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Aust. J. Rural Health (2014) 22, 316–322
Original Research Clinical oral health of Australia’s rural children in a sample attending school dental services Diep Hong Ha, DDS, PhD,1 Leonard A. Crocombe, DDS, PhD,1,2,3 and Gloria C Mejia, DDS, PhD1 1
Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Adelaide, South Australia, 2University Department of Rural Health, University of Tasmania, Hobart, Tasmania, and 3School of Dentistry, University of Western Australia, Perth, Western Australia, Australia
Abstract Objective: To examine the association between children’s clinical oral health status and their residential location using the latest available data (2009) and to ascertain whether poor oral health among rural children is related to being Indigenous, having less access to fluoridated water or being of lower socioeconomic status (SES), than children from urban areas. Design: Cross-sectional survey. Setting and participant: Data were collected on 74 467 children aged 5–12 years attending school dental services in Australia (data were not available for Victoria or New South Wales). Main outcome measures: Clinical oral health was determined by the mean number of permanent teeth with untreated caries, missing and filled permanent teeth, and the mean decayed, missing and filled permanent teeth index (DMFT) of 8 to 12-year-old-children and the mean number deciduous teeth with untreated caries, missing and filled deciduous teeth, and the mean decayed, missing and filled deciduous teeth index (dmft) of 5–10-year-olds. Results: The multivariable models that included coefficients on whether the child was Indigenous, from an area with fluoridated water and SES, were controlled for age and sex. The mean DMFT of 8–12-year-old children and the mean dmft of 5–10-year-old-children were significantly higher in rural areas compared with urban centres after accounting for Indigenous status, fluoridated water and SES. Conclusion: Children’s oral health was poorer in rural areas than in major city areas. Correspondence: Dr Diep Hong Ha, Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Level 1 122 Frome Road, Adelaide, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 27 February 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: allied health, dental health, health outcomes research, oral epidemiology, rural health.
Introduction The oral health of Australian adults residing outside capital cities is poorer than that of those living in capital cities.1 Non-capital city residents are more likely to suffer complete tooth loss, have an inadequate dentition (less than 21 teeth), wear dentures, have untreated coronal dental caries and a higher mean DMFT (untreated caries, missing due to caries and filled permanent teeth) than capital city residents.2 People aged over 60 years in rural areas are more likely to be edentulous than those from urban areas.3 Geographical location is also a major factor in the frequency of use of dental services and reason for dental visits.4 The difference in dental caries indicators between capital city and non-capital city residents is still present after accounting for differences in socioeconomic status (SES), preventive dental behaviours and access to dental care.5 The inequalities in oral health between urban and rural adult residents suggest that there might be an inequality in child oral health as well. Although child oral health improved between 1977 and 2009,6 the Australian Institute of Health and Welfare7 reported that in 2001 children from rural and remote areas had higher prevalence and higher mean caries experience than children from metropolitan areas. Likewise, children who live in rural locations are disproportionally represented among those receiving dental treatment under a general anaesthetic.8 It is well known that Indigenous children or children living in non-fluoridated areas have worse dental health than their counterparts.9–11 The differences in oral health might be explained by the fact that more Indigenous children live in rural areas and most of rural areas are not fluoridated. There is a lack of research doi: 10.1111/ajr.12107
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What is already known on this subject: • The oral health of Australian children and adults residing outside capital cities is poorer than that of those living in capital cities. • The difference between rural and urban residential status is still present after controlling for other covariate such as SES, Indigenous status or water fluoridation among Australian adults. • The evidence on the differences in oral health between rural and urban when controlling for other characteristics in children has been lacking.
What this study adds: • The latest available data (2009) indicated that the oral health of Australian children residing outside capital cities continues to be poorer than that of those living in capital cities. • This study suggests that the differences in oral health between rural and urban children still exist after controlling for SES, Indigenous status and water fluoridation.
