Temporomandibular dysfunction experience is associated with oral health-related quality of life: an Australian national study.

BACKGROUND: There are very few studies of the association between temporomandibular dysfunction (TMD) and oral health-related quality of life (OHRQoL) in a representative sample from the Asia-Pacific region. Accordingly, we aimed to quantify the association of TMD with OHRQoL dimensions and overall measurement scores in a representative sample of Australian adults while accounting for a range of confounders, and statistically estimating whether TMD experience is meaningfully associated with OHRQoL. METHOD: Australia's National Survey of Adult Oral Health 2004-2006 data were used. The outcome variables were the Oral Health Impact Profile (OHIP-14) domains and overall scores while the main exposure was self-reported Diagnostic Criteria Question for TMD. The analysis accounted for confounders including oral health status obtained from the oral examination, demographics, socioeconomics, health behaviours and health including perceived stress subscales of the PSS-14. We conducted complex samples analysis while using Cohen's f2 effect size to estimate whether the association is meaningful. RESULTS: TMD prevalence was 9.9% (95% CI: 8.4-11.6%) among 4133 Australian adults. TMD experience was associated with impairments to the seven OHIP-14 OHRQoL domains (P < .05) with higher impairments observed in physical pain (B = 0.82, 95% CI: .45-1.20, P < .001), psychological discomfort (B = 0.68, 95% CI: .29-1.06, P = .001) and psychological disability (B = 0.52, 95% CI: .20-.84, P = .001) in adjusted multivariate analyses. The difference in the mean OHIP-14 scores for those reporting TMD (Mean = 13.1, 95% CI: 12.0-14.0) and those who did not (Mean = 6.6, 95% CI: 6.0-6.8) was significant (t = 7.51, P < .001). In an adjusted multivariable model for OHIP-14 scores, TMD experience was associated with higher OHIP-14 scores (B = 3.34, 95% CI: 1.94-4.75, P < .001) where the Cohen's f2 was .022. Further, perceived stress subscales: perceived distress and perceived control were associated with TMD experience and OHIP-14 scores (P < .05). CONCLUSION: Lower OHRQoL was observed in Australian adults who reported TMD experience but with small clinical importance which might support considering TMD in regular dental care. The higher impairments observed in physical pain, psychological discomfort and psychological disability domains of OHRQL can help clinicians and researchers focus their attention on these domains. The confounding effect exhibited by the perceived stress subscale might support their inclusion in future TMD and OHRQoL research.

Trust in dentist-patient relationships: mapping the relevant concepts.

Trust has a central role in healthcare encounters. This review explored concepts relevant to trust in dentist-patient relationships. The findings were demonstrated by drawing visual system maps for better understanding of the inherent complexity. A pragmatic approach was employed to search for evidence. The approach was initiated with a systematised searching protocol and followed by an iterative process of drawing maps and complementing references. The analysis-synthesis process found relevant key concepts and sub-concepts presented within three frameworks: the continuum of studying trust (utilisation, measurement, and establishment); beneficiaries of trust utilisation (patients, dentists, and oral health system); and a transformational model of trust development (identification-based, knowledge-based, and deterrence/calculus-based trust). Trust in dentist-patient relationships needs to be assessed in a multidisciplinary approach for interconnectedness among relevant concepts. The findings are represented in patient-centred care and quality of care with common underlying values. Despite the centrality of trust in medical/dental contexts, empirical evidence is insufficient beyond normative suggestions from previous studies. Based on the implications of thematic analysis and interpretation of the system maps, this paper can serve as a guide and source of information for further research of trust in dentist-patient relationships.

Psychosocial factors and self-reported transitions in oral and general health.

