health
60
50
40
%
A Waiting > 2 years
30
B Waiting 2–4 months
20
10
0
Much
better
Better
About the
same
Worse
Much
worse
53
Figure 4.3: Self-rating of general health
50
45
%
40
35
30
A Waiting > 2 years
25
20
15
10
5
0
Excellent
Very good
Good
Fair
4.4
Clinical Outcomes
4.4.1
Number of Natural Functional Teeth
Poor
People who were clearly edentulous (had no teeth) prior to clinical assessment were
excluded from the study. Table 4.6 and Figure 4.4 show the number of natural
functional teeth (determined by clinical assessment) by waiting time. Overall,
nearly 9% of all study participants had no natural functional teeth and more than
20% had 12 or fewer teeth. Despite being younger than Group A on average, a
higher proportion of Group B had either no natural functional teeth (11.3%
compared with 6.3%) or 12 or fewer natural functional teeth (14.8% compared
with 10.9%). The mean number of natural functional teeth was 19.6 for those in
Group A, and 17.8 for those in Group B.
Table 4.6: Number of natural functional teeth by waiting time
Number of natural
functional teeth
Group A
Group B
Total
Waiting > 2 years
Waiting 2-4 months
n (%)
n (%)
n (%)
No natural
functional teeth
8 (6.3)
13 (11.3)
21 (8.6)
1-12 teeth
14 (10.9)
17 (14.8)
31 (12.8)
13-20 teeth
38 (29.7)
32 (27.8)
70 (28.8)
>20 teeth
68 (53.1)
53 (46.1)
121 (49.8)
128 (100.0)
115 (100.0)
243 (100.0)
Total
Pearson’s Chi
Square
NS
54
Figure 4.4: Number of natural functional teeth by waiting time
60
50
40
A Waiting > 2 years
30
20
Total
10
0
No natural
functional
teeth
4.4.2
1-12
teeth
13-20
teeth
>20 teeth
Community Periodontal Index
Despite the lower average number of natural teeth in Group B, comparison of the
Community Periodontal Index (CPI) scores shows that significantly more healthy
sextants—the six areas of the mouth defined by tooth positions—were present in
Group B compared with Group A which had waited longer (p=0.036). This
difference disappeared when people with 20 natural functional teeth or fewer were
excluded (see Table 4.7 and Figure 4.4).
55
Table 4.7: Healthy Community Periodontal Index (CPI=0) by waiting time for all
participants and for participants with at least 20 functional teeth
Number of
healthy quadrants
Group A
Waiting >
2 years
All participants
Group B
Pearson’s Chi
Square
Total
df=6
Waiting 2-4
months
n (%)
n (%)
n (%)
None
14 (10.8)
14 (12.1)
28 (11.4)
1
55 (42.3)
35 (30.2)
90 (36.6)
2
6 (4.6)
17 (14.7)
23 (9.3)
3
12 (9.2)
9 (7.8)
21 (8.5)
4
13 (10.0)
7 (6.0)
20 (8.1)
5
14 (10.8)
10 (8.6)
24 (9.8)
All
16 (12.3)
24 (20.7)
40 (16.3)
130
(100.0)
116 (100.0)
246 (100.0)
Total
13.447
p=0.036
Participants with at least 20 natural functional teeth
Total
None
13 (19.1)
12 (22.6)
25 (20.7)
1
38 (55.9)
22 (41.5)
60 (49.6)
2
4 (5.9)
6 (11.3)
10 (8.3)
3
1 (1.5)
3 (5.7)
4 (3.3)
4
2 (2.9)
3 (5.7)
5 (4.1)
5
5 (7.4)
3 (5.7)
8 (6.6)
All
5 (7.4)
4 (7.5)
9 (7.4)
68 (100.0)
53 (20.7)
121 (100.0)
NS
Table 4.8 shows the number of healthy sextants present by the waiting time for all
study participants and for each age group. There was no statistical difference in the
number of healthy sextants between the two groups in each age group. However,
a relatively low proportion of participants in both groups had only one healthy
sextant (36.6%).
56
Figure 4.5: Number of healthy sextants by waiting time
45
40
35
30
% 25
20
15
10
5
0
A Waiting >2yrs
B Waiting 2–4mths
All
None
1
2
3
4
5
All
57
Table 4.8: Number of healthy sextants (CPI=0) by waiting time by age range
Group A
Group B
Waiting >
2 years
Waiting 24 months
94 (74.6)
78 (71.6)
172 (73.2)
7.712(a)
1
7 (5.6)
10 (9.2)
17 (7.2)
p=0.260
2
4 (3.2)
8 (7.3)
12 (5.1)
3
8 (6.3)
3 (2.8)
11 (4.7)
4
3 (2.)
5 (4.6)
8 (3.4)
Number of healthy sextants
Pearson’s Chi Square
Total
df=6
All aged 18 years and more
None
5
5 (4.0)
1 (0.9)
6 (2.6)
All healthy quadrants
5 (4.0)
4 (3.7)
9 (3.8)
Total
126
(100.0)
109 (100.0)
235 (100.0)
None
7 (87.5)
13 (72.2)
20 (76.9)
1
1 (12.5)
0 (0)
1 (3.8)
2
0 (0.0)
0 (0.0)
0 (0.0)
3
0 (0.0)
1 (5.6)
1 (3.8)
4
0 (0.0)
1 (5.6)
1 (3.8)
5
0 (0.0)
0 (0.0)
0 (0.0)
All
0 (0.0)
3 (16.7)
3 (11.5)
8 (100.0)
18 (100.0)
26 (100.0)
Age-range = 18-34 years
Total
4.640(b)
p=0.326
Age-range = 35-64 years
None
45 (72.6)
42 (72.4)
87 (72.5)
1
3 (4.8)
5 (8.6)
8 (6.7)
2
4 (6.5)
5 (8.6)
9 (7.9)
3
3 (4.8)
1 (1.7)
4 (3.3)
4
2 (3.2)
3(5.2)
5 (4.2)
5
3 (4.8)
1 (1.7)
4 (3.3)
2 (3.2)
1 (1.7)
3 (2.5)
62 (100.0)
58 (100.0)
120 (100.0)
42 (75.0)
22 (68.8)
64 (72.7)
3 (5.4)
5 (15.6)
8 (9.1)
2
0 (0)
3 (9.4)
3 (3.4)
3
5 (8.9)
1 (3.1)
6 (6.8)
4
1 (1.8)
1 (3.1)
2 (2.3)
5
2 (3.6)
0 (0)
2 (2.3)
3 (5.4)
0 (0)
3 (3.4)
56 (100.0)
32 (100.0)
88 (100.0)
Total
3.118 (c)
p=0.794
Age-range = >65 years
None
1
Total
11.745(d)
p=0.068
a) 6 cells (42.9%) have expected count less than 5. The minimum expected count is 2.78.
b) 8 cells (80.0%) have expected count less than 5. The minimum expected count is .31.
c) 12 cells (85.7%) have expected count less than 5. The minimum expected count is 1.45.
d) 11 cells (78.6%) have expected count less than 5. The minimum expected count is .73.
58
4.5
Oral Health Impact Profile
People in Group B were more likely than those in Group A to report higher
frequencies of uncomfortable eating (p=0.030 [Table 4.9]) and feeling that life was
less satisfying in the last four weeks because of problems with their teeth, mouth or
dentures (p=0.011 [Table 4.10] ).
Table 4.9: Frequency of experience of uncomfortable eating in last
four weeks by waiting time
Group A
Frequency
Waiting > 2
years
Never
Waiting 2-4
months
40 (30.8)
Hardly ever
Occasionally
Fairly often
Chi square
Total
29 (25.2)
df=4
69 (28.2)
9 (6.9)
1 (0.9)
10 (4.1)
35 (26.9)
31 (27.0)
66 (26.9)
6 (4.6)
14 (12.2)
20 (8.2)
40 (30.8)
40 (34.8)
80 (32.7)
130 (100.0)
115 (100.0)
245 (100.0)
Very often
Total
Pearson
Group B
10.718(a)
p = 0.030
a) 1 cell (10.0%) has expected count less than 5. The minimum expected count is 4.69.
Table 4.10: Frequency of experience of feeling life less satisfying in last
four weeks by waiting time
Group B
Group A
Waiting > 2
years
Frequency
Never
Hardly ever
Occasionally
Fairly often
Very often
Total
Pearson
Waiting 2-4
months
n (%)
n (%)
Chi square
Total
df=4
n (%)
81 (62.8)
54 (47.8)
7 (5.4)
5 (4.4)
135 (55.8)
12 (5.0)
29 (22.5)
29 (25.7)
58 (24.0)
12.981(a)
2 (1.6)
13 (11.5)
15 (6.2)
P = 0.011
10 (7.8)
12 (10.6)
22 (9.1)
129 (100.0)
113 (100.0)
242 (100.0)
a) No cells (.0%) have expected count less than 5. The minimum expected count is 5.60.
4.6
Costs of Proposed Treatment and the Treatment Plans
4.6.1
Cost of Proposed Treatment
The total proposed costs to the system of care for both groups were more than
$900 per person. The average cost of the proposed treatment for people in Group B
was slightly lower than those in the longer-waiting Group A ($912.22 compared
with $935.88). The mean difference was $23.66 (95%CI $5.14 to $42.18). This
difference was statistically significant but considered to be not financially
significant. Table 4.11 shows the treatment plans proposed to both groups, with the
number of proposed procedures and costs.
59
Table 4.11: Number of proposed treatment procedures and costs
Group A
Waiting >2 years
(n=130)
Type of
Procedures
Group B
Waiting 2-4 months
(n=116)
Number of
procedures
Total cost
($)
Number of
procedures
Total cost
($)
Diagnostic
401
13,766.15
333
11,995.20
Preventive
212
9772.85
184
8,583.90
36
3553.2
13
888.3
Oral surgery
122
9781.1
170
14133.9
Endodontics
59
6822.45
57
5370.95
483
45913.55
398
39852.1
15
360.7
13
476.5
1446
121,665.40
1237
105,817.70
11.12
$935.88
10.66
$912.22
Periodontal
Restorative
Other
TOTAL
Average per
person
There was a significant difference in the types of proposed treatment for the two
groups (p=0.00079).
There were also significant differences in the costs of each type of treatment
proposed for the two groups, apart from those of preventive services (see Table
4.12 and Figure 4.5). The average cost for the proposed treatment among the
longer-waiting Group A was higher for diagnostic services and periodontal,
endodontic, and restorative treatments, and for dentures. Costs for oral surgery
and other services—mainly interpreter services—were higher for the shorter-waiting
Group B. See Appendix 10 for a complete list of the dental items proposed for each
group.
60
Table 4.12: Mean costs of proposed dental treatment by type
Group A
Waiting > 2 years
n=130
Mean cost $ (std
dev)
Group B
Waiting 2-4
months
n=115
Mean cost $ (std
dev)
t-test
Pearson’s Chi
square
Diagnostic
services
105.89 (9.29)
103.41 (9.60)
Preventive
services
75.18 (6.59)
74.00 (6.87)
Periodontal
treatment
27.33 (2.40)
7.66 (0.71)
p<0.00001
Oral surgery
75.24 (6.60)
121.84 (11.31)
p<0.00001
24.91
p-value=0.00079
p=0.0411012
NS
Endodontic
treatment
52.48 (4.60)
46.30 (4.30)
p=0.0118236
Restorative
treatment
353.18 (30.98)
343.55 (31.90)
p=0.0173495
Dentures
243.81 (21.38)
211.35 (19.62)
p<0.00001
Other
TOTAL
2.77 (0.24)
4.11 (0.38)
935.88 (62.06)
912.22 (84.70)
p<0.00001
p=0.014164
Figure 4.5: Proposed treatment costs by proposed treatment type for each group
Figure 4.5: Proposed treatment costs by waiting time
Waiting >2yrs
Waiting 2-4mths
D
ia
gn
os
Pr
tic
ev
se
en
Pe
rv
tiv
ri
ic
od
e
es
on
se
rv
ta
ic
lt
es
re
at
En
m
O
do
en
ra
do
t
ls
nt
Re
u
r
al
ge
st
tr
or
ry
e
at
at
iv
m
e
en
tr
t
ea
tm
en
D
en t
tu
re
s
O
th
er
400
350
300
250
200
150
100
50
0
4.7
Impact of Proposed Treatment on Number of Functional Teeth
The total number of natural functional teeth for all people in this study was 4558
before treatment; the mean number of teeth for people waiting two to four months
for a dental appointment (Group B) was 17.8, and 19.6 for those waiting two years
or more (Group A).
61
The dental plans proposed a total of 292 extractions (6.4%) and 881 fillings
(19.3%; [see Table 4.13 and Figure 4.6]). After the proposed extractions the mean
number of natural functional teeth will be 14.6 for those in Group A and 12.8 for
those in Group B.
Table 4.13: Number of natural functional teeth after proposed treatment
Total natural functional teeth
present
Total proposed extractions
Total proposed restorations
Total proposed teeth treated
Group A
Group B
Waiting > 2 years
Waiting 2-4 months
n (%)
n (%)
2507 (100.0)
All
n (%)
2051 (100.0)
4558 (100.0)
122 (4.9)
170 (8.3)
292 (6.4)
483 (19.3)
398 (19.4)
881 (19.3)
605 (24.1)
568 (27.7)
1173 (25.7)
Total teeth proposed untreated
1902 (75.9)
1483 (72.3)
3385 (74.3)
Mean number natural
functional teeth before
proposed treatment
19.6
17.8
18.8
Mean number natural
functional teeth after proposed
treatment
14.6
12.8
13.8
Figure 4.6: Proposed treatment plans for teeth by percentage of natural teeth
for each group
80
70
60
50
A Waiting >2yrs
% 40
B Waiting 2-4 mths
All
30
20
10
0
Extractions
4.8
Restorations
Untreated
Key findings
•
•
•
•
•
People in the shorter-waiting Group B were significantly younger
than those who had waited two years or more in Group A.
Group B had fewer natural teeth and reported more symptoms
than those in Group A.
The proportion and costs for proposed dental treatment were
different for those in Group B compared with those in Group A.
The proposed dental plans for Group B included more extractions
and fillings than those in Group A.
The proposed dental plans for Group A included more root canal
therapy and treatment for gum disease than for Group B.
62
•
•
If the proposed treatment proceeds as intended the mean number
of natural teeth will reduce from 17.8 to 12.8 in Group B and from
19.6 to 14.6 in Group A.
The average cost of proposed treatment for Group B was $23.66
lower than for Group A ($912.22 compared with $935.88). This
difference was statistically significant but considered to be not
financially significant.
63
5.
QUALITATIVE DATA FROM THE QUESTIONNAIRE
Overview
During the face-to-face interviews, in addition to noting the rating scales, the
research assistants were encouraged to record all additional responses. These
descriptive data were recorded as either verbatim accounts or as narrative
summaries of the stories told to them. Of the 246 people who participated in the
study, 115 explained or expanded their responses. This additional information was
transcribed electronically, coded and categorised. The analysis provided additional
insight into people’s experiences of oral health problems.
About one in seven people in the study rated their health as fair or poor compared
with others of the same age. Chronic health problems were common among people
who provided narrative accounts to the interviews.
Many of these chronic
conditions were linked to oral health problems directly or indirectly by study
participants. This supports current literature linking oral health to general health
(see Chapter 1). Participants described how their poor oral health impacted upon
their daily lives—avoiding main meals, not eating properly and taking pain killers
regularly. More than one in four people in the study frequently felt self-conscious
about their oral condition. Some said they avoided smiling because they were
embarrassed about the look of their teeth and some were constantly aware of their
mouth odour. People who smoked found it hard to quit smoking because of stress
from dental pain.
Problems with mouth or teeth had impact on self-esteem; some participants
reported they were unable to find employment because of their oral health
conditions. Some participants described how their social activities were limited
because of the embarrassment associated with eating problems or bad breath.
These include going out and being intimate with partners.
