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Supplement to SOL Submission

October 2015

Are there any occupations that you represent where there is evidence of imbalances in the demand for and supply of skills in the medium-to-long term?

We believe there is an imbalance between supply and demand for both Dental Technicians and Dental Prosthetists in the medium to longer term.

Dental Technicians

The Dental Technician sector has undergone significant change in recent years since the deregulation of the profession. One downside of deregulation is that, as an unregulated profession, it is difficult to obtain firm quantitative data. However, anecdotal evidence indicates that a number of dental laboratories and dental technicians are currently experiencing oversupply of practitioners and a medium– severe downturn in business at the current time, and this is expected to continue into the medium-longer term.

This is due largely to the impact of the internet and the ability to purchase the products formerly made by the local laboratories directly from overseas suppliers at a considerably lower cost. This is a position that is highly likely to continue into the future, with early indications that the profession itself may decline to minimal numbers or, indeed, virtually disappear.

There would therefore seem to be little logic or need to keep this profession on the SOL, given that existing practitioners are already unable to gain sufficient work to make their businesses viable.

Dental Prosthetists

Dental prosthetists work as independent practitioners in the assessment, treatment, management and provision of removable dentures and flexible, removable mouthguards used for sporting activities.

In relation to Dental Prosthetists, the mid-longer term scenario needs to take into account three key impacts:

• the impact of the overall rate of edentulism (i.e. no teeth) within the population. • Government policy in relation to dental services and • the scope of practice for members of the profession

Further information in relation to each of these dot points is set out later in this submission.

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Is it expected that your employment sector will be impacted by any medium-to-long term trends which will impact upon demand and/or supply (excluding costs associated with training, labour hire, and international sponsorship)? Please provide evidence (e.g. data source, policy document) which substantiates these claims.

Yes, there are a number of major impacts:

Impact of edentulism

Two papers are attached which indicate that the rate of edentulism within the Australian population is declining -- a decline which is expected to continue into the future.

• “based on the assumption that prevalence of edentulism will increase by no more than 1 per cent each 15-20 years within cohorts, prevalence in the adult population is projected to decrease to 2.7 – 3.1 per cent by 2021 and .4-1.0 per cent by 2041.” “Decline of the edentulist epidemic in Australia”. Australian Dental Journal, 2007;52:(2): 154-156

• “The rates of edentulism have decreased substantially from 15.4% in 1979 to 5.2% in 2005”. “Projected demand for dental care to 2020”. Australian Research Centre for Population Oral Health, AIHW Dental Statistics and Research Unit Research Report No 42

The papers indicate that, whilst Australia will see an increasing number of people in the ‘aged’ category, the likelihood of those people having total tooth loss will diminish, due primarily to the improvements in dental health in recent decades.

With the direct links between the rate of edentulism in the population and the need for dental prosthetists, the longer term projection would suggest that the demand for dental prosthetists will significantly diminish.

Government policy

The demand for dental prosthetists is also directly impacted by the availability of government schemes that allow clients to access the services of a dental prosthetist,

At the current time, there is no national dental scheme and no plans to introduce such a scheme on the planning horizon. Without such a scheme, access to adequate dental care is limited to those members of the population with private health cover, access to care under a state dental scheme, or access via some other funded arrangement (such as through the DVA). This is evidenced by the strong correlation between overall oral health and socio-economic status and between dental services obtained by those with private health insurance relative to the population as whole.

Unless a national scheme is implemented, there is no indication that the demand for the services of dental prosthetists will increase beyond current levels. To illustrate, members of our profession saw a significant downturn in business since the cessation of the Chronic

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Diseases Dental Scheme. However, those engaged in work in the public arena through state-funded schemes face an ongoing and continued demand for services.

Scope of Practice Issues

Dental prosthetists practice within a defined, restricted scope of practice as determined and regulated by the Dental Board of Australia. Dentists are similarly covered by a Scope of Practice. It is important to note that the entire scope of practice for a dental prosthetist is included in the defined scope for a dentist i.e. the scope of practice for a dental prosthetist is only a small sub-set of dentistry.

Whilst dentists can make partial and full dentures and learn these skills in their undergraduate training, the Australian and overseas trend is that new dentist graduates have minimal training in these areas This has been of particular significance as the older generation of dentists retire, meaning that there has been a much smaller proportion of the dentist workforce with significant training in this area. The overall impact is that some dentists currently refer this work to dental prosthetists.

When considering the mid-longer term scenario, however, the position is likely to significantly change. The Australian Dental Association maintains that there is currently an oversupply of dentists within Australia, and we note that dentists have now been removed from the SOL. Given that the scope of practice for dental prosthetists also falls entirely within the scope of practice of dentists, there seems to be little logic in removing dentists from the SOL without also removing dental prosthetists (and similarly, dental technicians, dental hygienists and dental therapists).

The further impact of the removal of dentists from the SOL is that the surplus within the ‘dentist’ profession may have flow-on effects to the dental prosthetist profession. Dentists who see their workload diminishing due to oversupply may choose to personally undertake work they may have otherwise referred to a dental prosthetist in order to keep themselves (and their staff) fully engaged.

Should this happen, there will be a significant impact on the work available to existing members of the dental prosthetist profession and those new graduates entering the profession.

Please provide any other information you consider relevant evidence to support your submission.For example, you may know of some independent studies about your occupation that supports your advice to us.

The recent HealthWorkforce Australia report, “Australia’s Future Health Workforce – Oral Health Detailed” (august 2014) suggests that the current supply/demand scenario for dental prosthetists is “some level of expressed demand exceeding available workforce, either through maldistribution or insufficient workforce numbers.”