Psychosocial factors may explain variance in health beyond conventional indicators, such as behaviours. This study aimed to examine changes in health associated with perceived stress, social support, and self-efficacy, controlling for sociodemographic characteristics and health behaviour. A random sample of 45- to 54-yr-old subjects was surveyed in 2004-2005, with a follow-up 2 yr later. The outcomes were self-reported changes in oral and general health. Explanatory variables included stress, social support, and perceived health competence with covariates of income, gender, dentition status, toothbrushing, and smoking. Responses were collected from 986 persons (response = 44.4%). At the 2-yr follow-up, 25.6% reported worsening in oral health and 15.3% reported worsening in general health. Prevalence ratios (PR) from adjusted log-binomial regression showed an association between worsening oral health and higher perceived health competence (PR = 0.75, 95% CI: 0.57-0.99), and worsening general health was associated with perceived health competence (PR = 0.82, 95% CI: 0.72-0.94) and stress (PR = 1.17, 95% CI: 1.03-1.32). Worsening oral and general health were seen for male subjects (PR = 1.33, 95% CI: 1.06-1.68 and PR = 1.14, 95% CI: 1.01-1.29) and low income (PR = 1.40, 95% CI: 1.04-1.89 and PR = 1.20, 95% CI: 1.03-1.40). Health-related self-efficacy representing psychosocial resilience was associated with oral and general health, while stress was associated with general health. Psychosocial factors were independent predictors of change in health after controlling for sociodemographic characteristics and health behaviours.

The long-term influence of orthodontic treatment on adults' psychosocial outcomes: An Australian cohort study.

OBJECTIVES: To assess the influence of orthodontic treatment on psychosocial outcomes in 30-year-olds. The research hypothesis tested was that participants previously treated orthodontically would have better psychosocial outcomes. SETTING AND SAMPLE POPULATION: A prospective longitudinal cohort design was used to follow-up a sample of 1859 30-year-olds from Adelaide, South Australia, who had previously participated in an oral epidemiology study. MATERIALS AND METHODS: Clinical examination in 1988-1989 recorded participants' malocclusion severity. In 2005-2006, participants were invited to complete a questionnaire collecting data on socio-demographic characteristics, dental health behaviours, receipt of orthodontic treatment and psychosocial factors. Data were analysed descriptively and by linear regression models. RESULTS: Data for 448 participants were available; 56% of participants were female. Over a third of participants had received orthodontic treatment. Higher income earners had the best psychosocial outcomes while participants with a basic level of secondary education had the lowest. Regardless of initial malocclusion severity, orthodontic treatment was not associated with better psychosocial outcomes. Instead, a pattern of better psychosocial outcome was observed amongst untreated participants, regardless of malocclusion severity, this being significant for optimism. Adjusted models controlling for socio-demographic, dental health behaviour and malocclusion severity showed no association between orthodontic treatment and self-efficacy, health competence or social support. There was, however, a strong association with optimism. CONCLUSION: There was no difference in long-term psychosocial outcomes based on orthodontic treatment. Our study does not support the contention that orthodontic treatment produces better psychosocial functioning later in life.

General health, wellbeing and oral health of patients older than 75 years attending health assessments.

Annual health assessments by general practices for community-dwelling people aged 75 years and over are important for the early intervention and monitoring of chronic health conditions, including oral disease. Uptake of the health assessment to date has been poor, and little is known of the general and oral health profile of patients. Older patients attending health assessments at general practices in South Australia were sampled for this study. Data on demographic and socioeconomic characteristics, and patients' general and oral health, were collected by mailed questionnaire from 459 respondents. By comparison with national estimates, patients attending health assessments fared worse in many of the measures, such as self-rated general health, quality of life and the prevalence of most chronic conditions, as well as their socioeconomic circumstances. Also identified were a high degree of nutritional risk and clear need for oral health treatment, with poor self-rated oral health being three-fold higher than the national age-eligible population. Patients attending health assessments would likely benefit from nutritional screening (by a validated tool) and specific assessment of their oral health and dentition, supported by appropriate referral or intervention.

Work-Family Conflict Modifies the Association of Smoking and Periodontal Disease.