Cost of treatment (co-payment) was a major barrier to using public dental services;
several stories were told about the financial hardship people experienced as they
sought dental care. The lengthy wait for an appointment was another major
problem. People also described the problems they found when using public dental
services and their disappointment with them. Some did not understand the waiting
list system, or that their cultural needs—such as a requirement to see female
dentist—could not be met. Many participants reported bad experiences with public
emergency services, including poor responses to patients’ telephone calls and long
waiting times. Because of these barriers and bad experiences, people reported
seeking dental services outside the public system and even overseas. Those who
saw private dentists faced significant cost consequences. Some who had sought
treatment from overseas or from local, unregistered dental practitioners did not
have a proper treatment and subsequently returned to the public system.
The rest of this chapter provides fuller descriptive information and analysis of the
above.
64
I am a diabetic. I have four teeth left only. I have been on baby foods
for most of the time. I grind everything before I eat. I used to miss a
dental appointment because of family problems and the next
appointment took some five years. I don’t enjoy eating—with no teeth
you can’t eat much. I tried to get used to it. …Smell is a real problem for
me. …When you have no teeth, you have no life on your face. …You
can’t smile, it looks dangerous. People used to ask “why is he not
smiling?”
(46-year-old man, waiting more than two years for a dental appointment)
5.1
About one in seven people in the study said their general health was fair or poor
compared with others of the same age. Despite this, many people mentioned some
type of chronic health condition at some time during the interview.
Most
commonly, diabetes, heart disease and arthritis were mentioned. One person had
had a liver transplant, and others were recovering from surgery. Overall, the
responses suggest that chronic ill-health is seen as ‘normal’ among the public
dental clinic population.
People linked their poor general health to their oral health in three ways. It either
directly, or indirectly, affected their oral health, or oral health was seen in the
context of poor general health.
A reported, direct link between oral health and general health was apparent in a
number of comments. For example, an 80-year-old man said his kidney stones,
prostate and urinary difficulties upset his stomach. This made his tongue cracked
and painful and caused a constant sour taste in his mouth. Others related their
weight problems to poor oral health because they could not eat properly:
I opt for processed food only. I have gained weight due to lacking of
proper food.
One of the research assistants noted:
A middle-aged woman feels she is underweight. She cannot eat well
because of dental problems. She has sepsis in her nostrils, constant pain
in her neck and ears because of dental problems. She is seeing four
doctors including a psychiatrist at the moment. She feels that every day
her health is being deteriorated because of the lack of nutrition. She has
multiple problems but dental health remains a major one.
Some participants reported a direct link between their poor oral health and their
mental health, such as experiences of psychological stress due to recurring pain
and discomfort. Others felt anxious due to their embarrassment caused by eating
difficulties or from concerns about more tooth loss. According to the research
assistant’s notes:
65
A 40-year-old woman felt very down and stressed about her dental
health situation. She felt embarrassed about her teeth. She felt her face
has changed its shape, and that she is prematurely ageing
psychologically and physically, due to dental health. She had no back
teeth, her front teeth ache from chewing. She did not like eating in
public.
The indirect link between poor general health and oral health was from poor health
impeding access to dental health services. For example, two people with chronic
back pain reported problems caused by prolonged sitting, which they associated
with the extended waiting times at the dental clinic.
The third link between oral health and general health is the influence they have on
each other. People judge the state of their oral health in the context of other health
problems. Those who live with ongoing health problems tend to think less about
their oral health conditions. For example, one research assistant noted:
A former spray painter has had multiple chronic health problems. He has
had throat cancer, is on medication for cardio-vascular diseases, and
has asthma that has caused him to be hospitalised three times and
many other conditions such as various stones and cysts. He has only a
couple of front teeth left to use for chewing, “like a rabbit”, he said. He
considers his teeth the least of his worries.
5.2
Oral Health and Quality of Life
5.2.1
Daily Problems
Difficulty eating
Over 40% of people who took part in the study reported that in the previous four
weeks they found it uncomfortable to eat either fairly often or very often. Many
people gave details about their poor eating experiences. Interrupted meals are
common and many avoid hot or cold foods. People who find it uncomfortable to eat
cope by eating slowly, eating only soft food, avoiding foods that cause pain,
pureeing all meals, eating prepared baby food or even skipping meals. One man
said:
I have stopped eating lunch at work to avoid tooth pain.
Pain and psychological impacts
Problems with eating can have a psychological impact:
I’m less satisfied with life when food comes to my mouth. I actually got
sick of eating.
Pain is a major problem. People in the study described a number of strategies they
used to manage pain and dental sensitivity. They cleaned their teeth more often,
cleaned their teeth more thoroughly, used dental floss several times throughout the
day, rinsed regularly with salted water or commercial mouthwash, bought gel or
drops from chemist shops, or used either a cold or warm pack. About one in six
people used over-the-counter pain killers to manage pain caused by their dental
problems fairly often or very often. Some took them daily:
66
Panadol are my “lollies”. I do get the pain every day.
Others reported using alternative remedies to reduce pain. To numb teeth, people
used a wide range of substances including oil of cloves, Chinese medicine, olive oil,
ginger, herbal teas (rosemary, thyme and chamomile), alcohol such as brandy or
Greek whisky used as a mouth-rinse, and Turkish cologne. When nothing works
they put up with the pain.
Although few participants reported smoking to cope with dental pain occasionally to
very often (6.7%), some found that pain made it difficult to quit smoking. For
example, a 51-year-old man said he gave up smoking four years ago but that he
wanted to smoke again because of dental pain and depression. An older man from
Italy said:
You don’t smoke to manage pain but when it is painful you become
upset and then you feel like smoking.
5.2.2
Employment
About one in 10 people in the workforce felt that problems with their oral health
affected their employment prospects either fairly often or very often. Two main
reasons were evident in people’s responses—the impact of pain and poor selfesteem. One woman said it was hard for her to look for work when she was in pain.
A 37-year-old former social worker said she had to fix her teeth before looking for a
job. She could not deal with people face-to-face because of her bad breath. A
middle-aged man said:
It’s all about confidence. When I talk to people I am not confident
because of my dental problems. I am not working because my selfesteem goes down.
5.2.3
Social Life
The questionnaire included questions about social aspects of life, including selfconsciousness and intimacy. These received extensive responses from study
participants. More than a quarter of people in the study reported feeling selfconscious either fairly often or very often in the past four weeks because of their
poor oral health. This seems to occur especially when they talked or smiled because
of the condition of their teeth or mouth odour. A 64-year-old man from Malta said
he even avoided smiling, feeling embarrassed all the time. Others said:
Even little kids notice I have a hole in my teeth.
You are subconsciously aware of the odour of your mouth.
For some people social activities were limited because of embarrassment due to
eating problems. Two women, aged 37 and 73, both said they made excuses to
avoid going out if eating was involved. Another participant, a middle-aged man,
said he was very uncomfortable sharing foods with others as he had to wait for
everything to cool down before he could eat, as a consequence his social life
suffered.
More than one in 10 people said their poor health caused problems with intimacy
fairly often or very often. This was largely due to bad breath and pain. One 70year-old man commented that he felt bad when his wife complained of his bad
67
breath, while a 50-year-old woman would not let anyone to touch her face or jaw
because it was too painful. One woman in her thirties said:
I have avoided intimacy completely.
The following narrative from a research assistant recounts the story of a young
woman and highlights the impact of oral health problems on several aspects of her
life:
A 29-year-old process worker had [a] chipped tooth and severe pain.
She did ring the emergency service but the line was busy. She resorted
to private dentists for emergency. She said it cost her so much money.
The chipped tooth has caused pain for three to four months and has got
worse in the last four weeks. She has lost seven kilograms since she has
to stop eating meat and hard fruits and veggies. She has her meals
interrupted three or four times each time she eats. She said her daily
routine is destroyed by pain. She has difficulty sleeping every night due
to pain. She takes Panadeine Forte up to four times a day. She said she
is “not in the mood for an outing”.
5.3
Barriers to Public Dental Services
5.3.1
Costs
In Victoria public dental patients pay an $88 co-payment for the course of their
treatment in instalments—$22 is paid at the first appointment. In the study, this
initial co-payment was waived for those who had waited more than two years but
not for those who had joined the waiting list in the previous four months. We found
that the initial co-payment was sufficient to deter some people from seeking
treatment. Ten of the 62 people who returned the non-participation survey (16%)
said they did not take part in the study because they could not afford to see the
dentist at the pubic clinic (see Chapter 6).
Some of the participants who provided extensive responses to the interview raised
the co-payment as an important consideration for them. For example, one young
woman wanted to reschedule her appointment to see the dentist because she was
not able to make the co-payment on that day.
Other comments relating to the costs of treatment concerned the family budget. It
is apparent that there are competing demands for family resources and money for
dental treatment must come from other areas of need:
I can’t afford to look after my teeth when I have two children and my
husband is not working.
We pensioners can’t bear both our expenses and health care costs.
When we have to pay a dentist for emergency treatment, we have less
money to buy food. When I talk to other people of my age and my
situation, all of them have the same problems.
5.3.2
Waiting Time
The waiting time for a dental appointment was an important reason for delayed
dental treatment for more than half the people in the study. It affected people by
causing frustration, extending the period of suffering and contributing to their
68
deteriorating oral health. One man reported that he had been on waiting lists in
South Australia and Victoria for 10 years and that his teeth had become
considerably worse over that time. He now had many cavities and was experiencing
pain.
Another possible consequence of an extended waiting time is that it becomes an
expected part of the system of dental care. This in turn can influence people’s
decisions and expectations of the dental health system. The focus of the service
shifts from preventive care to therapeutic treatment, although that is not what
people want. One said:
I have wanted to use dental service due to pain but I hesitated because
of long waiting time, and I’m not sure if I would be seen.
A research assistant noted that:
[This gentleman] just puts up with his problems. Once or twice a day,
glue for his dental plate wears off and he has problems eating and
swallowing. He thinks there are people worse off than him so he didn’t
come back for check up.
A participant suggested that:
Waiting time should be reduced, so that people can have regular, maybe
yearly, dental check-ups.
5.3.3
Service Problems
Although only a small proportion of participants said that problems with the manner
of health professionals (3.7%) or other staff members (4.9%) were reasons for not
seeing a dentist, several people gave accounts of poor experiences with public
dental services. Complaints about staff and communication issues meant people felt
un-informed, misinformed or simply did not know what to expect. For example, a
33-year-old woman felt she had been on the waiting list for a long time but when
she called to see how much longer she had to wait she was told that she was not on
their list. As a result of the confusion, she took out a loan to get her teeth fixed
privately:
When you go on a waiting list you don’t get a receipt or even any
written confirmation of going on the list, so you can’t prove you had
been waiting.
One elderly man with a non-English speaking background spoke of problems with
conflicting information. He reported that initially the receptionist told him he was
eligible for services, yet when he attended the clinic, he was told he was in another
area and not eligible. He found this very frustrating and went to the dental hospital
instead.
Some participants reported they did not know that public dental health services
were available to them. They had endured pain because they could not afford the
cost of private dentists, borrowed money to see private dentists or gave up—only
seeking treatment when told about the public clinic. This seemed particularly true of
recent refugees, as a research assistant noted:
69
[This woman] started to notice one of front teeth becoming discoloured
four years ago. Costs of private dental service prevented her from
seeking treatment. She didn’t know that public dental was available. A
friend told her about it and she made an appointment in 2005.
A challenge for public dental services is to meet the needs of clients from culturally
and linguistically diverse (CALD) backgrounds. Over 70% of participants in the
study were born overseas, and although health interpreter services are available,
most CALD participants who needed language assistance brought a family member
to act as their interpreter. This raises a number of issues, from the quality of the
information exchange between the service and clients to the reasons for the
reluctance to use professional interpreters. (This issue was not explored further in
the study.)
The study also reveals another culturally specific need that deterred people from
seeking treatment—the availability of services from specific genders. A 48-year-old
woman from Lebanon said:
As a Muslim, I can only see female dentists. Sometimes a female
dentist is not available I have to forgo my appointment.
5.3.4
Emergency Service
Participants also identified problems they experienced with dental emergency
services generally.
Frequently mentioned were the problems with access to
services and waiting times. People were frustrated by slow responses and
unanswered telephone calls. One woman reported problems getting an appointment
with an emergency service. Another said he was denied access to the service
because his perception of ‘emergency’ was different to that of the service:
Unless you are about to die with pain, they won’t consider you an
“emergency”.
Some people reported waiting for two hours or longer at an emergency service
before seeing a dentist. Some were told to come back in a few days. Even people
who would be expected to be familiar with the system, such as an ex-dental nurse,
reported poor experiences:
I sat and waited, but didn’t actually see someone. I did this twice.
Finally I went home and took painkillers.
5.4
The Consequences
The barriers to public dental clinics and the urgency of oral health conditions forced
many people to seek dental treatment elsewhere. Many reported seeing dentists in
private practice, or dental technicians, because there was no other choice. A few
reported poor treatment and service quality from private dentists. For example, an
elderly woman reported severe pain from her denture, which kept breaking despite
several appointments with a private dental technician. An elderly man from Tunisia
said he felt intimidated by private dentists because they insisted that he return
every three months.
For recent immigrants the financial consequence of private dental treatment can be
severe. A 28-year-old mother from Lebanon, speaking through her sister as
interpreter, was distressed and related the following story:
70
She came to Dianella three months ago for an emergency treatment,
because she had very bad tooth pain. She was told she had to wait for a
few days for treatment. She couldn’t wait because the pain was just too
much, and went to have treatment with private practice. It was for root
canal and was very expensive. Her family had to borrow money for it.
She feels traumatised by the expense and she is now paying back the
money. She still has problems with her teeth, a gap where foods always
get in. She is very afraid of what the dentist might find with her teeth.
(Research assistant’s notes)
A small number of people in the study reported seeking dental treatment in their
country of origin when they returned for other reasons. They acknowledged that
while the service was cheaper, the treatment quality was generally poor, and they
needed more care in Australia. One 65-year-old immigrant had seen an
unregistered dentist in Melbourne but did not go back when he became concerned
about risks to his health.
Some people told of losing teeth because treatment from the public dental services
was not timely and they could not afford private dentists. For example, one 70year-old man from Malta pulled his own teeth over the years. He only had one top
tooth left, and his bottom teeth were loose. Another participant, a 37-year-old
medical receptionist, said that she had to wait for her tooth to fall out because she
could not see a dentist.
Epilogue
I think it’s not fair for old people…to make them wait for so long on
the waiting list. If they should at least get one appointment quickly
for the first time, dentist can do a general examination. Then they
can put us on the waiting list for treatment. I am given this
appointment after waiting for six years. I was left alone to worry
about my dental health for so long. I wish I could have a general
examination and got the idea if there was anything wrong to worry
about.
(67 year-old man, a former accountant)
5.5
Key Issues
•
The extended delay for dental visits had a number of important
consequences for both the dental service and those receiving care. People
in this study told us they were suffering, and disappointed with the dental
health system.
•
Poor oral health can affect both physical and mental health and quality of
life. Many of those waiting for dental treatment sought different ways to
manage their conditions.
•
Findings from the descriptive data suggest some ways that the experience
of waiting for dental treatment can be improved. These included:
o
o
Improved information about the public dental service and the
alternatives.
A booking system that allows people to track their position on the
waiting list.
71
o
o
o
o
More information about dental vouchers and interpreter services so
people can use them more effectively.
Communication skills training for staff working with people from
diverse cultural and linguistic backgrounds.
An evaluation of the current triage system.
Investigation into the effective use of dental health professionals
other than dentists—such as dental hygienists, dental therapists
and dental nurse practitioners—to maximise the dental health
workforce.
72
73
6.
NON-PARTICIPANT SURVEY
Overview
We wanted to know more about why people did not want to take part in the study,
so we included a non-participant questionnaire in the information about the study
sent out to potential participants. Sixty-two people returned the questionnaire,
citing either a single reason or a combination of reasons for not taking part.
Several reasons people gave related to participating in the study itself but others
related to problems with accessing public dental services.
Lack of time, poor health and the costs of seeing a dentist were the three reasons
most frequently identified by people who returned the questionnaire.
Lack of time was a reason for non-participation for people who were carers of
family members and for people who also reported that they now worked, although
it was not clear whether working meant that they were still eligible for public dental
services. Illness and physical limitations were also reasons given by people who
chose not to participate in the study.
Cost was seen as a barrier to accessing public dental services, and was nominated
as a reason for not taking part, by one in five of those who returned the survey.