Remoteness determining whether the inequality in oral health between rural and urban still exists after controlling for water fluoridation, and Indigenous and SES statuses. Reducing inequalities in oral health was a major focus of the Australia’s National Oral Health Plan.12 Monitoring clinical oral disease might shed light on regional differences in child oral health, is a critical part of the assessment of public health and is important for the planning of oral health service provision. Thus, the information is essential for guiding current and future efforts to improve population oral health. The aims of this study were to update the information on the association between children’s oral health status and their residential location using the latest available data and to examine the association between the residential remoteness status and child oral health after controlling for being Indigenous, access to the benefits of water fluoridation and SES.
Methods
Remoteness areas were defined using the Australian Standard Geographical Classification – Remoteness Areas system that divides Australia into five regions: ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’.13 The postcode of the child’s residence, or of the clinic attended, was used to classify the child’s remoteness. Because of the low numbers, children from remote and very remote areas were considered as one group.
Putative confounders The Socio-Economic Indexes for Areas indices use information from 2006 Census to assign a measure of SES to all geographic areas (postcode) in Australia. Water fluoridation status was defined by postcode. If the fluoride level in drinking water was greater than 0.3 ppm, the water was defined as fluoridated.14 The categories of ‘Aboriginal’ or ‘Torres Strait Islander’ or ‘Aboriginal and Torres Strait Islander’ or ‘South Sea Islander’ were grouped as Indigenous.
Child Dental Health Survey 2009
Dependent variables
The Child Dental Health Survey (CDHS) monitors the oral health of children enrolled in school dental services (SDS) in Australia. Data were derived from routine examinations of children attending SDS in 2009. All children enrolled in SDS in South Australia, the Australian Capital Territory, Tasmania and the Northern Territory were selected for this study. Queensland and Western Australia adopted a systematic sampling procedure based on a random sample of children using date of birth. More specifically, at the time of examination, children were sampled at random by selecting those born on a specific day of the month. Victoria and New South Wales data were not included as the data were not available.
Clinical oral health status was measured by the mean number teeth with untreated caries, and by the mean number of missing or filled deciduous teeth of children aged 5–10 years, and of permanent teeth of children aged 8–12 years. Deciduous tooth caries experience in children aged 5–10 years was recorded as the number of deciduous teeth that had untreated caries, or were missing or filled because of dental caries (dmft) based on the coding scheme of Palmer et al.15 For children aged 8–12 years, permanent caries experience was reported as the number of permanent teeth that had untreated caries, or were missing or filled because of dental caries (DMFT), based on the World Health Organization protocol.16
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Analysis
TABLE 2:
To quantify the level of advantage and disadvantage for areas in which the child lived, the Australian Bureau of Statistics’ Socioeconomic Indices for Areas dataset was merged with CDHS dataset. Data sourced from the annual CDHS were weighed at the regional level. Population counts by age and postcode were based on the ‘2009 Estimated Resident Population of Australia by postal area by age’. Bivariate and multivariable regression analyses were used to determine associations with child oral health. The difference in the relative change in the clinical oral health outcome indicators between groups was considered statistically significant if the 95% confidence intervals did not overlap. Analysis was conducted with SAS 9.3 (SAS Institute Inc., Cary, NC, USA).
Results The surveillance covered over 57 000 (57 118) children aged 5–10 years, and 46 114 children aged 8–12 years. There were 74 020 children aged 5–12 years (Table 1). Of those, 2219 were from Queensland, 9748 from Western Australia, 38 276 from South Australia, 15 313 from Tasmania, 5463 from the Australian Capital Territory and 3001 from the Northern Territory (data are not shown).
Descriptive data Over half the children of both age groups were from major city areas, with the number of children examined decreasing with increasing remoteness (Tables 1,2). Age
TABLE 1: Distribution of children in the sample by their remoteness, 2009
Age (years)
Number of children sampled (n)
Major cities (%)
Inner regional (%)
Outer regional (%)
Remote/ very remote (%)
5 6 7 8 9 10 11 12 Total
8675 9472 9759 9787 9728 9697 9122 7780 74 020
53.6 52.9 51.8 53.1 52.0 51.7 50.8 49.8 52.01
22.7 22.5 23.7 22.7 22.3 22.9 22.6 23.8 22.87
19.2 19.9 19.6 19.8 21.2 20.8 21.6 21.5 20.41
4.6 4.8 4.9 4.4 4.6 4.6 5.0 4.9 4.71
Unweighted number.