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We believe this excess demand relates primarily to regional and remote locations and those without good access to a dental prosthetist (eg those in aged care facilities). For the balance of the population, we content that the current supply/demand scenario is, in fact, in balance at the current time or in a position of slight over-supply (based on member feedback since the cessation of the CDDS scheme).

As set out in an earlier question, it is also our contention that the imbalance in supply/demand for some disadvantaged sectors of the community cannot be adequately addressed through the entrance of overseas qualified practitioners. Rather, funding and relocation assistance is required that will encourage existing practitioners to either relocate to remote areas or to expand their practices (such as through a mobile or fly-in, fly-out service) to enable access from those unable to currently visit a local practitioner.

The HealthWorkforce Australia report also provides the most recent projections in relation to future demand for dental prosthetists. Page 12 of that report indicates:

“in contrast to the workforce projections for dentists and oral health practitioners, the workforce projections for dental prosthetists show that demand is projected to exceed supply across the entire projection period to 2025 under the comparison scenario”.

However, there are 2 key issues that were not taken into consideration at the time of preparation of this report and which would significantly change the finding had details been available at the time of report preparation:

• Detailed analysis of the report indicates that the under-supply is in the range of 68 to 137 practitioners. This report was prepared prior to the recent introduction of the TAFE Brisbane Bachelor of Dental Prosthetics Program. This program commenced in August 2015, with the first full cohort of entrants to commence in 2016. If it is assumed that approx 10 graduates will complete this course each year, with a lag of 5 years before the first graduating cohort joins the workforce, it can be seen that after a 10 year period, the unmet demand will be reduced to minimal numbers.

• The report also does not take in to account Scope of Practice issues and the likely flow-on effect of the current over-supply of dentists. These are detailed earlier in this submission.

Cindy Tilbrook CEO, ADPA Ltd 29 October 2015

all aspects of data collection from the Human EthicsCommittee of The University of Adelaide.

National Oral Health Survey of Australia 1987–88The 1987–88 National Oral Health Survey of Australia

(NOHSA) was an examination survey of a representativesample of Australian adults and children living in the sixStates and the Australian Capital Territory. They weresampled at random from residential dwellings located withinselected Census Collection Districts using a stratified,clustered sampling design. The survey collected similarinformation to NSAOH, although from an independentsample of people. In NSAOH, dentist-examiners assessedwhether study subjects were dentate or edentulous. For thisanalysis, data were weighted to reflect the age-, gender- andState/Territory distribution of the Australian population,excluding the Northern Territory, in 1986.

The passage of time between population surveys capturestwo dimensions of time.7 One dimension represents theeffects of age and events that occur between surveys on thelife course of individuals in the population. The other reflectsthe unique historical experiences of the different birthcohorts, also called generations, that constitute the

INTRODUCTIONEdentulism, the loss of all natural teeth, reflects both the

accumulated burden of oral disease and the consequences ofits treatment by dental extraction. Edentulism is dentistry’sequivalent to mortality. For the individual, edentulismsubstantially reduces quality of life.1 The welfare andmanagement of edentulous adults remains an importantpublic health issue, having direct reference to the globalgoals for oral health by 2010.2 It is a determinant of thedemand for dental care within populations because peoplewithout teeth visit the dentist far less frequently than dentatepeople.3 The prevalence of edentulism (i.e., the percentage ofpeople with no natural teeth) has declined in the last 50 yearsin most Western nations.4 In Australia, edentulism prevalencereduced between 1979 and 2002 among all ages and genders,and in all States/Territories.5 This paper provides an updateon that trend, and further analyses prevalence of edentulismwithin birth cohorts to illustrate that the decline is relatedentirely to the passing of generations that experienced anepidemic of complete tooth loss during the first half of thetwentieth century.

METHODSNational Survey of Adult Oral Health 2004–06

The most recent information about edentulism in theAustralian population comes from the National Survey ofAdult Oral Health 2004–06 (NSAOH).6 Subjects for theSurvey were sampled at random from an electronic databaseof residential phone numbers listed in the electronic whitepages. Sampling was stratified between metropolitan andnon-metropolitan parts of each State/Territory, and phonenumbers were clustered within selected postcodes. Some 14 123 adults, defined as people aged 15 years or more, wereinterviewed giving a participation rate of 49 per cent.Interviewed people were asked 79 questions including onequestion about complete tooth loss: “Do you have any ofyour own natural teeth?” Possible responses were “yes”, “no”and “don’t know” (although none of the latter were reported).Other questions asked about demographic characteristicsincluding age and state of residence.

For this analysis, data were weighted to reflect the age-,gender- and State/Territory distribution of the Australianpopulation in 2005. Permission was sought and received for

Decline of the edentulism epidemic in Australia

Australian Research Centre for Population Oral Health, The University of Adelaide, South Australia*

D ATA W AT C HAustralian Dental Journal 2007;52:(2):154-156

154 Australian Dental Journal 2007;52:2.

*Prepared by LA Crocombe and GD Slade.

Table 1. Percentage of adults* with complete tooth lossAgeAll ages 6.415-34 years 0.035-54 years 1.755-74 years 13.975+ years 35.7

GenderMale 5.2Female 7.7

Indigenous identityIndigenous 7.9Non-Indigenous 6.4

Residential locationCapital city 5.0Other places 9.0

Level of schoolingYear 9 or less 21.9Year 10 or more 4.1

Public dental careEligible 17.1Ineligible 2.7

Dental insuranceInsured 3.1Uninsured 9.4

*People aged 15 years or more.

populations studied in each survey. Changes attributable toeffects within generations and between generations can beassessed using birth cohort analysis, whilst age groupanalysis aims to describe the amount of change in populationhealth for selected age groups.