Some people who had just joined the waiting list could not afford the co-payment
and hence decided not to accept an early appointment offered in the study.
It appeared that literacy was another factor contributing to poor responses to the
study recruitment (and possibly to responses to all correspondence from the Dental
Service). People from culturally and linguistically diverse backgrounds, as well as
English-speaking backgrounds, reported they found the document sent to them too
much to read or they did not understand it.
The rest of the chapter provides descriptive information and analysis of the above.
6.1
Survey Method
In the recruitment phase information about the study was sent to people on the
dental waiting list. This information included a non-participant questionnaire with a
reply-paid envelope (see Appendix 7).
The questionnaire contained a single question asking people why they did not want
to take part in the study. There were 10 fixed responses with tick-boxes and space
for an open-ended response. More than one answer could be given. People were
asked not to identify themselves and to return the completed questionnaire in the
envelope provided.
6.2
Responses
Sixty-two (62) people returned a completed questionnaire (28.4% of those who did
not make a dental appointment). Table 6.1 shows the distribution of responses to
the fixed reasons in the questionnaire.
74
Of these 62 people, 44 cited a single reason (71%), with or without further
explanations. The remaining 18 people gave a combination of reasons for not
participating. Table 6.1 shows a comparison of responses by those who gave a
single reason for not taking part in the study, and all the reasons given. Four
additional single reasons were given by respondents who gave a single reason only:
cultural reasons; old age; disappointment with the system; confusion with the
information about the study.
Table 6.1: Reasons for not taking part
All Responses
(N=62)
n (%)
Single response
(N= 44)
n (%)
I haven't time to take part
26 (41.9)
17 (38.6)
I am too sick
15 (24.2)
9 (20.5)
I can't afford to see the dentist
12 (19.4)
4 (9.1)
It is too much bother
7 (11.3)
1 (2.3)
I am working now
7 (11.3)
2 (4.5)
There is too much to read
6 (9.7)
3 (6.8)
It is too hard to get to the dental clinic
5 (8.1)
0 (0)
I don't need to see a dentist anymore
4 (6.5)
4 (9.1)
I don't like seeing the dentist
3 (4.8)
0 (0)
Costs of transport concerns me
3 (4.8)
0 (0)
0 (0)
4 (9.1)
Reasons
Other reasons
(cultural reasons, old age, disappointment with
system, confusion with information about the study)
6.3
Why People Did Not Take Part
Several of the reasons people gave for not participating related to the study but
others related to problems with accessing dental treatment. It was not always clear
whether their responses distinguished between these two issues.
6.3.1
Lack of Time
Lack of time was the most frequently given reason for not taking part in the study
(41.9% of all respondents), and the most common single reason (38.6%). One
person also indicated that “I am working now” and four others gave multiple
reasons (more than two). Six people described caring for family members as the
reason they had no time—caring for small children, grandchildren, sick husband
and aged mother. Five people added additional information. One said:
I am a full-time carer for my husband and therefore unable to take part.
Thank you for asking me. I had an emergency treatment approximately
one and a half months ago.
75
6.3.2
Ill-health
Being too sick was the next most frequently given reason for not taking part
(24.2%). Nine people indicated ill-health as the only reason for their nonparticipation, while another six gave a combination of reasons. The additional
comments for this group included:
I am getting over a prostate operation which hasn't been overly
successful as yet.
I have a bad back and suffer with arthritis and find it very difficult to get
around.
This lady is now suffering with a form of memory loss and it would not
be in her interest and Dianella's interest to take part in dental survey.
6.3.3
Costs of Seeing Dentists
Information sent to potential participants included details of the co-payment
required. People who had been on the waiting list for at least two years were told
the first co-payment of $22 would be waived; despite this, however, cost appeared
to remain an important barrier to care. The cost of dental care was given as a
reason for not taking part in the study by nearly one in five of those who returned
the non-participant questionnaire (19.4%). Four people said they “can’t afford to
see the dentist” as the only reason. The remaining eight people gave cost as one
of multiple reasons for not taking part. Costs, compounded with waiting time for
dental services, led to the following responses:
Cannot afford it. At my age, you are waiting for me to die before you
give me any assistance. I've been on waiting list for five years and now
still not ready. Shame on you and the government who run this.
I was told I need a crown and the dental clinics don't do crowns. At the
cost of $1,000, I can't afford that. Thank you very much anyway.
6.3.4
Too Much Bother
Seven people (11.3%) indicated that “it was too much bother” to take part in the
study. It was the only reason given by one person. Further understanding of just
how participation was a bother is seen in their additional comments and the other
reasons they gave. One person referred to waiting time and costs. Another, who
also identified “too much to read”, said they had a limited command of English and
a third wrote:
Due to age-related disabilities – I am legally blind.
6.3.5
I am Working Now
Seven people (11.3%) said they did not want to take part as they are now working.
Most of these (5) also said that they had no time but two gave it as the only
reason. It was not clear whether working meant that they were no longer eligible
for a Healthcare Card—and so not eligible for public dental service—but this could
not be verified.
76
6.3.6
Too Much To Read
Six people indicated that there was too much to read in order to be involved in the
study, with two of these identifying this as the only reason. One wrote:
I haven’t got enough English.
This person also returned a completed consent form, demonstrating that the
instructions for participation were not understood.
Speaking and writing English was also identified as a problem for two other people.
One said he or she needed a translator due to limited English. Three others did not
check the box “too much to read” but added comments about their problems
reading and speaking English. Other comments also suggested low levels of English
literacy.
6.3.7
Too Hard to Get to the Dental Clinic
Five people (8.1%) identified access to the dental clinic as one of multiple reasons
for not taking part in the study. Other reasons given by this group included: being
too sick; costs of transportation; too much bother; costs of seeing dentists; and not
liking to see dentists. One added another reason about transport to the clinic:
I live in Kilmore. I do not drive.
6.3.8
No Need to See the Dentist Anymore
Four people (6.5%) indicated that they did not need to see a dentist anymore as
their only reason for not taking part in the study. Three of these provided further
details. One had been to another community dentist after waiting for some time,
another now had mostly false teeth, and the third said:
I am paraplegic and confined to a wheel chair, so I find it almost impossible to find
transport to attend there for study.
A comment from a fifth person also suggested that no further need to see a dentist
influenced their decision not to participate:
…Thank you for asking me. I had an emergency treatment approx. one and a
half months ago.
6.3.9
Other Reasons
Four people included open-ended responses in reasons for not taking part.
identified a cultural issue:
One
Unable to take part because at that time I'll be fasting for the month of
Ramadan.
Two others gave their age as the reason for not taking part (age-related reasons
were discussed earlier). One of these also cited poor health as a factor.
Three responses expressed disappointment with the dental health system.
person gave this as the only reason for not participating in the study:
One
77
I have been on the waiting list for 3 to 4 years; I am very disappointed
that I have to wait such a long time to have a check-up. Quite frankly I
think this system is not fair.
Two others gave additional reasons but described their disappointment with some
degree of anger. One said:
Daylight robbery. Pensioners can't afford. Worked for 50 years, paid
tax, in return I get zero. Shame on government to treat me like this.
Been on waiting list for five years and now I get this silly invitation for
nothing.
The other response showed a misunderstanding about the study, as they evidently
thought they would have to pay to be involved:
The study should be for free. This will encourage me to participate.
6.4
Key Issues
Responses to the non-participation question are likely to reflect the opinions of
other public dental patients in the catchment area. Some key issues that emerged
in the non-participant survey are:
•
Literacy appears to be an issue that affected people’s decision to take part
in the study.
•
People felt they did not have time to take part in the study, particularly
those with a carer role.
•
Poor general health affected participation in the study and appeared to be
a barrier to accessing dental care.
The cost of dental treatment was a reason people gave for not taking part in the
study and for not using public dental services.
78
79
7.
DISCUSSION AND CONCLUSION
This is the first comprehensive study of the comparative costs of public dental
treatment of its type in Victoria that we have been able to identify.
The study involved people on the public dental waiting list at a Victorian community
health centre.
As noted earlier, although every effort was made to minimise bias where possible,
there was undoubtedly some bias in each study group given the low response rate,
although this rate was initially comparable to the usual response to offers of dental
treatment (around 40%). The addition of telephone follow-up increased the
average response rate to 48%, which is higher than the usual response to clinic
offers of treatment.
We found the two groups in the study differed significantly in terms of age but no
other significant demographic differences were identified. This age difference was
an important finding in itself; it has affected some of the comparisons made
between the two groups in the study.
7.1
Key Findings
Taking into account its relative strengths and limitations, this study offers several
important findings.
7.1.1
Cost of Dental Care
The primary aim of this study was to investigate the costs to the system of delayed
dental treatment for people who use a public dental clinic. The major finding was
that the mean proposed costs for dental treatment were slightly lower for the
shorter-waiting group compared with those in the longer-waiting group ($912.22
compared with $935.88). Although this difference is statistically significant, it is
not significant financially.
The costs of proposed dental treatment for people in the study ranged from $46 to
more than $4,000, with an average of $924.31. This average cost is higher than
expected, and more than three times higher than the average actual cost of general
dental treatment per course of care for Victorian public patients in 2006–2007 of
about $272,11 and more than twice higher than that of $406 per public patient using
dental vouchers. Nearly 80% of people in the study had their proposed treatment
costs greater than the state average.
There are several possible reasons for this difference. For this stage of the project,
the average costs in this study were calculated from proposed treatment plans, not
the actual treatment. Actual treatment may differ from the initial plan for a number
of reasons. A course of dental treatment generally occurs over a period of about six
months. In that time a patient’s oral health status may worsen and proposed
restorative treatments may be replaced by teeth extractions, which are cheaper.
People may not return for their full course of treatment because of similar barriers
to dental care identified in this study, such as poor general health and other
demands on time. People in Group A may have attended for emergency visits for
11
The 2006-2007 figure from Clinical Analysis and Evaluation, DHSV. As with the study’s average, it does not include dental
voucher and emergency services.
80
dental extractions while waiting for an appointment with the public dental clinic.
Forty per cent of participants reported having visited the dentist in the last 12
months; 57% of which were for emergency visits. The cost associated with
emergency visits was not able to be included in this study. The study would have
been strengthened with such data, and there is a strong case to conduct this larger
study.
The difference between proposed costs of dental treatment for people in this study
and the average amount actually spent on public dental patients in Victoria raises
concern about whether public dental patients receive all the dental treatment they
need. Further, it is already known from the literature that the public dental system
relies more on emergency care (reflected in larger proportions of patients receiving
extractions) and less on preventive and maintenance services, than private practice
(Brennan, Luzzi et al. 2008). Hence the average cost to the system per course of
care for emergency and general care combined, in 2006–2007, was only $97 per
public patient in Victoria, whereas that for general care only (including restorative
and prosthetic treatment) was $272 (Whelan 2008). This appears far from best
practice, and we are certain that both consumers and clinicians would wish for a
healthier balance.
7.1.2 Distribution of Costs and Types of Treatment
Differences in the proposed costs between the two groups were apparent in all
types of treatment apart from preventive care. The average cost for the proposed
treatment among the longer-waiting Group A was higher for diagnostic services,
periodontal, endodontic, restorative treatments, and dentures. Costs for oral
surgery (extractions) and other services—mainly interpreter services—were higher
for the shorter-waiting Group B.
This suggests that
moderate needs.
services), there is
treatment, such as
people initially seeking dental care have more acute yet more
After two years of waiting (and the use of emergency dental
less need for acute care, but greater need for more complex
endodontic, restorative, periodontal and dentures.
This study found that, overall, only 8% of all proposed treatment costs were
allocated to preventive care, which includes procedures such as plaque removal,
fluoride treatment and oral hygiene instruction. The smallest proportion of costs
(2%) was attributed to the proposed management of periodontal disease, despite a
prevalence of advanced periodontal disease of 22.2% and evidence of calculus in
61.2% of participants. More than one-third of all proposed costs were for fillings or
restorative treatment (37.7%), and nearly a quarter of proposed costs were for
dentures. The proposed services were typically of a more acute nature, reflecting a
reasonable clinical response to the high level of need. However, the relatively low
amount of preventive work proposed—an average of only one to two preventive
procedures per patient—suggests there is little emphasis on, or the service capacity
for, a preventive or population health approach.
7.1.3
Overall Oral Health Status
Three findings about oral health status are particularly important.
First, a high proportion of people in the study had a number of indicators of poor
oral health. Compared with the results of the National Survey of Adult Oral Health
(NSAOH; 2004–2006) (Spencer & Harford 2007a) more adults in this study had:
81
•
Inadequate dentition—20 or fewer natural functional teeth (51% DCS vs
11% NSAOH).
•
High levels of gum disease—severe gum disease (22.2% vs 2.4%) and
moderate gum disease (53.6% vs 20.5%; Roberts-Thomson & Do 2007).
The evidence of tooth loss among the study population was high, and,
unexpectedly, was higher among Group B, who more recently joined the waiting
list. The average number of natural functional teeth for all people in the study was
18.5 at their first dental visit; fewer than the minimal 20 teeth considered to be
essential for optimum chewing efficiency and dietary intake (Sheiham & Steele
2001) and for good oral health in adults (AIHW 2006a). This average would fall to
approximately 14 if all extractions proposed in the dental treatment plans were to
occur.
More extractions were proposed for people in the shorter-waiting Group B than the
longer-waiting Group A. Given the low number of natural teeth in both groups,
further tooth loss increases the need for dentures and may adversely affect dietary
intake. It should also be remembered that current treatment plans included
dentures, which accounted for almost a quarter of all proposed treatment costs.
Only nine, less than 4%, were found to have at least 20 natural functional teeth
with all gums healthy. Just over half of all study participants had fewer than 21
natural teeth (51%) compared with 11.4% of Australian adults; more than one in
five people showed evidence of advanced gum disease (periodontitis; 22.2%) and
more than half had moderate gum disease (53.6%) compared with a prevalence of
moderate or severe gum disease among Australian adults of 22.9% (RobertsThomson & Do 2007).
Second, people join the waiting list with immediate dental care needs, not in
anticipation of future treatment needs. This is important as the current system does
not address this need, nor does it provide any assistance to help people manage
their oral health while waiting for treatment. Immediate problems with dental
health appear to prompt people to seek treatment by joining the waiting list. Over
two-fifths (40%) of people in the study had visited a dentist during the 12 months
preceding the study, compared with 59.4 per cent in the 2004–2006 National
Survey of Adults Oral health (NSAOH; Spencer & Harford 2007).
Third, a long waiting time for dental treatment changes the nature of dental care
needs and people find ways to manage their acute needs either by accessing
emergency treatment or through private dentists. These issues have long-term
implications for both people’s oral and general health and to the structure of the
dental health system.
Many study participants had sought treatment elsewhere; for example, more than
28% used emergency dental services at either public or private providers in the
past six months. Physical and psychological discomfort was common.
The study revealed a considerable gap in dental care for this high needs population
group. It provides an example of the inequities in health status and available health
care in some population groups in Victoria.
82
7.1.4
Impact of Oral Health Status
The impact of poor oral health on people in the study was considerable; it affected
how people lived and how they felt about themselves, as the following quote
shows:
I am a diabetic. I have four teeth left only. I have been on baby foods
for most of the time. I grind everything before I eat. I used to miss a
dental appointment because of family problems and the next
appointment took some five years. I don’t enjoy eating—with no teeth
you can’t eat much. I tried to get used to it. …Smell is a real problem for
me. …When you have no teeth, you have no life on your face. …You
can’t smile, it looks dangerous. People used to ask, “why is he not
smiling?”
(46-year-old man, waiting more than two years for a dental appointment)
A large proportion of participants reported problems with eating. This raises
concern about the implications for nutrition and longer-term general health. Over
40% frequently found eating uncomfortable; a third regularly avoided cold foods
and more than one in five people reported problems with their teeth or mouth that
led to frequently interrupted meals or unsatisfactory diet. One in 12 bought special
or different foods because of the difficulty they had eating.
Eating was not the only aspect of life affected. Aching pain was often experienced
by more than a quarter of people in the study, with nearly 10% often finding it
difficult to sleep because of problems with their teeth or mouth.