PURPOSE: The aims of the study were to assess the association of periodontal loss of attachment with smoking and work-family conflict and assess whether work-family conflict modifies the association of smoking and periodontal disease. METHOD: A random sample of 45-54 year olds from metropolitan Adelaide, South Australia, was surveyed by mailed self-complete questionnaire during 2004-2005. Oral examinations were performed on persons who responded to the questionnaire, providing an assessment of periodontal status. RESULTS: A total of 879 responded (participation rate = 43.8 %), with n = 709 oral examinations (completion rate = 80.7 %). Prevalence of periodontal loss of attachment (LOA) of 6+ mm was higher (p < 0.05) for smokers (23.8 %) compared to non-smokers (7.8 %) among employed adults. The adjusted prevalence ratio for LOA 6+ mm was prevalence ratio (PR) = 4.9 (95 % CI 2.2-8.8) for smokers, and there was a significant interaction (p < 0.05) between smoking status and work-family conflict. CONCLUSION: Work-family conflict modified the association of smoking with periodontal disease. Higher levels of work interfering with family were associated with higher levels of periodontal LOA for smokers compared with non-smokers.

'Newness-struggle-success' continuum: a qualitative examination of the cultural adaptation process experienced by overseas-qualified dentists in Australia.

Objectives Overseas-qualified dentists constitute a significant proportion of the Australian dental workforce (approximately one in four). The aim of the present study was to provide a better understanding of the cultural adaptation process of overseas-qualified dentists in Australia, so as to facilitate their integration into the Australian way of life and improve their contribution to Australian healthcare, economy and society. Methods Life stories of 49 overseas-qualified dentists from 22 countries were analysed for significant themes and patterns. We focused on their settlement experience, which relates to their social and cultural experience in Australia. This analysis was consistent with a hermeneutic phenomenological approach to qualitative social scientific research. Results Many participants noted that encounters with 'the Australian accent' and 'slang' influenced their cultural experience in Australia. Most of the participants expressed 'fascination' with the people and lifestyle in Australia, primarily with regard to the relaxed way of life, cultural diversity and the freedom one usually experiences living in Australia. Few participants expressed 'shock' at not being able to find a community of similar religious faith in Australia, as they are used to in their home countries. These issues were analysed in two themes; (1) language and communication; and (2) people, religion and lifestyle. The cultural adaptation process of overseas-qualified dentists in Australia is described as a continuum or superordinate theme, which we have entitled the 'newness-struggle-success' continuum. This overarching theme supersedes and incorporates all subthemes. Conclusion Family, friends, community and organisational structures (universities and public sector) play a vital role in the cultural learning process, affecting overseas-qualified dentist's ability to progress successfully through the cultural continuum. What is known about the topic? Australia is a popular host country for overseas-qualified dentists. Migrant dentists arrive from contrasting social and cultural backgrounds, and these contrasts can be somewhat more pronounced in dentists from developing countries. To date, there is no evidence available regarding the cultural adaptation process of overseas-qualified dentists in Australia or elsewhere. What does this paper add? This study provides evidence to support the argument that the cultural adaptation process of overseas-qualified dentists in Australia can be viewed as a continuum state, where the individual learns to adapt to the people, language and lifestyle in Australia. The ongoing role of family and friends is primary to a successful transition process. Our research also identifies the positive role played by community and organisational structures, such as universities and public sector employment schemes. What are the implications for practitioners? A potential implication for policy makers is to focus on the positive roles played by organisational structures, particularly universities and the public sector. This can inform more supportive migration policy, as well as strengthen the role these organisations play in providing support for overseas-qualified dentists, thus enabling them to integrate more successfully into Australia's health care system, economy and society.

Work-Family Conflict and Oral and General Health-Related Quality of Life.