RESULTSCross-sectional findings

In 2004–06, edentulism was virtually non-existent amongpeople aged 15–34 years, but its prevalence was greater forsuccessively older age groups, reaching 35.7 per cent amongpeople age 75 years or above (Table 1). Edentulismprevalence was greater among people with nine years or lessof schooling compared with people who had 10 years ormore, among people who were eligible for public dental carecompared with people who were not, and among peoplewithout private insurance compared with people with privateinsurance. In contrast, prevalence differed only to a smalldegree between the genders, between Indigenous and non-Indigenous people, and between people who lived in capitalcities compared with other places. As reported elsewhere,8

some between-group differences were a consequence both of

the effect of the variable itself and of age. When theprevalence of complete tooth loss within each age group wascompared, the effects of level of schooling and eligibility forpublic dental care were attenuated but not removed, whilstthe effect of no private insurance was not diminished.

Age group analysisIn the 17 years between the two national surveys, the

prevalence of edentulism halved, from 14.4 to 6.4 per cent(Fig 1). There were dramatic reductions in every 10-year agegroup, with the relative reduction being greater amongyounger age groups.

Birth cohort analysisWhen comparing the same birth cohort at the two survey

times, the prevalence of edentulism was unchanged, nomatter which age group was considered (Fig 2).9 In otherwords, population prevalence did not change as members ofeach birth cohort aged the 17 years between the two surveys.This conclusion is valid, even though different individualswere studied in each survey because each survey was anindependent representative sample of the Australianpopulation.

Projections of prevalence of complete tooth lossThe analysis of the historical trends in edentulism allows

projection into the future of the prevalence of complete toothloss. Based on the assumption that prevalence of edentulismwill increase by no more than 1 per cent each 15–20 yearswithin cohorts, prevalence in the adult population isprojected to decrease to 2.7–3.1 per cent by 2021 and 0.4–1.0per cent by 2041 (Table 2).

DISCUSSIONThese latest findings confirm the continuing trend of

declining edentulism prevalence in the Australian population.In addition to an overall halving of prevalence in the 17 yearsbetween surveys, the birth cohort analysis illustrates anintriguing paradox: edentulism is unrelated to age and insteadis entirely dependent upon when people were born. In anyone survey, these two dimensions of time overlap

Australian Dental Journal 2007;52:2. 155

Fig 1. Age group trends in percentage of Australian adults with completetooth loss, 1987-88 to 2004-06.

Fig 2. Birth cohort trends in percentage of Australian adults with completetooth loss, 1987-88 to 2004-06.

Table 2. Projected prevalence of complete tooth loss inAustralia

Age (years) 2004-062021 2041

Low – High Low – High

40-44 0.8% 0.0-0.0%45-49 2.1% 0.0-0.0%50-54 3.9% 0.3-1.3%55-59 7.5% 0.8-1.8%60-64 12.9% 2.1-3.1% 0.0-1.0%65-69 17.9% 3.9-4.9% 0.0-1.0%70-74 23.3% 7.5-8.5% 0.3-2.3%75-79 33.6% 12.9-13.9% 0.8-2.8%80-84 36.2% 17.9-18.9% 2.1-4.1%85+ 42.7% 23.3-24.3% 3.9-5.9%Projected % Edentulous 2.7-3.1% 0.4-1.0%

*Low: Assuming continued trend of no within-cohort increase in prevalence.High: Assuming continued trend of 1% within-cohort increase in prevalence.

REFERENCES1. Slade GD, Spencer AJ. Social impact of oral conditions among older

adults. Aust Dent J 1994;39:358-364.

2. Hobdell M, Peterson PE, Clarkson J, Johnson N. Global goals for theoral health 2020. Int Dent J 2003;53:285-288.

3. Joshi A, Douglass CW, Feldman H, Mitchell P, Jette A. Consequencesof success: Do more teeth translate into more disease and utilization? JPublic Health Dent 1996;56:190-197.

4. Burt BA, Eklund SA. Dentistry, dental practice and the community. 5thedn. Pennsylvania: WB Saunders, 1999.

5. Sanders AE, Slade GD, Carter KD, Stewart JF. Trends in prevalence ofcomplete tooth loss among Australians, 1979-2002. Aust N Z J PublicHealth 2004;28:549-554.

6. Slade GD, Spencer AJ, Roberts-Thompson KF, eds. Australia’s dentalgenerations: the National Survey of Adult Oral Health 2004-06. AIHWcat no. DEN 165. Canberra: Australian Institute of Health and Welfare(Dental Statistics and Research Series No. 34), 2007.

7. Riley MW, Foner A. Aging and society. Vol. 3: A sociology of agestratification. New York: Russell Sage Foundation, 1972.

8. Roberts-Thompson KF, Do LG. Oral health status. In: Slade GD,Spencer AJ, Roberts-Thompson KF, eds. Australia’s dental generations:the National Survey of Adult Oral Health 2004-06. AIHW cat no. DEN165. Canberra: Australian Institute of Health and Welfare (DentalStatistics and Research Series No. 34), 2007:81-142.

9. Slade GD, Sanders AE. Trends in oral health. In: Slade GD, Spencer AJ,Roberts-Thompson KF, eds. Australia’s dental generations: the NationalSurvey of Adult Oral Health 2004-06. AIHW cat no. DEN 165.Canberra: Australian Institute of Health and Welfare (Dental Statisticsand Research Series No. 34), 2007:196-235.

10. Hershfield JJ. William Hunter and the role of ‘oral sepsis’ in Americandentistry. Bull Hist Dent 1985;33:35-45.

Address for correspondence:Australian Research Centre for Population Oral Health

School of DentistryFaculty of Health SciencesThe University of Adelaide

Adelaide, South Australia, 5005Fax: +61 8 8303 3070

Email: gary.slade@adelaide.edu.au

156 Australian Dental Journal 2007;52:2.

unavoidably, therefore masking the separate effects of ageingand history. However, the birth cohort analysis reveals noeffect of ageing during the 17 years between surveys. Instead,the difference between age groups within one survey is dueentirely to different historical experiences of those agegroups.

