Results: NSAOH respondents with good access to dental care had lower OHIP-14 summary measures .... highest education level (degree/teacher/nurse, trade/.
Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2013; 58: 192–199
SCIENTIFIC ARTICLE
doi: 10.1111/adj.12060
Will improving access to dental care improve oral health-related quality of life? LA Crocombe,*† GD Mahoney,‡ AJ Spencer,* M Waller‡ *Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia. †University Department of Rural Health, The University of Tasmania, Hobart, Tasmania. ‡Centre for Military and Veterans’ Health, School of Population, The University of Queensland, Queensland.
ABSTRACT Background: The aim of this study was to determine if Australian Defence Force (ADF) members had better oral healthrelated quality of life (OHRQoL) than the general Australian population and whether the difference was due to better access to dental care. Methods: The OHRQoL, as measured by OHIP-14 summary indicators, of participants from the Defence Deployed Solomon Islands (SI) Health Study and the National Survey of Adult Oral Health 2004–06 (NSAOH) were compared. The SI sample was age/gender status-adjusted to match that of the NSAOH sample which was age/gender/regional location weighted to that of the Australian population. Results: NSAOH respondents with good access to dental care had lower OHIP-14 summary measures [frequency of impacts 8.5% (95% CI = 5.4, 11.6), extent mean = 0.16 (0.11, 0.22), severity mean = 5.0 (4.4, 5.6)] than the total NSAOH sample [frequency 18.6 (16.6, 20.7); extent 0.52 (0.44, 0.59); severity 7.6 (7.1, 8.1)]. The NSAOH respondents with both good access to dental care and self-reported good general health did not have as low OHIP-14 summary scores as in the SI sample [frequency 2.6 (1.2, 5.4), extent 0.05 (0.01, 0.10); severity 2.6 (1.9, 3.4)]. Conclusions: ADF members had better OHRQoL than the general Australian population, even those with good access to dental care and self-reported good general health. Keywords: Dental care/utilization, dental health surveys, oral health, outcome assessment (health care), quality of life. Abbreviations and acronyms: ABS = Australian Bureau of Statistics; ADF = Australian Defence Force; ERP = Estimated Residential Population; NSAOH = National Survey of Adult Oral Health; OHRQoL = oral health-related quality of life; SI Health Study = Defence Deployed Solomon Islands Health Study. (Accepted for publication 30 August 2012.)
INTRODUCTION Dental services are one of the least subsidized areas of health in Australia,1 and it has been argued that this has resulted in service rationing by limiting the access to and the range of dental services supplied by both private and public dental services.2 Public funded dental care for adults is limited to those who hold health concession cards which are issued by Centrelink, an agency of the Australian Government’s Family Assistance Office.2 Health care card holders are means tested largely by income and include aged pensioners. Access is limited by triaging for priority care, waiting times for general dental care and the scope of services is narrowed to routine dental services. Private dental care for adults is rationed by availability of providers, some queuing and by the fee of alternative services. 192
Not surprisingly research has focused on access to dental care in terms of the difficulties encountered and on associations with poor oral health outcomes. For example, health care card holders who visit public dental clinics are at least twice as likely to experience toothache, to avoid certain foods and to suffer from the social embarrassment of bad teeth, compared to non-card holders.3 Low income adults without private insurance are more likely to have had all their teeth extracted than high income adults with insurance.4 Longitudinal studies have investigated the association between routine dental care and oral health-related quality of life (OHRQoL), but these have been limited to older adults,5–8 and/or subjects with an oral disadvantage,5,8,9 where an oral disadvantage was defined as avoiding laughing or smiling because of unattractive teeth or gums, avoiding talking to someone because of unattractive teeth or gums or bad breath, © 2013 Australian Dental Association
Dental care access and quality of life or being embarrassed by the appearance of teeth or gums.9 Little attention has been paid to investigating if good access to dental care is associated with positive OHRQoL outcomes. Beck et al.10 defined dental access as the ‘opportunity for each individual to enter into the dental care system and to make use of dentists’ services as the best way of preventing and controlling oral disease’. The Australian Defence Force (ADF), in maintaining its members dentally ‘fit to fight’, requires each member undergo a compulsory annual dental assessment and any treatment deemed necessary by the treating dental officer (a qualified dentist). This service is provided at no charge to the ADF member. Any necessary treatment whilst on leave is also free.11,12 Outside the ADF, one would expect that people with good access to dental care would not have difficulty paying a $100 dental bill, would not have to avoid or