BACKGROUND: The characteristics of the work environment and relationships with family roles may impact on health and be of public health significance. PURPOSE: The aims were to investigate the cross-sectional association of work-family conflict with oral- and general health-related quality of life, and well-being. METHOD: A random sample of 45-54-year olds from Adelaide, South Australia, was surveyed by self-complete questionnaire in 2004-2005 (n = 879, response rate = 43.8%). Health-related quality of life was measured with the OHIP-14 and EQ-VAS instruments, and well-being by the Satisfaction With Life Scale. RESULTS: In adjusted analyses controlling for sex, income, education, tooth brushing frequency and social support, the higher Family Interferes with Work (FIW) tertile and the middle tertile of Work Interferes with Family (WIF) were associated with more oral health-related impacts as measured by OHIP-14 in relation to problems with teeth, mouth or dentures (Beta = 1.64, P < 0.05 and Beta = 2.85, P < 0.01). Both middle and higher tertiles of WIF were associated with lower general health (Beta = -4.20 and -5.71, P < 0.01) and well-being (Beta = -1.17 and -1.56, P < 0.01). CONCLUSION: Work-family conflict was associated with more oral health impacts and lower general health and well-being among employed middle-aged adults. This supports the view of work-family conflict as a psychosocial risk factor for health outcomes spanning function, health perceptions and well-being, and encompassing both oral health and general health.

Trends in dental service provision in Australia: 1983-1984 to 2009-2010.

OBJECTIVE: To investigate time trends in dental service provision. METHODS: A random sample of Australian dentists was surveyed by mailed questionnaires in 1983-1984, 1993-1994, 2003-2004, and 2009-2010 (response rates 67-76%). The service rate per visit was collected from a log of services. RESULTS: The rate of service provision per visit [rate ratio (RR)] increased from 1983-1984 to 2009-2010 for the service areas of diagnostic (RR=1.8; 1.6-1.9), preventive (RR=1.9; 1.6-2.1), endodontic (RR=2.1; 1.7-2.6), and crown and bridge (RR=2.9; 2.3-3.8), whereas prosthodontic services decreased (RR=0.7; 0.6-0.9). CONCLUSIONS: The profile of services provided by dentists changed over the study period to include less emphasis on replacement of teeth and more on diagnosis, prevention, and retention of natural dentitions.

Characteristics and practice profiles of migrant dentist groups in Australia: implications for dental workforce policy and planning.

INTRODUCTION: Migrants comprise a growing proportion of the dental workforce in Australia. To date, research on migrant dentists is limited, raising policy questions regarding the motivations for migration, demographic profiles and work patterns. The purpose of this paper was to present findings from the first national survey of migrant dentists in Australia. METHODS: All dentists with a primary dental qualification from an overseas institution and registered with the Australian Dental Association (n=1,872) or enrolled as a graduate student in any of the nine dental schools in Australia (n=105) were surveyed between January and May 2013. RESULTS: A total of 1,022 participants (response rate=54.5%) were classifiable into three migrant dentist groups: direct recognition (n=491); Australian Dental Council (ADC) (n=411); and alternative pathway (n=120). Overall, 41.8% of migrant dentists were female. More than half of the ADC group (54.1%) were from lower middle income countries. The most frequent motivation for migration according to the direct recognition group (21.1%) was 'adventure', whereas other groups migrated for 'better opportunity'. The majority of ADC respondents (65%) were under 45 years of age, and a larger proportion worked in the most disadvantaged areas (12.4%), compared with other groups. Gender, marital status, years since arrival in Australia and having children varied between the groups (chi square; P<0.05). CONCLUSION: Dentist groups migrate to Australia for different reasons. The large proportion of the migrant dentist workforce sourced from lower middle income countries points towards deficiencies in oral health systems both for these countries and for Australia. The feminisation of the migrant dentist profile could in future affect dentist-practice activity patterns in Australia. Further research, especially on the settlement experiences of these dentists, can provide better insights into issues faced by these dentists, the nature of support that migrant dentists receive in Australia, the probable future patterns of work and potential impact on the dental workforce and dental service provision.

Health-related quality of life and income-related social mobility in young adults.