The findings of this study provide some evidence to show how poor oral health can
affect nutrition intake and general health. Such outcomes are likely to create more
demand in the wider health system and lead to additional health costs.
The experience of poor oral health affected the quality of life among study
participants in ways other than its adverse impact on eating. About one-quarter or
more felt self-conscious, embarrassed or tense because of problems with their
teeth, and one in seven felt their poor oral health affected their job prospects or
personal relationships.
7.1.5
Health-seeking behaviour
Another important finding was that study participants reported a high level of
health-seeking behaviour. Most had seen their GP at least once in the previous six
months (87%) with more than half of these reporting three or more visits in that
time. Although people in the study generally rated their general health more highly
than their oral health they clearly differentiated between them.
The relationship between self-rating of health and health-seeking behaviour is not
clear but this study allows some comparison of such behaviour in regard to dental
and general health. The study shows that among this population, people reported
regular access to medical services and that they rated their general health more
highly than their oral health. Several studies have shown associations between poor
oral health and poor general health in low-income populations (ADAVB 2004; Mason
2004; Spencer & Harford 2007b; NIDCR 2008) and oral diseases are known to
complicate management of other diseases (Spencer & Harford 2007b).
83
While participants were not asked directly about their knowledge of oral health, it is
difficult to identify possible information sources available to them. They are likely to
need some education about how to maintain oral health.
Models for health promotion interventions targeting oral health need to be
developed to ensure effective implementation in public dental populations.
7.1.6
Low Response Rates to Offers of Treatment
Initially the research team was surprised to learn that the majority of people (60%)
offered dental treatment after two years on the waiting list do not make
appointments (Raju 2006). On reflection, it was understandable given that
changing personal circumstances and access to emergency dental care could affect
responses. However, this explanation was challenged when those who had recently
joined the waiting list (two to four months previously) responded at a similar rate.
Telephone follow-up calls improved the response rate considerably—increasing to
49% of people approached who had waited for two years or longer, and 47% of
those waiting two to four months.
The response rate raised several questions:
•
Had people sought dental care elsewhere, either for emergency treatment
or as a private patient—even those who had joined the waiting list within
the last four months? This would be feasible, given the acute nature of
people’s needs, as revealed by the dental examinations.
•
Was the co-payment cost a significant barrier to dental care for some
people?
•
Were people too sick to worry about their oral health?
•
Was literacy a barrier to understanding the offers made by the service and
by the study?
•
Had some people become ineligible for public dental care because they had
found sufficient employment?
•
Were people no longer experiencing pain and so thought that dental
treatment was no longer needed?
In any case, the lack of difference in response rates between the two groups shows
that within two to four months, half of those seeking care no longer wanted it or
were unable to use it. The non-participant survey and feedback during the
interviews showed that cost and general health were significant barriers to
accessing dental care.
Further, although this study suggests some answers to the above questions,
relatively little is known about people using public dental services in terms of their
motivations or circumstances.
The study revealed a low level of literacy among the study population, which
provides another highly feasible explanation for a poor response.
84
Recommendations
The study revealed that this group of public dental patients had significant dental
needs. Apart from the often repeated but still very important recommendation to
significantly increase funding for public dental care, we make the following
recommendations across the areas of policy development, public dental service
practice, and further research.
Policy development
Public dental policy needs to promote a population health focus aimed at preventing
avoidable tooth loss. It should include the following elements: early identification of
need, early intervention, prevention and appropriate treatment.
Specific issues need immediate short-term strategies:
•
Greater capacity to reduce the waiting list
•
Action to maximise oral health as people wait for dental treatment.
•
Develop and implement
preventive care.
•
Promotion of health literacy in regard to dental care.
workforce
structures
to
provide
effective
Funding mechanisms are needed that facilitate effective triage, a population health
approach, and that remove disadvantages to providing preventive care.
Public dental service practice
Public dental clinics need to create supportive environments that enable oral health
practitioners to provide effective dental treatment and preventive care.
Increase promotion of good dental health as part of good general health. To be
relevant and effective, targeted strategies for disadvantaged communities need to
be developed in partnership with those communities.
There is an urgent need for the introduction and evaluation of interventions to help
people preserve their teeth while waiting for dental treatment. This may include a
preventive care appointment with dental hygienists.
Strategies to improve the uptake of offers of dental treatment such as telephone
calls need to be trialled and evaluated to find ways of improving responses to
treatment offers.
Further research
More research is needed to investigate the costs related to public dental programs
and the needs and experiences of clients to help reduce inequalities in access to
dental care. This research could include:
•
An economic evaluation of the impact of oral health on other health
outcomes.
85
•
An economic evaluation of the costs of public dental care, which
includes the costs of emergency and private dental care, should be
conducted.
•
The Dental Cost Study should be repeated in other public dental clinic
populations to compare findings across population and service
groups.
•
A longitudinal study of Australian adults registered for public dental
care, to explore motivating factors and barriers to attend services and
other dental health-seeking behaviours.
•
A descriptive assessment of the socio-demographic characteristics,
oral health literacy, attitudes and health behaviour knowledge and
practices of people waiting for public dental care in Victoria. This
should include an investigation of consumer attitudes and opinions
towards public oral health services.
•
An investigation of the knowledge and use of dental vouchers among
public dental patients, to determine how to improve the use and
efficiency of vouchers in public dental care.
•
Comparison of actual dental treatment with the proposed treatment
plan in Victorian public dental services, to determine differences in
treatment and assess the usefulness of proposed treatment plans in
estimating treatment costs.
86
87
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9.
APPENDICES
APPENDIX ONE:
STUDY PROTOCAL
DENTAL COSTS STUDY
BACKGROUND
This study intends to investigate the impact of delayed dental treatment for users
of public dental health clinics. These costs include the direct costs of dental
treatment but also indirect health costs and social costs for those who await dental
care.
Australian adults eligible for public dental care have consistently shown lower levels
of oral health compared to other Australian adults in studies based on self-report
despite population trends of improved oral health (AIHW 2001, AIHW 2005, AIHW
2006). They also are more likely to rate their oral health as poor and to be
dissatisfied with life (Sanders 2005). These self-perceptions of poor oral health are
confirmed by clinical assessments of public dental patients that reveal a higher rate
of extractions and emergency dental treatment compared to the Australian
population (Brennan 1997, AIHW 1999, Brennan 2001, AIHW 10 2002, AIHW 13
2002).
One of the main reasons attributed to the poor oral health of poorer Australians is
because they are less likely to attend dentists regularly and more likely to attend
when a problem exists than people from higher income groups (Chen 1996, Harford
2004, Sanders 2004). The pattern of dental attendance is the only dental self-care
behaviour that differs between people with different socio-economic status
(Sanders 2006, Chen 1996).
While there is no evidence to support the practice of annual dental visits access to
timely clinical examination is likely to be beneficial because it enables early
detection or diagnosis, and the use of preventive interventions (Wright 2000).
However, organisational barriers, such as extended waiting times, may limit the
effectiveness of dental health services to provide timely care. Limited resources in
the public sector have led to waiting times exceeding five years in some parts of
Victoria (Scopelianos 2006).
Extended waiting for dental visits could have a number of important consequences
for both the dental service and those receiving care. First oral health is likely to
deteriorate leading to a need for more extensive restorative treatment or even
increasing the risk of tooth loss. Poor oral health can impact general health and also
negatively affect quality of life in terms of its effect on social and employment
relationships. Next, delayed treatment is likely to lead to greater demand for
emergency dental services, thereby shifting costs from preventive to emergency
treatments. Finally, there are likely to be increased costs to those waiting for dental
treatment as they seek ways to manage oral condition.
RATIONALE FOR THIS STUDY
A search of the literature, including a handsearch of relevant Australian journals
Australian Dental Journal and Australian and New Zealand Journal of Public Health)
was unable to locate any study that has investigated the impact of delayed dental
treatment for public dental patients, although a number of studies indicate that
failure to seek timely dental care is an important contributor to poor oral health.
92
This study appears to be the first Australian study that will look at the effect of
delaying treatment in terms of its costs, both financial and social.
AIMS
The primary aims of the study are to:
•
investigate the costs associated with a public dental care when dental
treatment is delayed for two years;
•
investigate the social and other costs associated with an extended delay for
public dental care;
•
identify potential measures to monitor the effective use of public dental
health care.
HYPOTHESES
Extended time on a waiting list for public dental health care leads to delayed dental
treatment that:
a. increases the costs of dental treatment without tooth loss
a. increases the risk of tooth loss
b. increases the use of emergency dental services
c. increases the impact on the quality of life due to poor oral health
d. increases social costs in terms of health behaviours in nutrition, pain
management, productivity and employment and social relationships
e. increases the use of health services
RESEARCH PLAN
The study will involve two cohorts on a public dental waiting list who will be offered
dental treatment. One group will comprise people who are eligible for dental
treatment after a waiting period of approximately two years (control group) and the
second group (intervention group) will comprise people who have been on the
waiting list for two months only. (The intervention is the provision of dental
treatment within three months.)
Phase One:
Comparison of costs of proposed dental treatment and estimated social
costs
In Phase One of the study both groups will undergo a dental health assessment and
will have a dental treatment plan developed as part of usual care at the dental
service.
Data will be collected from the dental record, from a clinical assessment and
through a structured face-to-face interview.
Assessment of use of dental services among people eligible for control
group
De-identified data from all those eligible to be in the control group will be used to
assess their use of emergency dental services and its potential impact on decisions
to take up an offer of a dental appointment.
Phase Two: Comparison of actual treatment costs and use of emergency
dental services
After twelve months dental records will be reviewed to determine the actual dental
treatment and its costs. Analysis will include assessment of the pattern of
attendance, influences on adherence to treatment plans, the use of emergency
93
dental services at the health centre and will evaluate the usefulness of an initial
dental treatment plan as an economic assessment tool.
PROCEDURE
Timely Dental treatment
a) Two to three hundred dental consecutive patients on the dental waiting list who
are due to be offered dental appointments will be asked to take part in the study.
Requests will be sent out in batches of 100 to ensure that clinic will be able to
manage requests for appointments, until about 100 agree to take part. (Currently
30-40% of people on the waiting list offered a dental appointment make
appointments.)
People who are eligible for the control group will be sent a non-participant’s
questionnaire with a replied paid envelope. People who agree to take part will have
their initial co-payment waived.
b) The first mail-out to potential members of the control group will also include 110
letters to the Intervention group, who will also be offered a dental appointment.
This group will not have their first co-payment waived.
c) All potential study participants will be sent an information sheet about the study
and asked to make a dental appointment and arrive one hour ahead if they wish to
take part in the study. They will called the day before their appointment (or on the
previous Friday if a Monday appointment) as a reminder.
d) A research assistant will meet with potential participants prior to their
appointment to explain the study, its purpose and requirements, and address any
concerns. Consenting patients will sign the informed consent document giving
permission to access their dental records.
e) A face-to-face structured interview will involve the administration of a question
prior to the dental appointment, using an interpreter where necessary.
f) Consenting patients in the control group will have the initial co-payment ($22)
waived.
g) Dentists will not have access to information about the study participants waiting
list status
Emergency dental treatment audit
a)
De-identified data from those eligible for the intervention and control groups
will be used to compare the profile of people on the waiting list and those that
attend for dental visits and participate in the study.
b)
The comparison will include the use of emergency dental services at the time
of study recruitment. In Phase 2 the use of emergency dental care in the first 12
months after joining the waiting list will be compared for all people eligible for the
control and intervention groups.
Inclusion and exclusion criteria
People will be eligible for the study if they are on the dental waiting list at the
Dianella Community Health, and they are due to be offered a dental appointment or
are in the first 120 people who joined the list after the 1st March 2006, and are
competent to give consent.
94
People will be excluded from the study if they are unable to give informed consent,
and if they fail to attend for an initial dental appointment at Dianella.
People consenting to take part in the study who have pre-existing medical
conditions will be excluded from periodontal assessment.
MEASURES
Primary outcome:
Phase 1
• cost of proposed treatment plan.
Phase 2
• cost of actual dental treatment plan.
Secondary outcomes:
Phase 1
• clinical assessments.
• type of dental treatments – extraction or restoration
• other dental treatments (eg emergency and private care)
• co-payments charged to patient
• Impact of oral health [OHIP-14]
• Impact on social costs (from consumer interview)
• Use of health service (from consumer interview)
Phase 2
• Actual type of treatment.
• Use of emergency dental services.
DATA COLLECTION
Consumer demographic information:
Demographic information will be collected in a structured interview including:
gender; level of education attained; (previous) occupation; country of birth; and
language spoken at home.
Patient records will be reviewed to collect information including: date of joining
waiting list; number of missing teeth; use of emergency dental services: types of
treatment received; costs of treatments; and co-payments paid.
Cost of proposed dental treatment:
Costs associated with dental treatment (from the perspective of the health service)
are itemised and recorded in the dental record. Costs for treatments are
determined according to the Department of Veteran’s Affairs dental schedule.
Costs associated with oral health issues (from the perspective of the consumer) will
be assessed from the assessment by the dentist (re private dental work estimated
to have occurred in past 6 months); and consumer interview.
Clinical assessment:
Four clinical outcomes will be collected. These will be ascertained by dentists at the
clinic at the initial dental visit. The electronic dental records will be adjusted to
restrict access to information about study participants experience on the waiting
list. This means that all dentists involved in clinical assessments will be effectively
blind to the allocation of study participant to either the intervention or control
groups. A random sub-sample comprising 10 percent of the study population will be
reassessed at their subsequent dental visit to provide a calibration of the
assessments.
a) Decayed, Missing and Filled Teeth or Surfaces index (DMFT or DMFS
index)
95
DFMT provides a summary assessment of dental decay and treatment: D= the sum
of decayed and recurrent caries or the level of untreated disease; F= the sum of
filled teeth; and M= the sum of extracted teeth due to caries or periodontal
condition. F and M provide a treatment history (Brennan 2004).
The DMFT index is calculated automatically from the dental chart in the dental
record software and will be extracted from the record after the initial clinical
assessment.
b) Mean number of functional teeth
The number of functional teeth will be determined by the initial clinical assessment
and extracted from the electronic dental record.
c) Dental Prosthesis status
Dentists will assess the Dentate Status [=All Own Teeth; Teeth and Dentures;
Edentulous] in the electronic dental record which will be used to determine the
Dental Prostheses status.
d) Community Periodontal Index (CPI)
The Community Periodontal Index (CPI) involves assessment of each dentate
sextant for the presence of gingival bleeding (which score 1), calculus at any supraor sub-gingival site (score 2), and the presence of pockets (pockets of 4-5mm score
3 and pockets of 6mm or more score 4). Periodontal health receives a score of 0.
The CPI will be charted by each dentist manually.
Other assessments
Oral Health Impact Profile – OHIP-14:
The 14-item scale OHIP-14 measures perceptions of social impact relating to oral
health over the preceding 4 weeks (Brennan 2004). It will form part of the
structured interview at the initial dental visit.
The scale is concerned with frequency of symptoms and uses response categories:
Never; Hardly ever; Occasionally; Very Often; and Fairly Often in a five point
Likert-type scale. The scale has been widely used in Australia.
Impact on health behaviour:
A 16-item scale was developed to assess behaviour relating to the dimensions of
nutrition, pain management, productivity and employment, and social relationships.
It will be included in the structured interview at the initial dental visit.
The scale uses response categories similar in format to the OHIP-14 for the
frequency of self-reported behaviour over the past four weeks: Never; Hardly ever;
Occasionally; Very Often; and Fairly Often in a five point Likert-type scale.
The scale is not validated and will be reviewed after the first twenty interviews to
see if the
use of dental and medical services in the last six months including emergency
services. Study participants will be asked about a specific public dental service and
public and private health services more generally. Recall of the use of the specific
public dental service will be compared with the dental record.
SAMPLE SIZE CALCULATION
The sample size of 100 in each group, using a statistical
power of 0.80, would give an effect size (d) of 0.40. (That is
there would be an 80% probability of detecting changes of
96
0.40 standard deviations in variables with a bidirectional test
and alpha of 0.05.)
Based on the value of the private dental voucher of $620, a
sample size of 100 in each group, using a statistical power of
0.80, and alpha of 0.5 will detect a 12 percent reduction in
dental costs.