The seemingly unspectacular finding that edentulism didnot significantly change for any birth cohort between1987–88 and 2004–06, needs to be understood within itshistorical context. In the first half of the twentieth centurypeople were exposed to a virtual “epidemic” of completetooth loss in direct response to the theory of focal infection.4

Hunter and others hypothesized that dental decay and otheroral diseases created reservoirs of bacteria that could spreadthrough the body, causing a wide range of systemic disease,some of them fatal.10 In response to this belief, full mouthextractions were commonplace between 1920 to the late1940s, a situation that changed rapidly after the late 1940s.

Because edentulism is influenced entirely by year of birth,and not by ageing, it is inevitable that its prevalence willcontinue to decline with the passing of generations born inthe first half of the twentieth century. The projectionspresented in this paper suggest that the decline will continueuntil the middle of this century, by which time only about 1 per cent of Australians will be edentulous. One of the“consequences of success”3 from this trend is an expectedincreasing demand and need for dental care, particularly inolder age groups.

ACKNOWLEDGEMENTSThe National Survey of Adult Oral Health 2004-06 was

supported by the National Health and Medical ResearchCouncil, the Australian Government Department of Healthand Ageing, the Australian Institute of Health and Welfare,Colgate Oral Care, the Australian Dental Association and theUS Centers for Disease Control and Prevention.

AIHW Dental Statistics and Research Unit

Research Report No. 42

Projected demand for dental care to 2020

emand for dental care reflects people’s want or desire for care and willingness to pay for services.

Demand is expressed as the use of dental services and hence is measured in dental visits received in a given year. This report provides information on the change in demand for dental care among Australians during the period 1979 to 2005. It also presents projected demand for dental care through to 2020.

1

Main findings

• The rates of edentulism have decreased substantially from 15.4% in 1979 to 5.2% in 2005.

• The number of dental visits per dentate person (per capita demand) has increased by half, from 0.99 in 1979 to 1.50 in 1995; however, in the decade from 1995 to 2005, per capita demand has remained stable.

• The number of services supplied per dental visit has increased by one-third (33%) over the period 1983 to 2003.

• Between 1983 and 2003 the largest increase in number of services provided per dental visit occurred for diagnostic, preventive and endodontic services.

• Per capita demand is expected to increase by 22.7% in the 65–74 years age group compared to 1.8% in the 25–34 years age group between 2005 and 2020.

• The number of dental visits is projected to increase from 28.2 million visits in 2005 to 38.8 million visits in 2020.

• Demand for dental services is projected to increase from 65.5 million services in 2005 to 94.6 million services in 2020.

Demand for dental care

For the purposes of this report demand for dental care is equivalent to expressed demand. Historical patterns of usage are used to estimate future demand. This definition does not take into account clinically determined ‘need’ for dental care or the occurrence of people wanting or seeking care but unable to access care.

Per capita demand (PCD) for dental visits is represented by the average number of dental visits per person per year. It is estimated separately for dentate (some natural teeth) and edentulous (no natural teeth) persons as demand among edentulous persons is substantially lower than that for dentate persons.

Total demand for dental visits is therefore a function of the size and age of the population, the percentage of edentulous persons and the PCD.

Projections of total demand for dental visits per year are estimated by multiplying age-specific PCD rates for dentate and edentulous persons by the number of persons projected to be in those age groups (Figure 1). For a detailed description of the methods used, see Teusner et al. 2008.

Figure 1: Projection model for demand of dental visits and data sources

=

x

x

=

x

x

Population by age group, projected to 2020

Population by age group, projected to 2020

Data: ABS projection (Series 8)

Per cent edentulous persons by age group, projected to 2020

Per cent dentate persons (100% – % edentulous) by age group, projected to 2020

Data: 1979 ABS; 1989 NHS; 1995, 1999, 2002

NDTIS; 2004–06 NSAOH

Demand for dental visits by edentulous persons

Demand for dental visits by dentate persons

Total demand for dental visits per annum=+

PCD for edentulous persons

Age-specific PCD for dentate persons

Data: 1979 ABS; 1988 NOHSA; 1995, 1999,

2002 NDTIS; 2004–06 NSAOH

Note: See section ‘Data Sources’ for description of data used in the projections model.

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Rates of edentulism in the Australian population

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There has been a dramatic reduction in the prevalence of edentulism in Australia in the 26-year period to 2005. The percentage of edentulous persons in the population has decreased from 15.4% in 1979 to 5.2% in 2005 (Table 1).

Table 1: Percentage of the population with no natural teeth, 1979, 1989, 1999 and 2005

Year

Age (years) 1979 1989 1999 20050–17 0.0 0.0 0.0 0.0

18–24 1.3 0.6 0.2 0.2

25–34 5.4 1.4 0.7 0.2

35–44 14.0 5.7 1.7 0.2

45–54 26.5 14.9 6.6 2.9

55–64 40.2 28.9 17.3 9.8

65–74 60.7 43.2 31.9 20.3

75+ 78.6 63.4 45.9 35.7Total 15.4 10.8 6.5 5.2

Sources: ABS SSS1 1979; NHS 1989; NDTIS 1999; NSAOH 2004–06.

Among those aged 75 years and over, edentulism is projected to decline to approximately one in three persons by 2010 and approximately one in four persons by 2020 (Carter & Stewart 2003) (Figure 2).

Figure 2: Projections of the percentage of Australians with no natural teeth

1979

1989

1999

2005

2010

2020

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30

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50

60

70

80

18–24 25–34 35–44 45–54 55–64 65–74 75+

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Dental visits per year (per capita demand)

The number of dental visits per year for edentulous persons increased from 0.30 in 1979 to 0.88 in 1999, decreased to 0.47 in 2002 and then increased to 0.67 in 2005 (Figure 3).