Distributions of children by age and region Aged 5–10 years
Aged 8–12 years
Region
n
%
n
%
Major cities Inner regional Outer regional Remote/very remote Total
29 987 13 018 11 463 2650 57 118
52.50 22.79 20.07 4.64 100.00
23 782 10 521 9657 2154 46 114
51.57 22.82 20.94 4.67 100.00
Unweighted number.
and sex distribution of the children was similar between the regions (data not shown). Remote/very remote areas had the highest proportion of Indigenous and low SES children in both age groups (Table 3). It was much more likely that both 5–10-yearolds and 8–12-year-olds from major city areas lived in areas with water fluoridation than their same-aged counterparts in regional areas.
Bivariate analysis The mean number of untreated caries deciduous teeth in 5–10-year-olds was higher in remote/very remote areas than in outer or inner regional areas, which in turn was higher than in major city areas (Table 4). There was a higher mean number of missing deciduous teeth in outer regional and remote/very remote areas compared with the inner regional and major city areas and a higher mean number of filled deciduous teeth in outer regional than in the other areas. Children from remote/very remote and outer regional areas had a higher dmft than children from inner regional areas, who had a higher dmft than children from capital cities. Among 8–12-year-old children (Table 5), there was a higher mean number of missing permanent teeth in inner regional than the other areas, but the mean number of untreated caries and filled teeth was highest in the remote/very remote areas, resulting in the DMFT score being highest in the remote/very remote areas.
Multivariable analysis In the multivariable models that controlled for being Indigenous, from a fluoridated area, of low SES, and for age and sex, the mean dmft of 5–10 year old children and the mean DMFT of 8–12-year-old children were significantly higher in the areas outside major city areas than within major city areas (Table 6). © 2014 National Rural Health Alliance Inc.
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TABLE 3:
Distribution of children characteristics by remoteness among 5–10- and 8–12-year-old children
Characteristics Among 5–10-year-olds Indigenous Non-fluoridated areas Lowest SES areas Among 8–12-year-olds Indigenous Non-fluoridated areas Lowest SES areas
Major cities (%) (95% CI)
Inner regional (%) (95% CI)
Outer regional (%) (95% CI)
Remote/very remote (%) (95% CI)
2.14 (2.08–2.2) 8.33 (8.25–8.42) 10.32 (10.22–10.41)
2.56 (2.43–2.69) 55.04 (54.77–55.32) 9.79 (9.63–9.96)
8.05 (7.83–8.27) 49.15 (48.85–49.45) 23.25 (23–23.51)
38.37 (37.77–38.96) 25.54 (24.99–26.1) 46.10 (45.49–46.71)
2.09 (2.02–2.15) 8.65 (8.56–8.74) 10.76 (10.66–10.86)
2.51 (2.51–2.37) 55.06 (55.06–54.76) 10.19 (10.19–10.01)
7.67 (7.6–7.44) 45.61 (45.61–45.28) 25.17 (25.17–24.88)
37.41 (36.75–38.08) 25.64 (25.00–26.28) 45.94 (45.26–46.62)
Weighted percentage. CI, confidence interval; SES, socioeconomic status.