DATA ANALYSIS
Data analysis will compare the proposed treatment costs and final treatment costs
for the control and intervention groups. Odds ratios with 95 percent confidence
intervals will be calculated.
Other variables will also be compared including clinical assessments, type of
treatment (extraction vs restoration), assessment of the social impact of oral health
and health service use. Data will stratified by age group (18-64 years; 65 years and
older), gender, language at home (English only vs not English only) and place of
birth (Australia vs not Australia). Sub-group analysis will be performed on those
patients for whom an extraction is proposed to compare the effect of patient
preference alone as reason for extraction if there are sufficient data.
97
APPENDIX TWO: COMPLETE LIST OF DATA ITEMS
Consumer demographic information:
Demographic information was collected in a structured interview including: gender;
level of education attained; (previous) occupation; country of birth; and language
spoken at home.
Patient records were reviewed to collect information including: date of joining
waiting list; number of missing teeth; use of emergency dental services: types of
treatment received; costs of treatments; and co-payments paid.
Cost of proposed dental treatment:
Costs associated with dental treatment (from the perspective of the health service)
were itemised and recorded in the dental record. Costs for treatments were
determined according to the Department of Veteran’s Affairs dental schedule.
Costs associated with oral health issues (from the perspective of the consumer)
were assessed from the assessment by the dentist (re private dental work
estimated to have occurred in past 6 months); and consumer interview.
Clinical assessment:
Four clinical outcomes were collected. These were ascertained by dentists at the
clinic at the initial dental visit. The electronic dental records were adjusted to
restrict access to information about study participants experience on the waiting
list. This means that all dentists involved in clinical assessments were effectively
blind to the allocation of study participant to either the intervention or control
groups. A random sub-sample comprising 10 percent of the study population will be
reassessed at their subsequent dental visit to provide a calibration of the
assessments.
(a) Decayed, Missing and Filled Teeth or Surfaces index (DMFT or
DMFS index)
DFMT provides a summary assessment of dental decay and treatment: D= the
sum of decayed and recurrent caries or the level of untreated disease; F= the
sum of filled teeth; and M= the sum of extracted teeth due to caries or
periodontal condition. F and M provide a treatment history (Brennan 2004).
The DMFT index is calculated automatically from the dental chart in the dental
record software and will be extracted from the record after the initial clinical
assessment.
(b) Mean number of functional teeth
The number of functional teeth was determined by the initial clinical
assessment and recorded by the dentist.
(c) Dental Prosthesis status
Dentists assessed the Dentate Status [=All Own Teeth; Teeth and Dentures;
Edentulous] in the electronic dental record which will be used to determine the
Dental Prostheses status.
(d) Community Periodontal Index (CPI)
The Community Periodontal Index (CPI) involves assessment of each dentate
sextant for the presence of gingival bleeding (which score 1), calculus at any
supra- or sub-gingival site (score 2), and the presence of pockets (pockets of
4-5mm score 3 and pockets of 6mm or more score 4). Periodontal health
receives a score of 0. The CPI was charted by each dentist manually.
98
Other assessments: Oral Health Impact Profile – OHIP-14
The 14-item scale OHIP-14 measures perceptions of social impact relating to oral
health over the preceding 4 weeks (Brennan 2004). It formed part of the structured
interview at the initial dental visit.
The scale is concerned with frequency of symptoms and uses response categories:
Never; Hardly ever; Occasionally; Very Often; and Fairly Often in a five point
Likert-type scale. The scale has been widely used in Australia.
Impact on health behaviour:
A 16-item scale was developed to assess behaviour relating to the dimensions of
nutrition, pain management, productivity and employment, and social relationships.
It was included in the structured interview at the initial dental visit.
The scale uses response categories similar in format to the OHIP-14 for the
frequency of self-reported behaviour over the past four weeks: Never; Hardly ever;
Occasionally; Very Often; and Fairly Often in a five point Likert-type scale.
The scale is not validated.
use of dental and medical services in the last six months including emergency
services. Study participants were asked about a specific public dental service and
public and private health services more generally. Recall of the use of the specific
public dental service was compared with the dental record.
Emergency dental treatment audit
De-identified data from those eligible for the intervention and control groups will be
used to compare the profile of people on the waiting list and those that attend for
dental visits and participate in the study.
99
APPENDIX THREE: DIANELLA’S LETTER OF OFFERING ON
AN APPOINTMENT
Dianella Community Health Inc
Date
Name
Address
Dear
Re: LETTER OF OFFER FOR GENERAL TREATMENT
You have been on our waiting list for a Dental appointment and we
are pleased to inform you that you have been selected as study group
and offered treatment at Dianella Dental Practice. Attached with this
letter is an information pack.
If you are still a holder of a Health Care Card or a Pension Concession
Card, please come into the Dianella Community Health Dental
Department and make appointment. When you come to make this
appointment please bring this letter together with your current Health
Care or Pension Card between 1.30 pm and 4.00 pm Monday to
Friday.
From 1997 Co-Payment for Dental treatment has been introduced,
you will be required to pay a fee of $88 to the Dental Practice. Please
note your maximum contribution for dental treatment will be $88
only.
Please come or contact us on 8345 5410/8345 5827 to make an
appointment before the (date).
Please disregard this letter if you have been to this clinic for
General dental treatment within the last twelve months. You
may place your name on our Waiting List as per the
instruction sheet that was given to you when your treatment
was last completed.
Yours sincerely,
Dental Receptionist
100
APPENDIX FOUR:
HEALTH ISSUES CENTRE’S LETTERS
EXPLAINING THE STUDY
DATE
Dear
Dental Costs Study
As someone who has reached the top of the dental waiting list at Dianella Community
Health, we invite you to take part in a study to find out more about the costs dental
treatment and waiting lists. We have included information about the study for you to read.
If you agree to take part in the study:
•
•
•
•
•
•
•
•
You will have your dental treatment at Dianella Community Health.
The usual co-payment of $22 for your first treatment will be waived.
You will need to call Dianella Community Health to make an appointment for dental
treatment as described in their letter enclosed.
You need to attend the clinic an hour before your appointment time so that we can
explain the study and answer any questions you may have about it.
You will need to sign a consent form which will be explained to you.
You will need to answer some questions about your dental health and how it affects
you. The questions should take about 30 minutes.
To participate in this study, we need your permission to give the researchers access to
your dental treatment records. We need information about your dental treatment plan,
your use of emergency dental care and your dental treatments over the next 12
months. Information from your records will only be used for the Dental Costs Study.
Your name and personal details will not be revealed in the study.
It’s entirely up to you
Taking part in this study is completely up to you. If you do not wish to take part you do not
have to and it will not affect your oral health treatment at Dianella Community Health in any
way.
It would be helpful for us to know the reasons why you decide not to take part so we have
enclosed a brief survey and return paid envelope. You do NOT have to add a stamp. Please
DO NOT write your name on this survey.
What you need to do now
If you want to be in the study you need to call Dianella Community Health’s Dental Reception
at (03) 8345 5410 or (03) 8345 5827 by the date in the LETTER OF OFFER FOR
GENERAL TREATMENT. Tell the Receptionist that you want to be in the Dental Costs Study.
If you have any questions about this study, please call Charin at (03) 9479 3614.
Yours sincerely
Charin Naksook
Senior Project Officer
101
Date
Dear
Dental Costs Study
As someone who has recently joined the dental waiting list at Dianella Community Health, we
invite you to take part in a study to find out more about the costs dental treatment and
waiting lists. We have included information about the study for you to read.
If you agree to take part
•
•
•
•
•
•
•
•
You will be able to have your dental treatment at Dianella Community Health in the
next few weeks.
You will need to call Dianella Community Health to make an appointment for dental
treatment as described in their letter enclosed.
You will be required to meet the usual co-payment for your treatment.
You will need to attend the clinic an hour before your appointment time so that we can
explain the study and answer any questions you may have about it.
You will need to sign a consent form which will be explained to you.
You will need to answer some questions about your dental health and how it affects
you. The questions should take about 30 minutes.
If you participate in this study we need your permission to give the researchers access
your dental treatment records. We need information about your dental treatment plan,
your use of emergency dental care and your dental treatments over the next 12
months. Information from your records will only be used for the Dental Costs Study.
Your name and personal details will not be revealed in the study.
It’s entirely up to you
Taking part in this study is completely up to you. If you do not wish to take part you do not
have to and it will not affect your oral health treatment at Dianella Community Health in any
way. If you do not wish to take up this offer you will remain on the waiting list until it is your
turn for treatment.
It would be helpful for us to know the reasons why you decide not to take part so we have
enclosed a brief survey and return paid envelope. You do NOT have to add a stamp. Please
DO NOT write your name on this survey.
What you need to do now
If you want to be in the study you need to call Dianella Community Health’s Dental Reception
at (03) 8345 5410 or (03) 8345 5827 by the date required by the LETTER OF OFFER
FOR GENERAL TREATMENT. Tell the Reception that you want to be in the Dental Costs
Study.
If you have any questions about this study, please call Charin at (03) 9479 3614.
Yours sincerely
Charin Naksook
Senior Project Officer
102
APPENDIX FIVE:
1.
PROJECT INFORMATION SHEET
Participating in this study
We would like you to take part in a research project called The Dental Costs
Study which is looking at the costs of dental care and waiting lists.
Before you decide to take part, we will provide you with the relevant information
about what the study involves. If you are not sure about anything, please ask us.
You can call Dr Charin Naksook at (03) 9479 3614 or Dr Sachidanand Raju at (03)
8345 5410.
Taking part in any research project is completely up to you. If you do not wish to
be involved you do not have to and it will not affect your oral health treatment at
Dianella Community Health in any way.
If you agree to take part in the study, you will need to sign a consent form. If you
decide to take part and later change your mind, you can pull out of the study. If
this happens we will not use any information about you that has been collected and
not yet analysed.
Your dental treatment will be the same as anyone else on the waiting list.
2.
What is the study about?
We are doing this study to find out more about the costs of delayed dental
treatment. We will compare the costs of dental treatment for people who have had
an extended time on a waiting list with people who have only waited two months.
We are also interested in any other costs related to your health during the past six
months, including any other dental treatment you may have had.
3.
Who is taking part?
We hope to involve about 200 people seeking dental treatment at Dianella
Community Health in this project.
About half of these are due to get an
appointment for dental treatment after having been on the waiting list for some
time and about half will have joined the waiting list since May 2006.
103
4.
What does the study involve?
If you agree to take part in the study you will need to:
•
attend the dental clinic an hour before your first dental appointment. We
will call to remind you of this appointment;
•
give your signed consent to the project team to let them access your
dental records at Dianella Community Health. We want to learn more about
your dental treatment plan, any emergency dental treatment you may
have had and your dental treatments over the next 12 months;
•
answer some questions about how your dental health and how it affects
you. This will take about 30 minutes;
•
have an oral health assessment completed by a dentist at Dianella
Community Health.
5.
What about reimbursement?
People who have been on the waiting list for an extended period and who agree to
be in the study will have the co-payment for their first treatment waived. People
who have early dental treatment because they are part of this study will need to
pay their co-payment as per usual.
6.
Who is funding the study and who is doing it?
We are able to do this study through funding from the Department of Human
Services and VicHealth (Victoria Health Promotion Foundation). Health Issues
Centre, Dental Health Services Victoria and Dianella Community Health will work
together on this project.
Health Issues Centre is an independent non-government organisation that
promotes and researches consumer perspectives. If you have access to the Internet
at home or at your local library you can read more about Health Issues Centre at
www.healthissuescentre.org.au
7.
What are the possible benefits from the study?
People who take part in this study, especially those who have waited for a long
time, will learn more about the costs associated with delayed dental treatment. The
other benefit will be helping to know more about the costs of dental waiting lists.
8.
What are the possible risks?
Physical risks involved in this project are the same as those with normal dental
treatment, including any x-ray that may be taken for routine dental examinations.
As in usual care, the dentist will decide if you need an x-ray.
There is a small risk that thinking about how you have managed your dental health
problems while waiting for an appointment may upset you. If this happens, you can
pull out of the study and you can access a free confidential session with an
experienced counsellor to help you if you want it. This will not affect your dental
care in any way.
104
9.
How will information be kept private?
We will collect information in writing and on the computer. All data will be coded so
that names will not appear with it. All computerised information will be passwordprotected. Any information that we get in this project that can identify the people in
the study will remain confidential. Only people on the research team will see
individual data, other than the information people usually see when they provide
your dental care. People who take part in the study can see any information about
them that we collect if they wish. No one will be identifiable in any reports that are
produced.
All data will be stored in a locked filing cabinet at Health Issues Centre, retained for
seven years and shredded after that time.
10.
What will happen to the study results?
We will write reports on the study findings for the Department of Human Services
and VicHealth. These may also be used to prepare papers for wider publication. In
any publication, no person who takes part in the study will be identified.
No one will make any money from the results of this study.
If you want a summary of the 2006 findings of the study, it will be sent to you in
later this year. A summary of the full study will be available by the end of 2007.
11.
Ethical Guidelines
This project will be carried out according to the National Statement on Ethical
Conduct in Research Involving Humans (June 1999) produced by the National
Health and Medical Research Council of Australia. This statement was developed to
protect the interests of people who agree to participate in human research studies.
If you want to read this statement please contact Health Issues Centre. This
research study has been approved by the Human Research Ethics Committee of
Dental Health Services Victoria.
12.
Who is doing the research?
The Principal Researchers for this study are: Tony McBride who is the CEO of Health
Issues Centre, Dr Dell Horey, Senior Project Officer at Health Issues Centre and Dr
Hanny Calache, Clinical Director at Dental Health Services Victoria.
The Associate Researchers are: Dr Sachidanand Raju from Dianella Community
Health and Dr Charin Naksook from Health Issues Centre.
13.
Further Information
If you want to know more about this study you can contact: Tony McBride, CEO
Health Issues Centre, (03) 9479 5827 or 0407 531 468, or Charin Naksook, (03)
9479 3614.
105
14.
Other Issues
If you have any complaints about any aspect of this project or have any questions
about your rights as someone taking part in a research project, you can contact:
Dr Hanny Calache
Clinical Director
Dental Health Services Victoria
Telephone:
(03) 9341 1291
July 2006
106
APPENDIX SIX:
CONSENT FORM
I have read, and I understand the information sheet about the Dental Costs Study,
dated July 2006.
I freely agree to take part in this study as described in the Information about the
Dental Costs Study sheet. I understand that I can withdraw from the study at any
stage if I wish to do so and that any information that has not yet been analysed will
not be used.
I will be given a copy of the Information about the Dental Costs Study sheet and the
Consent Form to keep.
I understand that the information I give in the questionnaire and oral health
assessment will be recorded manually or electronically. However, the researcher will
not reveal any of my personal details or my identity to any third party, nor will
he/she identify me in any published reports or presentations about the project.
I give the Dental Cost Study researchers permission to access my dental health
records at Dianella Community Health and the Royal Dental Hospital of Melbourne.
Participant’s Name (printed) ……………………………………………………………………………
Signature
Date
Name of Witness (printed) ………………………………………………………………………………
Signature
Date
Researcher’s Name (printed) ……………………………………………………………………………
Signature
Do you want a summary of the study findings?
Date
YES
NO
Note: All parties signing the Consent Form must date their own signature.
107
APPENDIX SEVEN: NON PARTICIPANT SURVEY
If you can’t take part in this study, or don’t want to, it would be helpful for us to know why.
Please let us know by sending back this form in the enclosed envelope.
You DO NOT need a postage stamp.
Please DO NOT write your name on this survey.
Just mark the boxes next to your reasons for not taking part.
I haven’t time to take part
There is too much to read
I am working now
I don’t need to see a dentist anymore
I am too sick
It is too hard to get to the dental clinic
I don’t like seeing the dentist
I can’t afford to see the dentist
It is too much bother
Cost of transport concerns me

Other reason (please tell us what it is)
..................................................................................................................
..................................................................................................................
..................................................................................................................
Thank you!
108
APPENDIX EIGHT:
INTERVIEW QUESTIONNAIRE
DENTAL COSTS STUDY
HEALTH ISSUES CENTRE, DENTAL HEALTH SERVICES VICTORIA AND
DIANELLA COMMUNITY HEALTH SERVICE
Funded by VicHealth and Department of Human Services, Victoria
STUDY ID:
Interpreter:
YES
NO
109
Thank you for agreeing to take part in this study.