BACKGROUND: To assess the association of income-related social mobility between the age of 13 and 30 years on health-related quality of life among young adults. METHODS: In 1988-89 n = 7,673 South Australian school children aged 13 years were sampled with n = 4,604 children (60.0%) and n = 4,476 parents (58.3%) returning questionnaires. In 2005-06 n = 632 baseline study participants responded (43.0% of those traced and living in Adelaide). RESULTS: Multivariate regressions adjusting for sex, tooth brushing and smoking status at age 30 showed that compared to upwardly mobile persons social disadvantage was associated (p < 0.05) with more oral health impact (Coeff = 5.5), lower EQ-VAS health state (Coeff = -5.8), and worse satisfaction with life scores (Coeff = -3.5) at age 30 years, while downward mobility was also associated with lower satisfaction with life scores (Coeff = -1.3). CONCLUSIONS: Stable income-related socioeconomic disadvantage was associated with more oral health impact, and lower health state and life satisfaction, while being downwardly mobile was associated with lower life satisfaction at age 30 years. Persons who were upwardly mobile were similar in health outcomes to stable advantaged persons.

Self-rated dental health and dental insurance: modification by household income.

BACKGROUND: Previous studies have reported that socioeconomically disadvantaged Australians have poorer self-rated dental health (SRDH), are less likely to be insured for dental services and are less likely to have regular dental visits than their more advantaged counterparts. However, less is known about the associations between dental insurance and SRDH. The aim of this study was to examine the associations between SRDH and dental insurance status and to test if the relationship was modified by household income. METHODS: A random sample of 3,000 adults aged 30-61 years was drawn from the Australian Electoral Roll and mailed a self-complete questionnaire. Analysis included dentate participants. Bivariate associations were assessed between SRDH and insurance stratified by household income group. A multiple variable model adjusting for covariates estimated prevalence ratios (PR) of having good to excellent SRDH and included an interaction term for insurance and household income group. RESULTS: The response rate was 39.1% (n = 1,093). More than half (53.9%) of the participants were insured and 72.5% had good to excellent SRDH. SRDH was associated with age group, brushing frequency, insurance status and income group. Amongst participants in the $40,000- < $80,000 income group, the insured had a higher proportion reporting good to excellent SRDH (80.8%) than the uninsured (66.5%); however, there was little difference in SRDH by insurance status for those in the $120,000+ income group. After adjusting for covariates, there was a significant interaction (p < 0.05) between having insurance and income; there was an association between insurance and SRDH for adults in the $40,000- < $80,000 income group, but not for adults in higher income groups. CONCLUSIONS: For lower socio-economic groups being insured was associated with better SRDH, but there was no association for those in the highest income group. Insurance coverage may have the potential to improve dental health for low income groups.

Age, period and cohort analysis of patient dental visits in Australia.

BACKGROUND: Understanding dentists' capacity to supply dental services over time is a key element in the process of planning for the future. The aim was to identify time trends and estimate age, period and cohort effects in patients' visits supplied per dentist per year. METHODS: Mailed questionnaires were collected from a random sample of Australian private general practice dentists. The response rates were 73%, 75%, 74%, 71%, 76% and 67% in 1983, 1988, 1993, 1998, 2003 and 2009, respectively. The time trends in the mean number of patient visits supplied per dentist per year (PPY) was described by using a standard cohort table and age-period-cohort analyses applying a nested general linear regression models approach. RESULTS: The mean number of PPY decreased across most age groups of dentists over the time of study. The age-period model showed that younger dentists (20-29 years) and older dentists (65-74 and 80-84 years) had lower PPY than middle-aged dentists, and the age-cohort model showed higher PPY among earlier cohorts, and lower PPY among more recent cohorts. CONCLUSION: The study found a period effect of declining PPY over the observation period. More recent cohorts of dentists provide lower numbers of PPY than earlier cohorts at similar ages, but the provision of PPY among these younger cohorts appeared to be stable as they moved into middle age.

Overseas-qualified dentists' experiences and perceptions of the Australian Dental Council assessment and examination process: the importance of support structures.