For dentate persons, the number of dental visits increased from 0.99 in 1979 to 1.50 in 1995, decreased to 1.44 in 2002 and then increased to 1.51 in 2005 (Figure 3).

Reasons for the plateau in PCD are unclear. One possible explanation may be that the capacity to supply visits by the dental labour force is capping growth in demand. Alternatively, limited growth in demand could be related to accessibility issues, for example affordability and uneven distribution of dental professionals.

Figure 3: Dental visits per person per year, edentulous and dentate persons

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1.4

1.6

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Dentate PCD 0.99 1.32 1.50 1.46 1.44 1.51Edentulous PCD 0.30 0.35 0.48 0.88 0.47 0.67

1979 1988 1995 1999 2002 2005

Sources: ABS 1979; NOHSA 1988; NDTIS 1995, 1999, 2002; NSAOH 2004–06. Note: PCD rates for edentulous persons were not age-specific due to limited data.

PCD varied by age group. In 2005 PCD was highest for teenagers in the 12–17 years age group. Between 1995 and 2005 PCD was stable within age groups with the exception of 5–11-year-old children and adults aged 55–64 years and older, where PCD increased (Table 2).

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Table 2: Dental visits per dentate person per year

Year Age (years) 1979 1988 1995 1999 2002 20050–4 0.20 0.20 0.20 0.20 0.20 0.20

5–11 1.18 1.65 1.85 1.56 1.63 1.64

12–17 1.49 1.90 2.17 2.40 2.14 2.17

18–24 1.15 1.13 1.34 1.09 1.14 1.27

25–34 1.06 1.06 1.11 1.15 1.08 1.14

35–44 0.97 1.23 1.41 1.40 1.33 1.33

45–54 0.82 1.13 1.52 1.47 1.44 1.55

55–64 0.91 1.26 1.54 1.53 1.68 1.71

65–74 0.75 1.26 1.49 1.44 1.39 1.63

75+ 0.69 1.13 1.40 1.35 1.51 1.53

Total 0.99 1.32 1.50 1.46 1.44 1.51Sources: ABS 1979; NOHSA 1988; NDTIS 1995, 1999, 2002; NSAOH 2004–06.Note: No data was available for the 0–4 years age group. Figures presented in

the table are based on anecdotal evidence.

Services per dental visit

The Longitudinal Study of Dentists’ Practice Activity (LSDPA) provides information on the number of services provided per dental visit by patient characteristics. The LSDPA collected data from a representative sample of dentists at 5-yearly intervals from 1983–84 to 2003–04.

The total number of services provided per dental visit has increased from 1.72 in 1983–84 to 2.29 in 2003–04. In the younger age groups the number of services per dental visit was generally higher in 2003–04 than in 1983–84, although there were some fluctuations in the intervening years. For most adult age groups over 25–34 years, the increase in the number of dental services per visits was more consistent (Table 3).

Table 3: Number of dental services per dental visit by age group

Year Age (years) 1983–84 1988–89 1993–94 1998–99 2003–040–4 1.22 1.35 1.45 1.33 1.21

5–11 1.64 1.60 1.73 1.75 2.01

12–17 1.73 1.65 1.94 2.03 2.18

18–24 1.75 1.81 2.08 2.08 2.46

25–34 1.76 1.82 2.09 2.16 2.35

35–44 1.85 1.90 2.13 2.23 2.35

45–54 1.61 1.70 2.06 2.19 2.43

55–64 1.73 1.78 2.10 1.94 2.13

65–74 1.53 1.75 1.83 2.02 2.26

75+ 1.74 1.78 1.86 2.00 2.21

Total 1.72 1.78 2.02 2.09 2.29Source: LSDPA. Note: Data includes dentate and edentulous persons; edentulous comprised only 1.3% of all patients in 2003–04.

Service mix

The mix of services provided at each dental visit has also changed between 1983–84 and 2003–04. Over the 20-year period there has been an increase in diagnostic, preventive and endodontic services provided per visit, while the remaining services have remained relatively stable (Table 4).

Table 4: Mix of dental services provided at each visit, 1983–84 to 2003–04

Year

Area 1983–84 1988–89 1993–94 1998–99 2003–04Diagnostic 0.49 0.49 0.60 0.62 0.80

Preventive 0.27 0.30 0.34 0.37 0.44

Periodontic 0.01 0.02 0.02 0.02 0.02

Oral surgery 0.09 0.09 0.09 0.08 0.07

Endodontic 0.06 0.06 0.11 0.14 0.12

Restorative 0.61 0.60 0.63 0.62 0.63

Crown & bridge 0.03 0.06 0.07 0.07 0.07

Prosthodontic 0.11 0.09 0.10 0.11 0.08

Orthodontic 0.01 0.02 0.02 0.01 0.01

General misc. 0.04 0.05 0.05 0.04 0.04

Total 1.72 1.78 2.02 2.09 2.29Source: LSDPA. Note: Dental service categories based on the Australian Dental Association’s Schedule of 10 main service areas.

Projected per capita demand for dental visits

Per capita demand for dental visits is a key input into the projection model described in Figure 1. Three scenarios of future growth in PCD were developed. The first, ‘no PCD growth’, assumes that no growth in PCD will occur between 2005 and 2020. The second, ‘continued PCD growth’, assumes that growth between 2005 and 2020 will continue at the same rate observed between 1979 and 1995. The third, ‘half PCD growth’, assumes that growth in PCD will continue at half the rate observed between 1979 and 1995.