delay dental treatment because of cost, would not be eligible for public dental care, would have dental insurance, and would usually visit a dentist for a check-up as opposed to a problem. The difference between the ADF members and people in the community at large with good access to dental care is that oral health care for ADF members is institutionalized and enforced. Those ADF members who do not attend for a dental appointment without good reason may be fined and a dental officer needs to ‘sign off’ that an ADF member is dentally fit before he/she can be deployed, promoted or undergo further training. ADF members may have access to dental care that they may never be able to afford outside the ADF. Therefore, access to dental care for ADF members may be regarded as optimum. It is important that policy makers, dental health administrators and dental clinicians know if good access to dental care is associated with good OHRQoL, so that positive outcomes can be expected from improved access in an environment where health resources are scarce and needed to be allocated efficiently. It is one thing to know that people with poor access to dental care are more likely to have poor OHRQoL. It is quite another to investigate if people with good access to dental care have good OHRQoL. The objectives of this study were to determine if ADF members have better OHRQoL than the general Australian population, and if so, whether ADF members have similar or better OHRQoL as Australians with good access to dental care. METHODS Data sources The OHRQoL of the survey participants from two cross-sectional surveys were compared: the Defence Deployed Solomon Islands Health Study (SI Health © 2013 Australian Dental Association
Study)13 and the National Survey of Adult Oral Health 2004–06 (NSAOH).14 The Solomon Islands (SI) is a Melanesian nation east of Papua New Guinea. In 2003, SI was in a political and security crisis, as a result of longstanding internal conflicts. The ADF deployed Operation ANODE in 2003 as part of the Regional Assistance Mission to the Solomon Islands. The SI Health Study aimed to determine whether the health of the veterans of Operation ANODE differed significantly from similar non-deployed ADF members. Both current and former ADF members were invited to participate. A nominal roll included 4089 individuals who were deployed to the Solomon Islands as part of Operation ANODE and a comparison group of 4092 ADF personnel frequency matched to the deployed group on gender, age group, service (Navy, Army or Air Force) and service type (Permanent or Reserve), from which 500 deployed and 500 comparison individuals were randomly selected.13 The self-report questionnaire, from which OHIP-14 was obtained, was completed between March and December 2007. The mean OHIP-14 scores were similar between the deployed and non-deployed groups.13 The NSAOH14 used a clustered, stratified, random sampling design to select a representative sample of people aged 15 years or more. NSAOH consisted of a computer-aided telephone interview, an oral epidemiological examination and a questionnaire. Full details of sampling, examination protocol have been described elsewhere.15 Dependent variables The dependent variables were the summary measures for the OHIP-14. The OHIP-14 has seven content areas of functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap. Each of the seven OHIP dimensions consists of two items (or questions). Each item could have one of five responses: ‘never’, ‘hardly ever’, ‘occasionally’, ‘fairly often’ or ‘very often’. The definitions for summary OHIP-14 measures were proposed by Slade.16 Frequency of OHIP–14 impacts (previously known as prevalence) was defined as the percentage of subjects who reported one or more items ‘fairly often’ and ‘very often’. Extent was summarized for each survey participant by the number of items reported ‘fairly often’ or ‘very often’. Severity was the sum of the ordinal responses where ‘never’ was coded as 0, ‘hardly ever’ as 1, ‘occasionally’ as 2, ‘fairly often’ as 3 and ‘very often’ as 4. A person could have an OHIP-14 severity ranging from 0 to 56. The severity measure using all response cate193
LA Crocombe et al. gories attempts to overcome limitations that may be inherent in restricting summary scores to arbitrary thresholds of impacts. A lower OHIP-14 summary score equates to better OHRQoL. General health As general and oral health may be linked, NSAOH participants were asked to rate their general health as either ‘excellent’, ‘very good’, ‘good’, ‘fair’ or ‘poor’. Respondents who answered either ‘excellent’, ‘very good’, ‘good’ were considered to have good self-perceived general health. Access to dental care From the NSAOH, seven putative measures that may be associated with good access to dental care were selected: not being eligible for public dental care, not having a lot of trouble paying a $100 dental bill, not avoiding or delaying dental care due to cost, usually visiting a dentist for a check-up, visiting at least annually, having visited a dentist in the last 12 months and having private dental insurance. Demographic covariates From both surveys, five demographic variables were selected: gender (male/female), age (18–