The first questions are about you.
Q1. Age:
Q2. Gender:
Male
(1)
Female
(2)
Q3a. What is your country of birth?
Q3b. (If not Australia) When did you arrive in Australia?
Q3c. What language do you speak at home?
English
Italian
Other
(1)
Turkish
(4)
(2)
Arabic
(YEAR)
(Tick all that apply)
Vietnamese
(3)
(5)
Greek
(6)
(7) (please indicate)___________________________________
The next questions are about your use of dental services.
Q4a. Where did you go for your last dental visit?
□
□
□
□
□
□
□
Dianella Community Health Centre
Other Community Health Centre
Dental Hospital
(3)
Private practice
(4)
Dental technician
Can’t recall
Other
(7).
(Tick one that applies)
(1)
(2)
(5)
(6)
Please, specify _______________________
Q4b. How long ago was your last dental visit?
□
□
□
□
□
Less than 12 months ago
1 to 2 years ago
(2)
2 to 5 years ago
(3)
More than 5 years ago
(1)
(4)
Never had dental visit before
(5)
Q5. Was your last dental visit for emergency treatment?
YES
NO
UNSURE
110
Q6. Have any of the following stopped you seeking oral health services?
(Check all that apply)
a) □ Cost
b) □ Availability of dentists
c) □ Time waiting for appointments (waiting lists)
d) □ Rude behaviour from dentists
e) □ Rude behaviour from non-professionals (receptionist, dental nurses)
□
g) □
h) □
i) □
j) □
k) □
l) □
f)
Location of services (transportation)
Waiting time in surgery
Fear of dentist/treatments/procedures
Physical disability (access)
General health problem
Communication/language problems
Mental health problem (eg depression, anxiety)
Q7. In comparison to the ORAL HEALTH of other people of your age, would you
say your oral health is? (Circle one only)
1
Much better
2
Better
3
About the same
4
Worse
5
Much worse
_____________________________________________________________
The next group of questions is about the PAST FOUR WEEKS. In that time…
[Please record
additional responses
in space below.]
Q8. [During the PAST FOUR WEEKS] how often have you had trouble pronouncing
any words because of problems with your teeth, mouth or dentures? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q9. [During the PAST FOUR WEEKS] how often have you felt that your sense of
taste has worsened because of problems with your teeth, mouth or
dentures? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q10. [During the PAST FOUR WEEKS] how often have you had painful aching in your
mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q11. [During the PAST FOUR WEEKS] how often have you found it uncomfortable to
eat any foods because of problems with your teeth, mouth or dentures?
(Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q12. [During the PAST FOUR WEEKS] how often have you been self-conscious
because of your teeth, mouth or dentures? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
111
SOCIAL COSTS OF DELAYED DENTAL TREATMENT SURVEY
Q13. [During the PAST FOUR WEEKS] how often have you felt tense because of
problems with your teeth, mouth or dentures? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q14. [During the PAST FOUR WEEKS] how often have you thought your diet has been
unsatisfactory because of problems with your teeth, mouth or dentures? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q15. [During the PAST FOUR WEEKS] how often have you had to interrupt meals
because of problems with your teeth, mouth or dentures? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q16. [During the PAST FOUR WEEKS] how often have you found it difficult to relax
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q17. [During the PAST FOUR WEEKS] how often have you been a bit embarrassed
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q18. [During the PAST FOUR WEEKS] how often have you been a bit irritable with
other people because of problems with your teeth, mouth or dentures? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q19. [During the PAST FOUR WEEKS] how often have you had difficulty doing your
usual jobs because of problems with your teeth, mouth or denture? (Circle one
only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q20. [During the PAST FOUR WEEKS] how often have you felt that life in general was
less satisfying because of problems with your teeth, mouth or dentures? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q21. [During the PAST FOUR WEEKS] how often have you been totally unable to
function because of problems with your teeth, mouth or dentures? (Circle one
only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
____________________________________________________________
Q22. In general, would you say your health is?
1
Excellent or
very good
2
Good
3
Average or fair
(Circle one only)
4
Poor
5
Very poor
___________________________________________________________________
112
[Please record additional
responses in space
below.]
HEALTH SERVICE USE
The next 5 questions are about your use of health services over the PAST SIX
MONTHS.
Q23. [In the PAST SIX MONTHS] have you used emergency dental services?
that applies)
YES
(Tick one
NO
Q23a. If yes, did you use
Q23a) Dianella Community Health Centre dental services?
YES
NO
Q23b) Other public emergency dental services?
YES
NO
Q23c) Private emergency dental services?
YES
NO
Q24. [In the PAST SIX MONTHS] have you used non-emergency dental services?
one that applies)
YES
(Tick
NO
Q24a. If yes, did you use
Q24a) Dianella Community Health Centre dental services?
YES
Q24b) Other public dental services?
YES
NO
Q24c) Private dental services?
YES
NO
NO
_________________________________________________________________________________________________________
Q25. [In the PAST SIX MONTHS] have you attended a general medical practitioner
(GP) or health clinic? (Tick one that applies)
YES
NO
Q25a. If yes, how may times?
Once only
2 or 3 times
3 to 6 times
More than six times
_________________________________________________________________________________________________________
Q26. [In the PAST SIX MONTHS] have you attended a medical hospital (not dental
hospital or clinic) as an out-patient? (Tick one that applies)
YES
NO
Once only
2 or 3 times
4 to 6 times
More than six times
113
Q27. In the PAST SIX MONTHS have you attended the emergency ward of a
medical hospital for health care? (Tick one that applies)
YES
NO
Once only
2 or 3 times
3 to 6 times
More than six times
_______________________________________________________________________________________________________________
_________
The next questions are about how you might have managed pain in your teeth
and mouth over the LAST FOUR WEEKS.
Q28. [During the PAST FOUR WEEKS] how often have you avoided cold
foods to manage pain with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
[For questions asking
‘how often’ please
record any descriptive
terms used such as
‘every day’ or ‘now
and then’ but ask
them to rate as per
scale – how it feels to
them.]
Q29. [During the PAST FOUR WEEKS] how often have you avoided hot foods to
manage pain with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q30. [During the PAST FOUR WEEKS] how often have you used painkillers
bought over the counter (eg at chemist or supermarket) to manage pain
with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q31. [During the PAST FOUR WEEKS]how often have you used alcohol to
manage pain with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
5*
n’t drink alcohol
Q32. [During the PAST FOUR WEEKS] how often have you smoked cigarettes
to manage pain with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
5*
Don’t smoke
Q33. [During the PAST FOUR WEEKS] how often have you used acupuncture
to manage pain with your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
[For questions
asking ‘how
often’ please
record any
descriptive
terms used
such as ‘every
day’ or ‘now
and then’ but
ask them to
rate as per
scale – how it
feels to them.]
4
Very often
Q34. [During the PAST FOUR WEEKS] how often have you seen a doctor to
get medication because of problems related to your teeth or mouth?
(Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
114
Q35. [During the PAST FOUR WEEKS] how often have you used nutrition
supplements because of problems related to your teeth or mouth? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q36. [During the PAST FOUR WEEKS] how often have you bought special
foods because of problems related to your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q37. [During the PAST FOUR WEEKS] how often have you missed work
because of problems related to your teeth or mouth? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
5
Not applicable
Q38. [During the PAST FOUR WEEKS] how often have you found it difficult
to sleep because of problems related to your teeth or mouth? (Circle one
only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q39. [During the PAST FOUR WEEKS] how often have you used a traditional
remedy, like oil of cloves, to manage pain with your teeth or mouth? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q40. [During the PAST FOUR WEEKS] how often do you think that problems
with your teeth, mouth or dentures affected your social activities? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
with your teeth, mouth or dentures caused problems with intimacy with
others? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
with your teeth, mouth or dentures affected your job prospects? (Circle
one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
5*
Not applicable
with your teeth, mouth or dentures stopped you attending important
functions? (Circle one only)
0
Never
1
Hardly ever
2
Occasionally
3
Fairly often
4
Very often
Q44. a) During the PAST FOUR WEEKS have you used any other ways to manage
pain with your teeth or mouth, eg using a cold pack? (Please describe)
________________________________________________________________________________________
________________________________________________________________________________________
115
Q44. b) If so, how often did you use it?
0
Never
1
Hardly ever
2
Occasionally
(Circle one only)
3
airly often
4
Very often
5
Not applicable
Finally, some questions about you.
Q45. What is the highest level of education you have reached?
applies)
□
No formal education
□
Primary incomplete (year 1-6)
□
Primary complete
□
□
Secondary complete
□
Tertiary education (complete or incomplete)
(Tick one that
Q46. What is (or was) your main occupation in your life?
_________________________________________________________________________________________________
Thank you!
NOTES:
RESEARCHER’S CHECKLIST
Have you given the envelope containing Thank You note?
□
116
APPENDIX NINE:
RELIABILITY TESTING
To determine the intra-, inter-rate reliability consensus on the assessment, the
intraclass correlation coefficient (ICC) was used.
ICC is used when data is
measured at an interval level and because of the sample size (smaller than 15).
Interpretation of the ICC is similar to Kappa. By convention, a Kappa value of 0.40
to 0.59 is moderate inter-examiner reliability, 0.60 to 0.79 substantial, and 0.80
outstanding (Landis and Koch 1977). Consequently, when ICC approaches 1, all
examiners give the same reading. That is, perfect inter-examiner reliability.
In the present case the inter-examiner reliability is generally low (either 0.30 or
0.46). Single measures are used when individual ratings constitute the unit of
analysis. Average measures are used when the mean of all ratings is the unit of
analysis. In this test a single measure is applicable. In either case, inter-examiner
reliability is low, or at best moderate.
Inter Examiner Reliability
Intraclass Correlation Coefficient
Intraclass
Correlation(a)
Lower Bound
Single
Measures
Average
Measures
95% Confidence
Interval
Upper
Bound
Value
F Test with True Value 0
Lower
df1
df2
Sig
Bound
.299(b)
-.076
.601
1.846
27.0
27
.059
.461(c)
-.164
.750
1.846
27.0
27
.059
Intraclass Correlation Coefficient: Rater 1 (Dentist A)
Intraclass
Correlation(a)
Lower Bound
Single
Measures
Average
Measures
95% Confidence
Interval
Upper
Bound
Value
df1
df2
Lower
Bound
Sig
1.000(b)
.
1.000
.
9.0
.
.
1.000(c)
.
1.000
.
9.0
.
.
Intraclass Correlation Coefficient: Rater 2 (Dentist B)
Intraclass
Correlation(a)
Lower Bound
Single
Measures
Average
Measures
95% Confidence
Interval
Upper
Bound
Value
df1
df2
Lower
Bound
Sig
.997(b)
.990
.999
764.949
9.0
9
.000
.999(c)
.995
1.000
764.949
9.0
9
.000
117
APPENDIX TEN:
PROPOSED TREATMENT ITEM NUMBERS
BY TREATMENT TYPE AND WAITING TIME
Table 1: Diagnostic procedures: People treated by waiting time
Waiting 2-4
months
n (%)
Waiting > 2yrs
n (%)
Item No 011
Oral examination ($40.25)
Total
n (%)
9 (6.9)
4 (3.4)
13 (5.3)
Item No 014
Consultation ($45.95)
72 (55.4)
61 (52.6)
133 (54.1)
Item No 015
Extended consultation
($75.25)
50 (38.5)
52 (44.8)
102 (41.5)
Number people with
one referral letter
36 (27.7)
38 (32.8)
74 (30.1)
Number people with
two referral letters
4 (3.1)
3 (2.6)
7 (2.8)
44
44
88
1 treatment
86 (66.2)
63 (54.3)
149 (60.6)
2 treatments
5 (3.8)
5 (4.3)
10 (4.1)
3 treatments
1 (0.8)
1 (0.9)
2 (0.8)
4 treatments
1 (0.8)
0 (0.0)
1 (0.4)
8 treatments
0 (0.0)
1 (0.9)
1 (0.4)
93 (71.5)
70 (60.3)
163 (66.3)
103
84
187
1 treatment
72 (55.4)
56 (48.3)
128 (52.0)