Under the ‘half PCD growth’ scenario the largest projected increase in dentate demand occurs in the 65–74 years age group (22.7%), while the 25–34 years age group is only expected to increase by 1.8%. In contrast, under the ‘continued PCD growth’ scenario, increases for the 65–74 and 25–34 years age groups are expected to be 45.4% and 3.5%, respectively (Figure 4).

For edentulous persons, demand in 2020 is projected to increase from 0.67 to 0.83 visits under

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the ‘half PCD growth’ scenario and to 0.96 visits under the ‘continued PCD growth’ scenario (a 23.9% and 43.3% increase, respectively).

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Figure 4: Dentate per capita demand for dental visits by age group, 2005, and projected demand, 2020

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vis

its

2005-No growth 1.64 2.17 1.27 1.14 1.33 1.55 1.71 1.63 1.532020-Half growth 1.97 2.50 1.33 1.16 1.54 1.86 2.00 2.00 1.872020-Continued growth 2.31 2.82 1.39 1.18 1.75 2.17 2.29 2.37 2.21

5–11 12–17 18–24 25–34 35–44 45–54 55–64 65–74 75+

Projected services per dental visit

The past trend in the provision of dental services was used as the basis for projecting dental services at each dental visit. While the overall number of services provided at each visit increased between 1983–84 and 2003–04, trends across age groups varied. Hence age-specific service rates were used to project the dental services per visit. Past trends in dental services were extrapolated to 2005 and projected to 2020 so as to align the years for projections of dental visits and services (Table 5).

Between 2005 and 2020 the number of services per visit is projected to increase from 2.36 to 2.82. The greatest number of services per visit is expected for adults in the 45–54 and 18–24 years age groups.

Table 5: Projected number of dental services per dental visit by age group, 2005 and 2020

Year

Age (years) 2005 2020 0–4 1.32 1.36

5–11 1.95 2.23

12–17 2.23 2.63

18–24 2.49 3.07

25–34 2.47 3.01

35–44 2.48 2.98

45–54 2.55 3.22

55–64 2.19 2.54

65–74 2.28 2.79

75+ 2.18 2.52 Total 2.36 2.82 Note: Estimates assume that the trend in dental visits observed between

1983–84 and 2003–04 will continue until 2020.

Projected service mix

The age-specific trends in dental services per visit for each of the 10 service areas were used to project the demand for specific services. Past trends in each service area were extrapolated for 2005 and 2020. Table 6 presents the total number of services per visit for specific areas for 2005 and 2020. Diagnostic, restorative and preventive services comprise the largest areas of dental care.

Table 6: Projected service mix for specific service areas for all age groups, 2005 and 2020

Year Area 2005 2020

Diagnostic 0.78 1.01

Preventive 0.44 0.57

Periodontic 0.02 0.02

Oral surgery 0.07 0.06

Endodontic 0.18 0.27

Restorative 0.64 0.66

Crown & bridge 0.08 0.11

Prosthodontic 0.09 0.08

Orthodontic 0.01 0.01

General misc. 0.04 0.04 Total 2.36 2.82

Note: Estimates assume that the trend in dental visits observed between 1983 and 2003–04 will continue until 2020.

Total demand for dental visits

Total demand for dental visits was calculated from a 2005 baseline to the year 2020. Total demand for visits is the product of the dentate and edentulous population estimates by age group and the estimated PCD for dental visits.

Between 2005 and 2020 the overall population is expected to increase by 16.6%. According to the ABS population projections, slight reductions are expected in the 5–11 and 12–17 years age groups, together with substantial increases in the 55–64 and 65–74 years age groups.

In addition to population and demographic changes, the number of edentulous persons is expected to decrease by 1.4%, while the number of dentate persons is expected to increase by 18.3% (Table 7).

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Table 7: Estimated number of dentate and edentulous persons (’000s) in 2005 and projected number in 2020

2005 2020 Age (years) Dentate

Edentu-lous All Dentate

Edentu-lous All

0–4 1,248.6 — 1,248.6 1,265.7 — 1,265.7

5–11 1,883.1 — 1,883.1 1,797.2 — 1,797.2

12–17 1,674.1 — 1,674.1 1,626.0 — 1,626.0

18–24 1,983.5 4.0 1,987.5 2,064.3 — 2,064.3

25–34 2,894.9 5.8 2,900.7 3,205.4 6.4 3,211.8

35–44 3,021.6 6.1 3,027.7 3,198.4 22.5 3,220.9

45–54 2,722.6 81.3 2,803.9 3,135.6 60.7 3,196.4

55–64 1,984.2 215.6 2,199.7 2,865.5 141.3 3,006.8

65–74 1,115.5 284.1 1,399.7 2,186.6 248.4 2,435.0

75+ 815.0 452.5 1,267.4 1,534.5 425.3 1,959.7

Total 19,343.2 1,049.3 20,392.5 22,879.1 904.6 23,783.7

Sources: NDTIS 2005; ABS population projections 2003 (Series 8).

5

These population estimates and projections were then multiplied by the age-specific PCD rates for dentate and edentulous persons under each of the three PCD growth scenarios (Table 8).

Under the ‘no PCD growth’ scenario there was an 18.9% increase in the total demand for dental visits, from 28.2 million visits in 2005 to 33.6 million in 2020. This scenario assumes that the per capita demand will remain static until 2020. The increase is mainly attributable to population growth and, to a lesser degree, declining edentulism. Demographic changes (ageing of the population) only account for a marginal increase.