TABLE 4: Mean number of untreated caries, missing, filled deciduous teeth and dmft among 5–10-year-old children by their characteristics
Characteristics Regional location Major cities Inner regional Outer regional Remote/very remote areas Indigenous Non-Indigenous Indigenous Fluoridation status Non-fluoridated areas Fluoridated areas Socioeconomic status Rank 1 (lowest) Rank 2 Rank 3 Rank 4 Rank 5 (highest)
Untreated caries Mean (95% CI)
Missing Mean (95% CI)
Filled Mean (95% CI)
dmft Mean (95% CI)
0.89 1.20 1.16 1.37
0.07 0.17 0.30 0.27
0.95 1.01 1.23 1.05
1.91 2.38 2.69 2.69
(0.87–0.91) (1.17–1.24) (1.12–1.20) (1.30–1.45)
(0.07–0.08) (0.15–0.18) (0.29–0.32) (0.23–0.30)
(0.93–0.97) (0.98–1.04) (1.19–1.27) (0.97–1.12)
(1.88, (2.33, (2.63, (2.57,
1.94) 2.44) 2.75) 2.81)
0.73 (0.72–0.75) 2.01 (1.95–2.07)
0.13 (0.12–0.13) 0.31 (0.29–0.34)
0.91 (0.89–0.92) 1.10 (1.04–1.16)
1.77 (1.75, 1.79) 3.42 (3.33, 3.52)
1.51 (1.48–1.54) 0.85 (0.83–0.87)
0.20 (0.18–0.21) 0.12 (0.11–0.12)
1.21 (1.18–1.24) 0.95 (0.93–0.96)
2.91 (2.87, 2.96) 1.91 (1.89, 1.94)
1.25 1.21 1.09 0.95 0.63
0.40 0.13 0.15 0.06 0.05
1.12 1.12 1.01 0.97 0.87
2.77 2.46 2.25 1.97 1.55
(1.20–1.29) (1.18–1.25) (1.05–1.12) (0.92–0.97) (0.60–0.67)
(0.38–0.42) (0.11–0.14) (0.14–0.17) (0.04–0.07) (0.03–0.07)
(1.08–1.16) (1.08–1.16) (0.98–1.04) (0.94–1.00) (0.84–0.90)
(2.71, (2.40, (2.20, (1.93, (1.50,
2.84) 2.52) 2.30) 2.02) 1.61)
Age and sex adjusted, weighted number. CI, confidence interval; dmft, decayed, missing and filled deciduous teeth index.
The mean number of untreated carious deciduous teeth in 5–10-year-olds was very high in remote/very remote areas, as was the mean number of deciduous filled teeth in outer regional areas. The mean DMFT of 8–12-year-olds living in remote/very remote areas was © 2014 National Rural Health Alliance Inc.
much higher (0.37) than for those children living in inner (0.12) or outer regional (0.11) or in major city areas, and the largest component explaining this fact was the much higher mean number of filled teeth in children from remote/very remote areas.
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TABLE 5: Mean number of untreated caries, missing, filled permanent teeth and DMFT among 8–12-year-old children by their characteristics
Characteristics Regional location Major cities Inner regional Outer regional Remote/very remote areas Indigenous Non-Indigenous Indigenous Fluoridation status Non-fluoridated areas Fluoridated areas Socioeconomic status Rank 1 (lowest) Rank 2 Rank 3 Rank 4 Rank 5 (highest)
Untreated caries Mean (95% CI)
Missing Mean (95% CI)
Filled Mean (95% CI)
DMFT Mean (95% CI)
0.29 0.36 0.28 0.45
0.03 0.07 0.03 0.04
0.29 0.37 0.34 0.63
0.61 0.80 0.65 1.12
(0.28–0.30) (0.34–0.38) (0.26–0.29) (0.41–0.49)
(0.02–0.04) (0.06–0.08) (0.02–0.04) (0.03–0.06)
(0.28–0.30) (0.35–0.39) (0.32–0.36) (0.59–0.67)
(0.59, (0.77, (0.62, (1.06,
0.62) 0.83) 0.68) 1.19)
0.21 (0.21–0.22) 0.59 (0.57–0.62)
0.03 (0.03–0.03) 0.06 (0.05–0.08)
0.27 (0.26–0.28) 0.54 (0.51–0.58)
0.51 (0.50, 0.53) 1.20 (1.16, 1.25)
0.40 (0.39–0.42) 0.27 (0.27–0.28)
0.07 (0.07–0.08) 0.03 (0.02–0.03)
0.36 (0.34–0.37) 0.31 (0.31–0.32)
0.83 (0.81, 0.86) 0.61 (0.60, 0.63)
0.43 0.37 0.27 0.26 0.25
0.03 0.09 0.03 0.02 0.03
0.40 0.36 0.36 0.31 0.22
0.86 0.82 0.66 0.59 0.49
(0.41–0.45) (0.35–0.39) (0.26–0.29) (0.24–0.27) (0.23–0.27)
(0.02–0.04) (0.08–0.09) (0.03–0.04) (0.02–0.03) (0.02–0.03)
(0.38–0.42) (0.34–0.38) (0.34–0.37) (0.29–0.32) (0.20–0.23)
(0.83, (0.79, (0.64, (0.57, (0.46,
0.90) 0.85) 0.69) 0.61) 0.52)
Age and sex adjusted, weighted number. CI, confidence interval; DMFT, decayed, missing and filled permanent teeth index. Statistical significant when 95%CIs do not overlap.