2 treatments
6 (4.6)
3 (2.6)
9 (3.7)
3 treatments
3 (2.3)
0 (0.0)
3 (1.2)
4 treatments
0 (0.0)
2 (1.7)
2 (0.8)
5 treatments
1 (0.8)
0 (0.0)
1 (0.4)
6 treatments
1 (0.8)
0 (0.0)
1 (0.4)
7 treatments
0 (0.0)
1 (0.9)
1 (0.4)
83 (63.8)
62 (53.4)
145 (58.9)
104
77
181
18 (13.8)
11 (9.5)
29 (11.8)
Item No 019
Referral letter ($15.50)
Total letters sent
Item No 022
Radiograph ($32.60)
Total people
Total radiographs
Item No 024
Radiograph same day ($22.05)
Total people
Total same day
radiographs
Item No 037
Panoramic radiograph ($0)
118
Table 2: Preventive treatment procedures: People treated by waiting time
Waiting
2-4 months
n (%)
Waiting > 2yrs
n (%)
Item No 111 plaque
removal ($41.50)
Total
n (%)
0 (0.0)
1 (0.9)
1 (0.4)
1 treatment
105 (80.8)
96 (82.8)
201 (81.7)
2 treatments
0 (0.0)
1 (0.9)
1 (0.4)
Item No 114 calculus
removal ($56.40)
3 treatments
1 (0.8)
1 (0.9)
2 (0.8)
106 (81.5)
98 (84.5)
204 (82.9)
110
101
211
1 treatment
2 (1.5)
3 (2.6)
5 (2.0)
2 treatments
1 (0.8)
0 (0.0)
1 (0.4)
Total people
3 (2.3)
3 (2.6)
6 (2.4)
Total treatments
4 (3.1)
3 (2.6)
7 (2.8)
1 treatment
7 (5.4)
6 (5.2)
13 (5.3)
2 treatments
1 (0.8)
0 (0.0)
1 (0.4)
Total people
8 (6.2)
6 (5.2)
14 (5.2)
Total treatments
9 (6.9)
6 (5.2)
15 (6.1)
Total people
Total treatments
Item No 115 calculus
removal >1
Item No 121 Fluoride
($25.05)
Item No 141 hygiene
instruction ($38.85)
86 (66.2)
69 (59.2)
155 (63.0)
Item No 161 fissure seal
($36.50)
0 (0.0)
1 (0.9)
1 (0.4)
Item No 165 desensitising
($19.60)
1 (0.8)
3 (2.6)
4 (1.6)
Table 3: Periodontal procedures: People treated by waiting time
Waiting
2-4 months
n (%)
Waiting > 2yrs
n (%)
Total
n (%)
Item No 222
Root planning ($98.70)
1 treatment
1 (0.8)
1 (0.9)
2 (0.8)
3 treatments
1 (0.8)
0 (0.0)
1 (0.4)
4 treatments
Total people
Total treatments
8 (6.2)
2 (1.7)
10 (4.1)
10 (7.7)
3 (2.6)
13 (5.3)
36
9
45
119
Table 4: Oral surgery: People treated by waiting time
Waiting 2-4
months
n (%)
Waiting > 2yrs
n (%)
Total
n (%)
Item No 311 removal
($90.75)
1 treatment
12 (9.2)
12 (10.3)
24 (9.8)
2 treatments
8 (6.2)
11 (9.5)
19 (7.7)
3 treatments
7 (5.4)
2 (1.7)
9 (3.7)
4 treatments
3 (2.3)
2 (1.7)
5 (2.0)
6 treatments
1 (0.8)
0 (0.0)
1 (2.0)
7 treatments
0 (0.0)
1 (0.9)
1 (0.4)
11 treatments
0 (0.0)
1 (0.9)
1 (0.4)
13 treatments
1 (0.8)
0 (0.0)
1 (0.4)
15 treatments
0 (0.0)
2 (1.7)
2 (0.8)
32 treatments
Total people
Total treatments
0 (0.0)
1 (0.9)
1 (0.4)
32 (24.6)
32 (27.6)
64 (26.0)
80
128
208
2 (1.5)
0 (0.0)
2(0.8)
2
0
2
Item No 314 sectional
removal ($121.50)
Total people
Total treatments
Item No 316 additional
removal ($59.95)
1 treatment
3 (2.3)
3 (2.6)
6 (2.4)
2 treatments
1 (0.8)
4 (3.4)
5 (2.0)
5 treatments
1 (0.8)
0 (0.0)
1 (0.4)
7 treatments
0 (0.0)
1 (0.9)
1 (0.4)
24 treatments
0 (0.0)
1 (0.9)
1 (0.4)
28 treatments
1 (0.8)
0 (0.0)
1 (0.4)
6 (4.6)
9 (7.8)
15 (6.1)
38
42
80
1 (0.8)
0 (0.0)
1 (0.4)
1 (0.8)
0 (0.0)
1 (0.4)
2
0
2
Total people
Total treatments
Item No 322 surgical
removal ($154.30)
2 treatments
Total people
Total treatments
120
Table 5: Endodontics: People treated by waiting time
Waiting > 2yrs
n (%)
Item No 415 complete root
preparation (1) ($174.35)
1 treatment
2 treatments
4 treatments
Total people
Total treatments
Item No 416 root
preparation (1) ($72.45)
1 treatment
2 treatments
3 treatments
6 treatments
Total people
Total treatments
Item No 418 root
obturation (+) ($72.45)
1 treatment
2 treatments
3 treatments
4 treatments
6 treatments
Total people
Total treatments
Item No 419 expiration
($99.85)
1 treatment
2 treatments
Total people
Total treatments
Item No 451 removal root
filling ($76.55)
2 treatments
Total people
Total treatments
Item No 455 irrigation visit
($76.55)
1 treatment
3 treatments
4 treatments
Total people
Total treatments
Item No 458 Interim root
filling ($102.05)
1 treatment
2 treatments
3 treatments
4 treatments
Total people
Total treatments
Waiting
2-4 months
n (%)
Total
n (%)
2 (1.5)
5 (3.8)
2 (1.5)
9 (6.9)
20
0 (0.0)
3 (2.6)
0 (0.0)
3 (2.6)
6
2 (0.8)
8 (3.3)
2 (0.8)
12 (4.9)
26
0 (0.0)
3 (2.3)
1 (0.8)
0 (0.0)
4 (3.1)
9
1 (0.9)
0 (0.0)
0 (0.0)
1 (0.9)
2 (1.7)
7
1 (0.4)
3 (7.8)
1 (0.4)
1 (0.4)
6 (2.4)
16
1 (0.8)
1 (0.8)
1 (0.8)
0 (0.0)
0 (0.0)
3 (2.3)
6
1 (0.9)
0 (0.0)
0 (0.0)
1 (0.9)
1 (0.9)
3 (2.6)
11
2 (0.8)
1 (0.4)
1 (0.4)
1 (0.4)
1 (0.4)
6 (2.4)
17
6 (4.6)
2 (1.5)
8 (6.2)
10
1 (0.9)
3 (2.6)
4 (3.4)
7
7 (2.8)
5 (2.0)
12 (4.9)
17
0 (0.0)
0 (0.0)
0 (0.0)
1 (0.9)
1 (0.9)
2 (1.7)
1 (0.4)
1 (0.4)
2 (0.8)
0 (0.0)
1 (0.8)
1 (0.8)
2 (1.5)
7
1 (0.9)
2 (1.7)
1 (0.9)
4 (3.4)
11
1 (0.4)
3 (7.8)
2 (0.8)
6 (2.4)
18
0 (0.0)
0 (0.0)
1 (0.8)
1 (0.8)
2 (1.5)
7
1 (0.9)
1 (0.9)
2 (1.7)
1 (0.9)
5 (4.3)
13
1 (0.4)
1 (0.4)
3 (7.8)
2 (0.8)
7 (2.8)
20
121
Table 6a: Restorative treatments: People treated by waiting time Items
511, 512, 513, 514, 515
Waiting
2-4 months
n (%)
Waiting > 2yrs
n (%)
Total
n (%)
Item No 511 metallic
restoration ($75.55)
1 treatment
20 (15.4)
9 (7.8)
29 (11.8)
2 treatments
6 (4.6)
9 (7.8)
15 (6.1)
3 treatments
4 (3.1)
2 (1.7)
6 (2.4)
4 treatments
2 (1.5)
1 (0.9)
3 (1.2)
5 treatments
1 (0.8)
0 (0.0)
1 (0.4)
6 treatments
1 (0.8)
1 (0.9)
2 (0.8)
0 (0.0)
1 (0.9)
1 (0.4)
34 (26.2)
23 (19.8)
57 (23.2)
63
50
113
1 treatment
25 (19.2)
18 (15.5)
43 (17.5)
2 treatments
17 (13.1)
5 (4.3)
22 (8.9)
3 treatments
6 (4.6)
6 (5.2)
12 (4.9)
4 treatments
2 (1.5)
4 (3.4)
6 (2.4)
5 treatments
0 (0.0)
1 (0.9)
1 (0.4)
6 treatments
2 (1.5)
1 (0.9)
3 (1.2)
7 treatments
1 (0.8)
0 (0.0)
1 (0.4)
7 treatments
Total people
Total treatments
1 (0.8)
0 (0.0)
1 (0.4)
54 (41.5)
35 (30.2)
89 (36.2)
112
73
185
1 treatment
9 (6.9)
11 (9.5)
20 (8.1)
2 treatments
2 (1.5)
3 (2.6)
5 (2.0)
8 treatments
Total people
Total treatments
restoration (3) ($114.05)
3 treatments
1 (0.8)
2 (1.7)
3 (1.2)
12 (9.2)
16 (13.8)
28 (11.4)
16
23
39
1 treatment
10 (7.7)
4 (3.4)
14 (5.7)
2 treatments
0 (0.0)
2 (1.7)
2 (0.8)
10 (7.7)
6 (5.2)
16 (6.5)
10
8
18
1 treatment
3 (2.3)
2 (1.7)
5 (2.0)
2 treatments
Total people
Total treatments
Total people
Total treatments
0 (0.0)
1 (0.9)
1 (0.4)
Total people
3 (2.3)
3 (2.6)
6 (2.4)
Total treatments
3 (2.3)
4 (3.4)
7
122
Table 6b: Restorative treatments: People treated by waiting time
Items 521, 522, 523, 524, 525, 531
Waiting > 2yrs
n (%)
Item No 521 resin
restoration (2)($87.25)
1 treatment
2 treatments
3 treatments
4 treatments
5 treatments
9 treatments
10 treatments
Total people
Total treatments
Item No 522 resin
1 treatment
2 treatments
3 treatments
4 treatments
5 treatments
Total people
Total treatments
Item No 523 resin
1 treatment
2 treatments
3 treatments
Total people
Total treatments
Item No 524 resin
1 treatment
2 treatments
Total people
Total treatments
Item No 525 ($167.75)
3 treatments
Total people
Total treatments
Item No 531 resin
1 treatment
2 treatments
3 treatments
4 treatments
Total people
Total treatments
Waiting
2-4 months
n (%)
Total
n (%)
8 (6.2)
7 (5.4)
1 (0.8)
2 (1.5)
0 (0.0)
1 (0.8)
2 (1.5)
21 (16.2)
62
8 (6.9)
1 (0.9)
1 (0.9)
2 (1.7)
2 (1.7)
0 (0.0)
0 (0.0)
14 (12.1)
31
16 (6.5)
8 (3.3)
2 (0.8)
4 (1.6)
2 (0.8)
1 (0.4)
2 (0.8)
35 (14.2)
93
17 (13.1)
10 (7.7)
3 (2.3)
1 (0.8)
2 (1.5)
33 (25.4)
60
15 (12.9)
7 (6.0)
6 (5.2)
2 (1.7)
0 (0.0)
30 (25.9)
55
32 (13.0)
17 (6.9)
9 (3.7)
3 (1.2)
2 (0.8)
63 (25.6)
115
4 (3.1)
6 (4.6)
1 (0.8)
11 (8.5)
19
14 (12.1)
4 (3.4)
3 (2.6)
21 (18.1)
31
18 (7.3)
10 (4.1)
4 (1.6)
32 (13.0)
50
4 (3.1)
1 (0.8)
5 (3.8)
6 (4.6)
2 (1.7)
1 (0.9)
3 (2.6)
4 (3.4)
6 (2.4)
2 (0.8)
8 (3.3)
10 (4.1)
0 (0.0)
0 (0.0)
0 (0.0)
1 (0.9)
1 (0.9)
1 (0.9)
1 (0.4)
3 (1.2)
3 (1.2)
20 (15.4)
5 (3.8)
3 (2.3)
1 (0.8)
29 (22.3)
43
13 (11.2)
7 (6.0)
3 (2.6)
2 (1.7)
25 (21.6)
44
33 (13.4)
12 (4.9)
6 (2.4)
3 (1.2)
54 (22.0)
67
123
Table 6c: Restorative treatments: People treated by waiting time
Items 532, 533, 534, 535, 572, 575, 577
Waiting > 2yrs
n (%)
Item No 532 resin
1 treatment
2 treatments
3 treatments
4 treatments
5 treatments
9 treatments
Total people
Total treatments
Item No 533 resin
1 treatment
2 treatments
Total people
Total treatments
Item No 534 resin
1 treatment
2 treatments
Total people
Total treatments
Item No 535 resin
1 treatment
3 treatments
Total people
Total treatments
Item No 572 provisional
1 treatment
Total people
Total treatments
Item No 575 pin retention
($21.90)
1 treatment
2 treatments
4 treatments
Total people
Total treatments
Item No 577 cusp capping
($21.90)
1 treatment
2 treatments
4 treatments
8 treatments
Total people
Total treatments
Waiting
2-4 months
n (%)
Total
n (%)
10 (7.7)
4 (3.1)
1 (0.8)
0 (0.0)
0 (0.0)
0 (0.0)
15 (11.5)
21
3 (2.6)
5 (4.3)
2 (1.7)
2 (1.7)
1 (0.9)
1 (0.9)
14 (12.1)
41
13 (5.3)
9 (3.7)
3 (1.2)
2 (0.8)
1 (0.4)
1 (0.4)
29 (11.8)
62
8 (6.2)
1 (0.8)
9 (6.9)
10
3 (2.6)
1 (0.9)
4 (3.4)
5
11 (4.5)
2 (0.8)
13 (5.3)
15
9 (6.9)
1 (0.8)
10 (7.7)
11
7 (6.0)
0 (0.0)
7 (6.0)
7
16 (6.5)
1 (0.4)
17 (6.9)
18 (7.3)
3 (2.3)
1 (0.8)
4 (3.1)
6
2 (1.7)
0 (0.0)
2 (1.7)
2
5 (2.0)
1 (0.4)
6 (2.4)
8 (3.3)
1 (0.8)
1 (0.8)
1 (0.8)
1 (0.9)
1 (0.9)
1 (0.9)
2 (0.8)
2 (0.8)
2 (0.8)
3 (2.3)
2 (1.5)
1 (0.8)
6 (4.6)
11
2 (1.7)
2 (1.7)
0 (0.0)
4 (3.4)
6
5 (2.0)
4 (1.6)
1 (0.4)
10 (4.1)
17
7 (5.4)
5 (3.8)
1 (0.8)
1 (0.8)
14 (10.8)
29
2 (1.7)
5 (4.3)
0 (0.0)
0 (0.0)
7 (6.0)
12
9 (3.7)
10 (4.1)
1 (0.4)
1 (0.4)
21 (8.5)
41
124
Table 7: Dentures: People treated by waiting time
Waiting > 2yrs
n (%)
Item 711 Complete upper
denture ($706.40)
Total
Item 712 Complete lower
denture ($706.40)
Total
Item 719 Complete upper
and lower dentures
($1265.60)
Total
Item 721A Part. resin upper
denture 1 tooth ($319.20)
Total
Item 721B Part. resin upper
denture 2 teeth ($354.55)
Total
Item 721C Part. resin upper
Total
Item 721D Part. resin upper
Total
Item 721E Part. resin upper
denture 5-9 teeth ($580.30)
1
2
Total
Total dentures
Item 721F Part. Resin upper
Total
Item No 731 retainer (per
tooth) ($31.90)
1 retainer
2 retainers
4 retainers
Total
Total retainers
Item 721E Part. resin lower
1
Total
Item 722F Part. Resin lower
Total
Item 765 replace tooth
($109.10)
3 replacements
4 replacements
5 replacements
Total
Total replacements
Item 768 Adding to part
denture($145.40)
Total
Item 776 Impression ($33.30)
Total
Waiting
2-4 months
n (%)
Total
n (%)
7 (5.4)
7 (5.4)
10 (8.6)
10 (8.6)
17 (6.9)
17 (6.9)
3 (2.3)
3 (2.3)
2 (1.7)
2 (1.7)
5 (2.0)
5 (2.0)
2 (1.5)
2 (1.5)
3 (2.6)
3 (2.6)
5 (2.0)
5 (2.0)
1 (0.8)
1 (0.8)
0 (0.0)
0 (0.0)
1 (0.4)
1 (0.4)
1 (0.8)
1 (0.8)
1 (0.9)
1 (0.9)
2 (0.8)
2 (0.8)
3 (2.3)
3 (2.3)
2 (1.7)
2 (1.7)
5 (2.0)
5 (2.0)
8 (6.2)
8 (6.2)
5 (4.3)
5 (4.3)
13 (5.3)
13 (5.3)
13 (10.0)
3 (2.3)
16 (12.3)
19
11 (9.5)
0 (0.0)
11 (9.5)
11
24 (9.8)
3 (1.2)
27 (11.0)
30
2 (1.5)
2 (1.5)
0 (0.0)
0 (0.0)
2 (0.8)
2 (0.8)
0 (0.0)
12 (9.2)
8 (6.2)
20 (15.4)
56
2 (1.7)
14 (12.1)
1 (0.9)
17 (14.7)
34
2 (0.8)
26 (10.6)
9 (3.7)
37 (15.0)
90
0 (0.0)
0 (0.0)
2 (1.7)
2 (1.7)
2 (0.8)
2 (0.8)
1 (0.8)
1 (0.8)
0 (0.0)
0 (0.0)
1 (0.4)
1 (0.4)
1 (0.8)
1 (0.8)
1 (0.8)
3 (2.3)
12
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0
1 (0.4)
1 (0.4)
1 (0.4)
3 (1.2)
12
1 (0.8)
1 (0.8)
2 (1.5)
2 (1.5)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (0.4)
1 (0.4)
2 (0.8)
2 (0.8)
125
Table 8: Other services: People treated by waiting time
Waiting
2-4 months
n (%)
Waiting > 2yrs
n (%)
Total
n (%)
Item 927 Medication
($19.90)
1 medication
6
6
12
3 medication
1
0
1
4 medication
1
0
1
8
6
14
Total people
Total medications
13
6
19
Item 935 Interpreter
($51.00)
2
6
8
Total
2
6
8
Item 986 Post-operative
care ($51.10)
1
0
1
1
Total
0
1
1
126
APPENDIX ELEVEN: ADDITIONAL TABLES FOR CHAPTER 3
Table A: Gender of Study Participants
Gender
Total
n (%)
Male
99 (40.2)
Female
147 (59.8)
Total
246 (100)
Table B: Age Range by Gender
Gender
Age range
<35yrs
35-64yrs
65 yrs & older
Total
Pearson’s
n (row %)
n (row %)
n (row %)
n (row %)
Chi Square
Male
4 (15.4)
44 (36.4)
51 (52.0)
99 (40.4)
Female
22 (84.6)
77 (63.3)
47 (48.0)
146 (59.6)
26 (100.0)
121 (100.0)
98 (100.0)
245 (100.0)
Table C: Country of birth
Country of birth
Total
n (%)
Australia
67(27.3)
Italy
40 (16.3)
Middle East
41 (16.7)
Other
97 (39.4)
Total
245 (99.6)
Other comprises:
Great Britain
7 (2.9)
Turkey
17 (6.9)
Greece
8 (3.3)
Malta
16 (6.5)
Cyprus
6 (2.4)
Poland
7 (2.9)
And people from other
countries
Middle East comprises
36 (14.7)
Lebanon
17 (6.9)
Iraq
18 (7.3)
Egypt
6 (2.4)
127
Table D: Length of time in Australia for overseas born
>50 yrs ago
Total
n (%)
28 (17.2)
20-50yrs ago
94 (57.7)
10-20 yrs ago
14 (8.6)
5-10 yrs ago
12 (7.4)
Time in Australia
< 5 yrs
15 (9.2)
163 (100.0)
Table E: Language at home
English
Total
n (%)
137 (55.7)
Turkish
18 (7.3)
Language at home
Italian
19 (7.7)
Arabic
29 (11.8)
Greek
7 (2.8)
Other
36 (14.6)
All
246 (100.0)
Table F: Education level
Education level
Total
n (%)
No formal education
7 (2.8)
Primary incomplete
17 (6.9)
Primary complete
44 (17.9)
94 (38.2)
Secondary complete
39 (15.9)
Tertiary education
All
45 (18.3)
246 (100.0)
128
Table G: Main occupation
Total
n (%)
Main occupation
No paid work
31 (12.7)
Managers/administrators
2 (0.8)
Professionals
14 (5.7)
Associate professionals
6 (2.5)
Tradespersons
48 (19.7)
Advanced clerical & services
7 (2.9)
Clerical sales & services
32 (13.1)
Production & transport
47 (19.3)
Basic clerical sales
16 (6.6)
Labourers & unskilled workers
41 (16.8)
TOTAL
244 (98.4)
Table H: Time since last dental visit
How long ago?