Table 8: Total demand for dental visits (’000s), 2005 and projected to 2020 by PCD growth assumptions and age group 2005 2020

Age (years) Baseline

No PCD growth

Half PCD growth

Continued PCD growth

Dental visits (‘000s)

0–4 249.7 253.1 253.1 253.1

5–11 3,083.9 2,943.2 3,545.3 4,147.5

12–17 3,636.0 3,531.4 4,059.8 4,588.1

18–24 2,522.4 2,622.3 2,747.1 2,871.9

25–34 3,315.6 3,671.3 3,726.9 3,782.6

35–44 4,030.8 4,278.0 4,949.6 5,621.3

45–54 4,279.7 4,908.5 5,886.2 6,863.9

55–64 3,528.9 4,986.3 5,848.3 6,710.4

65–74 2,010.9 3,741.6 4,579.1 5,416.7

75+ 1,547.6 2,639.5 3,220.4 3,801.4

Total 28,205.5 33,575.1 38,816.0 44,056.8

Under the ‘half PCD growth’ scenario the projected demand for dental visits is expected to increase from 28.2 million visits in 2005 to 38.8 million visits in 2020, a 37.5% increase. The ‘continued PCD growth’ scenario projects an increase to 44.1 million visits in 2020, a 56.2% increase (Table 8 and Figure 5).

Figure 5: Demand for dental visits, 1979 to 2005, and projected demand, 2006 to 2020

0

5

10

15

20

25

30

35

40

45

50

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

2017

2019

Year

Den

tal v

isits

(mill

ions

)

No PCD growth

Half PCD growth

Continued PCD growth

Note: The ‘no PCD growth’ model keeps age-specific demand for dentate visits constant and therefore represents the increase due solely to population growth, demographic changes and changes in the rate of edentulism. ‘Continued PCD growth’ assumes that PCD increases at the same rate as observed between 1979 and 1995.

Total demand for dental services

The total demand for dental services was projected from a 2005 baseline to 2020. Total demand for dental services is the product of the total demand for visits by the total number of services per visit by age group. Projections for each of the 10 service areas were then summed across age groups.

The projections in Table 9 are based on the assumption that PCD for dental visits continues at half the rate of growth observed between 1979 and 2005 (‘half PCD growth’ scenario presented above). The projected numbers of services were estimated under three scenarios. The 0% growth scenario assumes that there is no increase in the number of services per visit. The 100% growth scenario assumes that the trend observed between 1983–84 and 2003–04 will continue through to 2020. The 50% growth scenario assumes the trend will continue at half the rate observed between 1983–84 and 2003–04.

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In 2005 it was estimated that 28.2 million dental visits were supplied in Australia. This equates to an estimated 65.5 million services provided. The projected number of services in 2020 varies considerably under the different scenarios. Under the 0% growth scenario (where the number of services per visit remains constant through to 2020) the total number of services increases from 65.5 million in 2005 to 81.7 million services in 2020. At 50% of the trend the total number of services is projected to increase to 94.6 million services, while a 100% continuation of the trend results in a projected 108.0 million services (Table 9).

Increases in the projected number of services vary considerably by age group. Under the 50% growth scenario the projected number of services is expected to increase by 16% in the 18–24 years age group and 141% in the 65–74 years age group (Table 9).

As the total demand for dental services was projected from the number of services in each service area, the demand for services within service areas can also be calculated. Table 10 presents the total demand for specific service areas for 2005 and projected to 2020 under the assumption of a 50% continuation in the dental services per visit trend and a 50% continuation in the dental visits per person per year trend.

Table 9: Total demand for dental services (’000s), 2005 and projected to 2020 by trend assumptions and age group

Year

2020 Percentage of past trend in services per

visit continued over 2005–2020 Age (years) 2005 0% 50% 100%0–4 329.7 333.1 336.3 345.1

5–11 6,028.2 6,497.0 7,177.6 7,920.8

12–17 8,097.9 8,288.9 9,474.2 10,668.6

18–24 6,292.6 6,128.3 7,272.1 8,424.0

25–34 8,177.6 8,281.8 9,736.8 11,234.6

35–44 9,994.8 11,209.7 12,889.4 14,750.0

45–54 10,903.7 13,152.1 16,050.8 18,949.5

55–64 7,740.3 11,972.1 13,318.8 14,878.6

65–74 4,583.4 9,353.6 11,056.3 12,758.9

75+ 3,374.8 6,519.4 7,310.4 8,101.3

Total 65,522.9 81,736.0 94,622.6 108,031.4

Note: Projection assumes a 50% growth in per capita demand for dental visits from 2005 to 2020.

In 2005 diagnostic services accounted for one-third (34.4%), preventive services for one-quarter (25.3%) and restorative services for one-fifth (21.0%) of all dental services. Periodontic and orthodontic services were in the least demand, accounting for 0.7% and 0.9% of all dental services.

Table 10: Projected total demand for specific service areas (’000s), 2005 and 2020

Year

Area 2005 2020 Diagnostic 22,510.7 32,389.6

Preventive 13,771.1 19,605.8

Periodontic 448.0 658.0

Oral surgery 2,126.7 2,708.3

Endodontic 4,502.1 6,838.1

Restorative 16,555.0 23,968.9

Crown & bridge 1,905.6 3,232.1

Prosthodontic 1,797.7 2,724.9

Orthodontic 767.7 898.7

General misc. 1,138.5 1,598.2

Total 65,522.9 94,622.6

Note: There is an assumption of half PCD growth for dental visits and a 50% continuation in linear trend in demand for dental services per visit.

The projected demand for services indicates considerable increases in the number of services required for diagnostic, preventive, restorative and endodontic services. In terms of percentage increases, crown and bridge services (69.6%), endodontic services (51.9%) and prosthodontic services (51.6%) showed the largest increases, although these were from a relatively small base. Orthodontic and oral surgical services showed the smallest increases (17.1% and 27.3%, respectively).

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Discussion

The aim of this report was to describe the change in demand for dental care between 1979 and 2005 and to provide projections of future demand through to 2020. It did not explore the factors underlying the change in demand or the interrelationship between supply and demand. Instead, this report provided projections based on a range of possible scenarios from no growth to full continuation of past trends for both PCD and number of services per visit.