OBJECTIVE: The Australian Dental Council is responsible for the assessment of overseas-qualified dentists seeking to practice dentistry in Australia. The aim of this paper is to reflect on the Council's assessment and examination process through the experiences and perceptions of overseas-qualified dentists in Australia. METHODS: Qualitative methods were used. Life stories of 49 overseas-qualified dentists from 22 nationalities were analysed to discern significant themes and patterns. We focused on their overall as well as specific experiences of various stages of the examination. The analysis was consistent with a hermeneutic phenomenological approach to social scientific research. RESULTS: Most participants referred to 'cost' of the examination process in terms of lost income, expenses and time. The examination itself was perceived as a tough assessment process. Some participants seemed to recognise the need for a strenuous assessment due to differences in patient management systems in Australia compared with their own country. Significantly, most of the participants stressed the importance of support structures for overseas-qualified dentists involved in or planning to undertake the examination. These considerations about the examination experience were brought together in two themes: (1) 'a tough stressful examination'; and (2) 'need for support.' CONCLUSION: This paper highlights the importance of support structures for overseas-qualified dentists. Appropriate support (improved information on the examination process, direction for preparation and training, further counselling advice) by recognised bodies may prevent potential exploitation of overseas-qualified dentists. Avenues that have been successful in providing necessary support, such as public sector schemes, offer policy options for limited recruitment of overseas-qualified dentists in Areas of Need locations. Such policies should also be in line with the local concerns and do not reduce opportunities for Australian-qualified dentists.

Oral Health Impact Profile, EuroQol, and Assessment of Quality of Life instruments as quality of life and health-utility measures of oral health.

Oral-specific measures are often preferred to examine outcomes of oral disorders. However, generic measures can add additional information, including health utility. The aim was to assess the Oral Health Impact Profile (OHIP), EuroQol (EQ-5D), and Assessment of Quality of Life (AQoL) instruments in relation to oral health in terms of their discriminative and convergent validities. Data were collected from adults, 30-61 yr of age, in Australia by mailed survey during 2009 and 2010, including the OHIP-14, the EQ-5D, and the AQoL, a range of self-reported oral health variables, and by self-rated oral and general health. Responses were collected from 1093 subjects (a response rate of 39.1%). The OHIP, the EQ-5D, and the AQoL were associated with oral health variables, with effect sizes ranging from 0.6 to 1.1 for the OHIP, from 0.3 to 0.5 for the EQ-5D, and from 0.4 to 0.6 for the AQoL. The OHIP tended to be more strongly correlated with self-rated oral health (rho = -0.5) than with general health (rho = -0.3), whilst the EQ-5D and the AQoL were less strongly correlated with oral health (rho = -0.3 and -0.3, respectively) than with general health (rho = -0.4 and -0.5, respectively). Whilst the OHIP was more sensitive to differences in oral health, the generic measures of EQ-5D and AQoL both exhibited discriminative validity and convergent validity in relation to oral health variables, supporting their use in oral health studies.

Household income modifies the association of insurance and dental visiting.

BACKGROUND: Dental insurance and income are positively associated with regular dental visiting. Higher income earners face fewer financial barriers to dental care, while dental insurance provides partial reimbursement. The aim was to explore whether household income has an effect on the relationship between insurance and visiting. METHODS: A random sample of adults aged 30-61 years living in Australia was drawn from the Electoral Roll. Data were collected by mailed survey in 2009-10, including age, sex, dental insurance status and household income. RESULTS: Responses were collected from n = 1,096 persons (response rate = 39.1%). Dental insurance was positively associated with regular visiting (adjusted prevalence ratio (PR) = 1.18; 95% CI: 1.01-1.36). Individuals in the lowest income tertile had a lower prevalence of regular visiting than those in the highest income group (PR = 0.78; 95% CI: 0.65-0.93). Visiting for a check-up was less prevalent among lower income earners (PR = 0.65; 95% CI: 0.50-0.83). Significant interaction terms indicated that the associations between insurance and visiting varied across income tertiles showing that income modified the effect. CONCLUSIONS: Household income modified the relationships between insurance and regular visiting and visiting for a check-up, with dental insurance having a greater impact on visiting among lower income groups.