<12mths
Total
105 (42.9)
1-2 yrs
55 (22.4)
2-5yrs
52 (21.2)
>5yrs
31 (12.7)
No dental visit
Total
2 (0.8)
245 (100.0)
Table I: Type of last dental visit
Last visit emergency?
Total
No
99 (40.4)
Yes
140 (57.2)
Unsure
Total
6 (2.4)
245 (100.0)
129
Table J: Self-Rating Of Oral Health
Oral health status
Total
Much better
10 (4.2)
Better
48 (20.3)
About the same
101 (42.8)
Worse
56 (23.7)
Much worse
21 (8.9)
All
236 (100.0)
Table K: Number of functional teeth
Significant
reduction in
masticatory
efficiency
0 natural
functional
teeth
All
9 (9.1)
12 (8.3)
21 (8.6)
14 (14.1)
17 (11.8)
31 (12.8)
35 (35.4)
35 (24.3)
70 (28.8)
41 (41.4)
80 (55.6)
121 (49.8)
99 (100.0)
144 (100.0)
243 (100.0)
13-20 teeth
>20 teeth
Total
Female
Pearson’s
chi square
NS
1-12 teeth
Reduced
masticatory
efficiency
Maximum
masticatory
efficiency
Male
Table L: Mean costs of proposed dental treatment by type
Type of treatment
n=246
Mean cost $ (SD)
%Total Mean
Cost
Diagnostic services
104.30 (6.65)
11.3
Preventive services
74.62 (4.76)
8.1
Periodontal treatment
18.05 (1.15)
2.0
Oral surgery
97.22 (6.20)
10.5
Endodontic treatment
49.57 (3.16)
5.4
Restorative treatment
348.64 (22.23)
37.7
Dentures
Other
TOTAL
228.51 (14.57)
3.40 (0.22)
24.7
0.4
924.31 (58.93)
100.0
130
Table M: Range of proposed dental treatment cost
Cost of proposed treatment
Number of people
% of people
n = 229
<$100
4
1.7
$101-$200
20
8.3
$201-$300
19
7.9
subtotal
$0-$300
43
17.8
$301-$400
23
9.5
$401-$500
20
8.3
$501-$600
13
5.4
subtotal
$301-$600
56
23.2
$601-$700
20
8.3
$701-$800
14
5.8
$801-$900
12
5.0
$901-$1000
9
3.7
subtotal
$601-$1000
55
22.8
$1001-$1100
6
2.5
$1101-$1200
11
4.6
$1201-$1300
3
1.2
$1301-$1400
19
7.9
$1401-$1500
5
2.1
$1501-$1600
6
2.5
$1601-$1700
5
2.1
$1701-$1800
7
2.9
$1801-$1900
5
2.1
$1901-$2000
5
2.1
subtotal
$1001-$2000
60
24.9
$2001-$2500
8
3.3
$2501-$3000
3
1.2
>$3001
4
1.7
subtotal
TOTAL
>$2001
15
6.2
229
100
131
APPENDIX TWELVE:
MEAN COSTS, NUMBER OF PROPOSED
TREATMENT BY TYPE AND BY GROUP
Diagnostic Services
Diagnostic services include examination, consultation, referral letter and radiograph.
On average, fewer diagnostic services were proposed for people waiting two to four
months for dental care than those waiting two or more years (2.87 compared with
3.08). This resulted in a small but significant difference in the mean cost of the
proposed diagnostic services between the two groups (p=0.04, [see Table 1]).
Table 1: Mean costs and number of proposed diagnostic services by type
Waiting > 2 years
Total procedures
Mean number of procedures
t-test
333
3.08
2.87
$13,766.15
$11,995.20
$105.89 (9.29)
$103.41 (9.60)
Total cost
Mean cost per patient (SD)
Waiting 2-4 months
401
p-value
=0.0411012
Preventive Treatment Procedures
Preventive treatment procedures refer to plaque removal, fluoride treatment and
hygiene instruction, for example. The average number of preventive treatment
procedures was similar for the two groups (1.63 compared with 1.59). There was no
significant difference in the mean costs of the proposed preventive treatment.
Table 2: Mean costs and number of proposed preventive treatment
procedures by type
Waiting > 2 years
Waiting 2-4 months
t-test
Total procedures
212
184
1.63
1.59
$9,772.85
$8,583.90
Total cost
Mean cost per patient
$75.18 (6.59)
$74.00 (6.87)
NS
132
Periodontic Procedures
There were 49 periodontic procedures, for example root planning, proposed for the
study participants. More procedures were proposed for people who had waited more
than two years for dental treatment, which led to significantly lower costs for people
who had waited two to four months for dental care (p<0.00001, [see Table 3]).
Table 3: Mean costs and number of proposed periodontic procedures
Waiting > 2 years
Total procedures
Total cost
Waiting 2-4 months
36
t-test
13
0.28
0.11
$3,553.20
$888.30
$27.33 (2.40)
$7.66 (0.71)
p-value
<0.00001
Oral Surgery
Oral surgery includes extraction of natural teeth. The mean number of natural
functional teeth was 17.8 for those waiting a shorter time for a dental appointment
and 19.6 for those waiting longer. On average, the dental treatment plans showed that
more teeth are to be extracted from those waiting a shorter time than for those waiting
longer. The average costs of proposed oral surgery for those waiting a shorter time
was much higher (p<0.00001, [see Table 4]) than those who had waited longer.
Table 4: Mean costs and number of proposed oral surgery
Total teeth extracted
Mean teeth extracted
Total cost
Waiting > 2 years
122
0.94
$9,781.10
$75.24 (6.60)
Waiting 2-4 months
170
1.47
$14,133.90
$121.84 (11.31)
t-test
p<0.00001
Endodontics
Endodontics procedures are for example root preparation, removal root filling and
interim filling. There was no significant difference in the overall costs of the
endodontic procedures proposed for the two groups (see Table 4.16). However, when
the comparison is restricted to those procedures related to the proposed removal of a
tooth root or its filling, there is a significant difference in treatment costs between the
two groups. The average cost for endodontic treatments for people waiting two to four
months is significantly less than the costs for those waiting two years or more
(p=<0.00001, [see Table 5]).
Table 5: Mean costs and number of proposed endodontic procedures
Total procedures
Total cost
Waiting > 2 years
59
0.45
$6,822.45
$52.48 (4.60)
Waiting 2-4 months
57
0.49
$5,370.95
$46.30 (4.30)
t-test
NS
133
Table 6: Mean costs and number of proposed endodontic procedures
for items 415 416 and 451
Item Number
Waiting > 2 years
415 - complete root prep (1)
Waiting 2-4 months
t-test
20
6
416 - root prep (>1)
9
7
451 - removal root filling
0
2
Total number of procedures
29
15
0.22
0.13
Total cost 415
$3,487.00
$1,046.10
Total cost 416
$652.05
$507.15
Total cost 451
Total cost
$0.00
$153.10
$4,139.05
$1,706.35
$31.84 (2.79)
$14.71 (1.37)
p<0.00001
Restorative Treatments
The average number of proposed restorative treatments, or fillings, was 3.72 for those
waiting more than two years and 3.43 for those waiting two to four months. This
resulted in a significantly lower average cost for people waiting two to four months
(p=0.0173, [see Table 7]).
Table 7: Mean costs and number of proposed restorative treatments
Waiting > 2 years
Waiting 2-4 months
Total procedures
483
398
Mean number of
procedures
3.72
3.43
$45,913.55
$39,852.10
$353.18 (30.98)
$343.55 (31.90)
Total cost
Mean cost per
patient (SD)
t-test
0.0173
Tables 8, 9 and 10 compare the size of fillings, based on the number of surfaces (sides
of tooth that require filling) for both groups. There is no difference between the two
groups for one-surface (see Table 8) and two-surface fillings (see Table 9). However,
Table 4.21 shows that the mean number of restorations with three or more surfaces
for both groups is the same but the costs are significantly different (p=0.00001)
because of the distribution of types of fillings proposed (see Table 10).
134
with 1 surface fillings
Item Number
Waiting > 2
years
Waiting 2-4
months
t-test
511 metallic restoration (1)
63
50
521 resin restoration (1)
62
31
531 resin restoration p(1)
43
44
168
125
Total restorations
Mean number of restorations
1.29
1.08
$4,759.65
$3,777.50
$5,409.50
$2,704.75
$3,964.60
$4,056.80
$14,133.75
$10,539.05
$108.72
(9.54)
$90.85 (8.44)
Total cost restorations
Mean cost of restorations
(SD)
NS
with 2 surface fillings
Item Number
Waiting > 2 years
Waiting 2-4 months
t-test
112
73
19
31
21
41
152
145
1.17
$10,528.00
1.25
$6,862.00
$2,329.40
$3,800.60
$2,517.90
$4,915.90
$15,375.30
$15,578.50
$118.27 (10.37)
$134.30 (12.47)
Total restorations
Mean cost of restorations (SD)
NS
135
with 3 or more surface fillings
Waiting > 2 years
577 cusp capping
Total restorations
577 cusp capping
Waiting 2-4 months
16
10
3
19
6
0
10
11
6
29
23
8
4
31
4
3
5
7
2
12
110
0.85
$1,824.80
$1,340.50
$462.90
$2,329.40
$870.90
$0.00
$1,465.00
$1,895.30
$1,186.80
$635.10
$12,010.70
$92.39 (8.10)
99
0.85
$2,623.15
$1,072.40
$617.20
$3,800.60
$580.60
$503.25
$732.50
$1,206.10
$395.60
$262.80
$11,794.20
$101.67 (9.44)
t-test
p-value<0.00001
136
Tables 11, 12 and 13 compare the type of fillings for both groups. There is no
difference between the two groups for adhesive resin fillings (see Table 11). However,
Table 12 shows that more metallic fillings are included in the treatment plan of people
who have waited two or more years and that costs are significantly higher (p=0.00001).
Table 13 shows that composite resin fillings are because of the distribution of types of
fillings proposed.
Table 11: Mean costs and proposed restorative treatments for metal fillings
Item Number
Waiting 2-4
months
Waiting > 2 years
63
50
112
73
16
23
10
8
Total restorations
3
4
204
158
1.57
1.36
511 – metallic restoration (1)
$4,759.65
$3,777.50
$10,528.00
$6,862.00
$1,824.80
$2,623.15
$1,340.50
$1,072.40
$462.90
$617.20
$18,915.85
$14,952.25
$145.51 (12.76)
$128.90 (11.97)
p-value<0.00001
Table 12: Mean costs and proposed restorative treatments for adhesive resin fillings
Item Number
Waiting 2-4
months
Waiting > 2 years
62
31
60
55
19
31
6
4
0
3
Total restorations
147
124
1.13
1.07
$5,409.50
$2,704.75
$6,447.00
$5,909.75
$2,329.40
$3,800.60
$870.90
$580.60
$0.00
$503.25
$15,056.80
$13,498.95
$115.82 (10.16)
$116.37 (10.80)
NS
137
Table 13: Mean costs and proposed restorative treatments for composite resin fillings
Item Number
Waiting > 2 years
Waiting 2-4 months
43
44
21
41
10
5
11
7
6
2
Total restorations
91
99
0.70
0.85
$3,964.60
$4,056.80
$2,517.90
$4,915.90
$1,465.00
$732.50
$1,895.30
$1,206.10
Mean cost of restorations
(SD)
$1,186.80
$395.60
$11,029.60
$11,306.90
$84.84 (7.44)
$97.47 (9.05)
p-value<0.00001
Dentures
Table 14 shows there is no statistical difference in costs for dentures between the two
groups. The dental plans anticipated that more full dentures would be needed for the
group that had waited two to four months compared to those that waited two or more
years. The cost difference is significant (p<0.00001, [see Table 15]). On the other
hand, more partial dentures were proposed for the group that had waited two years or
more with a significant difference in costs (p<0.00001, [see Table 16]).
Table 14: Mean costs and number of proposed dentures
Waiting > 2 years
Total dentures and
repairs
118
Mean number of
dentures and repairs
70
0.91
0.60
$31,695.40
$24,516.85
$243.81 (22.64)
$211.35 (19.62)
Total cost
(SD)
Waiting 2-4 months
NS
138
Table 15: Mean costs and number of proposed complete upper and lower dentures
Item Number
Waiting > 2 years
Waiting 2-4 months
711 Complete upper
denture ($706.40)
7
10
712 Complete lower
denture ($706.40)
3
2
719 Complete upper and
lower dentures ($1,265.60)
2
3
Total dentures
12
15
0.09
0.13
711 Complete upper
denture ($706.40)
$4,944.80
$7,064.00
712 Complete lower
denture ($706.40)
$2,119.20
$1,412.80
719 Complete upper and
lower dentures ($1,265.60)
$2,531.20
$3,796.80
$9,595.20
$12,273.60
$73.81 (6.47)
$105.81 (9.82)
Mean number of dentures
p-value<0.00001
Table 16: Mean costs and number of proposed partial dentures
Item Number
721A Part. resin upper
denture 1 tooth ($)
721B Part. resin upper
denture 2 teeth ($)
721C Part. resin upper
denture 3 teeth
721D Part. resin upper
denture 4 teeth
721E Part. resin upper
denture 5-9 teeth
721F Part. resin upper
denture 10-12 teeth
722E Part. Resin lower
denture 5-9 teeth
722F Part. Resin lower
denture 10-12 teeth
Total partial dentures
Mean partial dentures
721A Part. resin upper
denture 1 tooth
721B Part. resin upper
denture 2 teeth
721C Part. resin upper
denture 3 teeth
721D Part. resin upper
denture 4 teeth
721E Part. resin upper
denture 5-9 teeth
721F Part. resin upper
denture 10-12 teeth
722E Part. Resin lower
denture 5-9 teeth
722F Part. Resin lower
denture 10-12 teeth
Waiting > 2 years
Waiting 2-4 months
1
0
1
1
3
2
8
5
19
11
2
0
0
2
1
35
0.27
0
21
0.18
$319.20
$0.00
$364.55
$364.55
$1,279.80
$853.20
$3,835.20
$2,397.00
$364.55
$364.55
$1,312.10
$0.00
$0.00
$1,160
$656.05
$8,131.45
$62.55 (5.49)
$0.00
$5,139.30
$44.30 (4.11)
p-value<0.00001
139
Other services
Other services included drug therapy, interpreter services and post-operative care.
There was no difference in the number of these services between the two groups
although the average cost of other services was significantly higher for those waiting
two to four months for a dental visit (p<0.00001,[see Table 17]).
Table 17: Mean costs and number of proposed other services
Waiting > 2 years
Total services
Mean number of services
Total cost
Waiting 2-4 months
p-value=
15
13
0.12
0.11
$360.70
$476.50
$2.77 (0.24)
$4.11 (0.38)
p-value<0.00001
140