Between 1979 and 1995 there were substantial increases in PCD for dental visits across most age groups. This was followed by a plateau in PCD for dental visits between 1995 and 2005. In addition to the change in PCD for dental visits, there was also a marked increase in the number of services per visits.

Although PCD has remained relatively stable across the decade to 2005, it has been argued that this was an artefact produced by the supply infrastructure ‘bottleneck’, whereby the capacity to supply visits by the dental labour force effectively capped growth in demand for dental visits (Teusner et al. 2008). The recent establishment of a dental school at Griffith University and the announcement of up to three new dental schools is likely to reduce the bottleneck, potentially improving accessibility to dental care.

The increase in the capacity to supply dental visits due to increasing access to dental care is likely to result in an increase in PCD. This provides support for demand projections exceeding the ‘no PCD growth’ scenario.

In terms of the number of dental services per visit, past trends indicate an intensification of service delivery, particularly for diagnostic, preventive and restorative services.

Any continuation of past trends in terms of demand for dental visits per person per year, or the number of services provided per visit, will only increase demand. For example, assuming that PCD increases at 50% of the trend between 1979 and 1995 and the number of services per visit increases by 50% of the previous trend, total demand for dental visits is projected to increase by 37.6% and the total number of services by 44.4%.

Data sources

This report uses population level data on dentate (some natural teeth) and edentulous (no natural teeth) persons and dental visits collected across a number of social surveys. These include: • The Australian Bureau of Statistics Special

Supplementary Survey of Sight, Hearing and Dental Health 1979 (ABS 1980)

• The National Oral Health Survey of Australia 1987/88 (NOHSA 1988) (Barnard 1993)

• The National Health Survey 1989 (NHS 1989) (ABS 1991)

• The National Dental Telephone Interview Surveys 1995, 1999, 2002 and 2004–2006 (NDTIS 1995, 1999, 2002, 2004–06) (Brennan et al. 1997; Carter & Stewart 2002, 2003; Slade et al. 2007).

Information on the number and types of services received during dental visits was collected from the Longitudinal Study of Dentist Practice Activity (LSDPA) in 1983–84, 1988–89, 1993–94, 1998–99 and 2003–04 (Brennan & Spencer 2002, 2006).

Finally, in order to estimate the Australian population’s demand for dental visits or services, the Australian Bureau of Statistics Population Projections Series 8 (ABS 2003) was used through to 2020.

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References ABS (Australian Bureau of Statistics) 1980. Dental health (persons aged 15 years or more), February–May 1979. Cat. no. 4339.0. Canberra: ABS.

ABS 1991. National Health Survey: summary of results, Australia. Cat. no. 4364.0. Canberra: ABS.

ABS 1996. National Health Survey: first results. Cat. no. 4364.0. Canberra: ABS.

ABS 2003. Population projections Australia 2002–2101. Cat. no. 3222.0. Canberra: ABS.

AIHW DSRU (Australian Institute of Health and Welfare Dental Statistics and Research Unit) 2003. Demand for dental care. Cat. no. DEN 103. (Dental Statistics and Research Series No. 8.) Canberra: AIHW.

Barnard PD 1993. National Oral Health Survey Australia 1987–88. Canberra: AGPS.

Brennan DS, Carter KD, Stewart JF & Spencer AJ 1997. Commonwealth Dental Health Program Evaluation Report 1994–96. Cat. no. DEN 14. Adelaide: AIHW Dental Statistics and Research Unit.

Brennan DS & Spencer AJ 2002. Dentists’ practice activity in Australia: 1983–84 to 1998–99. Cat. no. DEN 101 (Dental Statistics and Research Series No. 26). Canberra: AIHW.

Brennan DS & Spencer AJ 2006. Practice activity patterns of dentists in Australia. Cat. no. DEN 148 (Dental Statistics and Research Series No. 32). Canberra: AIHW.

Carter KD & Stewart JF 2002. National Dental Telephone Interview Survey 1999. Cat. no. DEN 109. Adelaide: AIHW Dental Statistics and Research Unit.

Carter KD & Stewart JF 2003. National Dental Telephone Interview Survey 2002. Cat. no. DEN 128. Adelaide: AIHW Dental Statistics and Research Unit.

Slade GD, Spencer AJ & Roberts-Thomson KF (eds) 2007. Australia’s dental generations: the National Survey of Adult Oral Health 2004–06. Cat. no. DEN 165. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 34).

Teusner DN, Chrisopoulos S & Spencer AJ 2008. Projected demand and supply for dental visits in Australia: analysis of the impact of changes in key inputs. Cat. no. DEN 171 (Dental Statistics and Research Series No. 38). Canberra: AIHW.

© AIHW Dental Statistics and Research Unit, October 2008 Catalogue No. DEN 190 ISSN 1445–775X (online)

For further information contact John Spencer by email <john.spencer@adelaide.edu.au> or phone (08) 8303 5438.

The AIHW Dental Statistics and Research Unit (DSRU) is a collaborating unit of the Australian Institute of Health and Welfare, established in 1988 at The University of Adelaide and located in the Australian Research Centre for Population Oral Health (ARCPOH), School of Dentistry, The University of Adelaide. DSRU aims to improve the oral health of Australians through the collection, analysis and reporting of information on oral health and access to dental care, the practice of dentistry and the dental labour force in Australia. Published by: AIHW Dental Statistics and Research Unit ARCPOH, School of Dentistry The University of Adelaide SOUTH AUSTRALIA 5005

Email: <aihw.dsru@adelaide.edu.au> Phone: 61 8/(08) 8303 4051 Fax: 61 8/(08) 8303 3070

www.arcpoh.adelaide.edu.au