Trends in dental visiting avoidance due to cost in Australia, 1994 to 2010: an age-period-cohort analysis.

BACKGROUND: The cost of dental care may be a barrier to regular dental attendance with the proportion of the Australian population avoiding or delaying care due to cost increasing since 1994. This paper explores the extent to which age, period and cohort factors have contributed to the variation in avoiding or delaying visiting a dentist because of cost. METHODS: Data were obtained from four national dental telephone interview surveys of Australian residents aged five years and over conducted in 1994, 1999, 2004 and 2010 (response rates 48%-72%). The trend in the percentage of persons avoiding or delaying visiting a dentist because of cost was analysed by means of a standard cohort table and more formal age-period-cohort analyses using a nested models framework. RESULTS: There was an overall increase in the proportion of people avoiding or delaying visiting a dentist indicating the presence of period effects. Financial barriers were also associated with age such that the likelihood of avoiding because of cost was highest for those in their mid-late twenties and lowest in both children and older adults. Cohort effects were also present although the pattern of effects differed between cohorts. CONCLUSION: The findings of this study suggest that, in addition to the increase in costs associated with dental care, policies targeting specific age groups and income levels may be contributing to the inequality in access to dental care.

Is clinical oral health poorer in regional areas compared with major city areas?

OBJECTIVE: To determine if clinical oral health outcomes differ between people who reside in major city, inner regional and outer regional areas of Australia. DESIGN: Data from the National Survey of Adult Oral Health 2004-06 that used a clustered stratified random sampling design with telephone interviews, standardised oral epidemiological examinations and self-complete questionnaires were used to compare the clinical oral health. MAIN OUTCOME MEASURES: Decayed, missing and filled permanent teeth. PARTICIPANTS: Australians aged 15 years or more. Data were weighted by age, sex and regional location to the Estimated Resident Population, bivariate analysis undertaken to determine confounders and multivariate analysis completed with dental caries clinical measures as dependent variables. RESULTS: Inner regional people had a significantly higher decayed, missing and filled teeth than people from major cities (Estimate = 1.15, P < 0.01), but there was no difference between inner and regional areas. Older people had higher outcomes for decayed, missing and filled teeth (15.42, P < 0.01) and missing teeth (9.66, P < 0.01), but less decayed teeth (-0.37, P < 0.01), and people with the highest incomes had lower dental caries experience (-1.34, P < 0.01) and missing teeth (-1.42, P < 0.01). CONCLUSION: Dental caries experience was greater in inner regional areas than in major city areas, but not outer regional areas. Dental caries experience was similar in outer regional and major city areas.

Income-based inequalities in dental service utilization: A multiple mediation analysis.

OBJECTIVES: With elimination of the financial burden of dental services, one can expect an increase in utilization of dental services. This study aimed to investigate the effective mechanisms of financial barriers to the utilization of dental services in an Australian adult population. METHODS: South Australian survey data from the Dental Care and Oral Health Study (2015) were analysed. Following the flexible mediation approach, the direct effect of income and indirect effect of income through mediators (insurance, concession card and service sector) on the outcomes (visit avoidance and treatment prevention due to the cost) were calculated. RESULTS: Findings showed that around half of the low-income people and one-third of the high-income South Australians experienced a financial burden on receiving a dental visit or service. The indirect effect of income on both outcomes of financial burden was negligible, while the direct effect was significant. By changing the potential outcome distribution to their counterfactual exposure distribution and if the mediators are drawn from their counterfactual exposure (lower/higher income) distribution, the odds of visit avoidance and treatment prevention due to the cost were almost twice (Odds Ratio: 2.13, 95% CI 1.72-2.60) and 98% (Odds Ratio: 1.98, 95% CI 1.67-2.35) than in the lower-income individuals, respectively. CONCLUSIONS: It can be concluded that the level of household income, directly and regardless of insurance status, concession card ownership and whether the service sector was public or private, affected the financial burden on utilization of dental services.