Discussion Deciduous teeth caries experience among children 5–10 years and the permanent teeth caries experience of 8–12-year-old children were significantly higher outside the major cities, and this was not explained by being Indigenous, living in an area without water fluoridation or being of low SES. The higher mean number of untreated deciduous teeth in remote/very remote areas might reflect the amount of disease with which these younger children present to the clinic, the very limited access to dental care or a different treatment philosophy in remote/very remote areas compared with other regions for children under the age of five years. Among children aged 8–12 years, the large mean number of filled permanent teeth in remote/very remote areas suggested that children had higher disease patterns in remote/very remote settings. These study findings are in accordance with the existing studies that indicate dentists from non-capital city areas supply more patient visits per year and might be busier than capital city dentists.17 Given that deciduous and permanent dentition caries levels remained high in remote/very remote children, the current predominant focus on treatment with inadequate resources, the problems with high levels of dental caries cannot be expected to reduce. More emphasis should be given on preventive measures including oral health promotion, oral health
checks by other health professionals, simple and effective applications of fluoride varnish and, where feasible, water fluoridation.18 Some of the results might, in part, be explained by different concepts of oral health. Humphreys19 suggested that people in rural areas might have a different concept of health. In the area of oral health, this is indicated by the fact that people in rural areas have a different dental visiting pattern, being more likely to have a problem-orientated pattern of dental attendance, less likely to make an annual dental visit and less likely to have a regular dentist than city-based people.7 The limitations of the study are that living in an area with water fluoridation may not be representative of lifetime fluoride exposure. For example, a child could have just moved into the area, or children might, or might not, use fluoridated toothpaste. As the child population of New South Wales and Victoria represent a sizeable proportion of the Australian child population, comparisons with national estimates should be made with caution. This was a large survey with over 74 000 participants, allowing the estimate to be quite precise. The study used dental caries data based on the clinical judgement of the examining dental therapist or dentist, which might vary between the clinicians, but to overcome this limitation, detailed instructions on data collection were provided to all clinics. Also, analyses were based on the presence/absence of © 2014 National Rural Health Alliance Inc.
© 2014 National Rural Health Alliance Inc.
0.02 0.02 0.02 0.02
0.48* 0.28* 0.24* 0.16*
0.23* 0.08* 0.04* 0.02*
−0.01 0.10* 0.20* −0.14* −0.14* 0.01 0.01 0.01 0.01
0.01 0.01 0.01 0.01 0.01 0.20* 0.14* 0.14* 0.06*
0.04 0.17* −0.02 0.08* 0.08*
β
0.02 0.02 0.02 0.02
0.04 0.02 0.03 0.03 0.03
SE
0.91* 0.50* 0.43* 0.25*
0.22* 0.26* 0.22* 1.37* 0.18*
β
0.04 0.04 0.04 0.03
0.05 0.03 0.04 0.06 0.05
SE
0.16* 0.09* 0.05* 0.03*
0.06* −0.00 0.07* 0.32* 0.07*
β
0.01 0.01 0.01 0.01
0.02 0.01 0.01 0.02 0.01
SE
0.00 −0.00 0.00 −0.00
−0.00 0.15* 0.00 0.01 −0.00
β
0.00 0.00 0.00 0.00
0.01 0.00 0.00 0.01 0.01
SE
0.08* 0.04* 0.09* 0.06*
0.31* 0.11* 0.04* 0.13* 0.03*
β
0.01 0.01 0.01 0.01
0.02 0.01 0.01 0.02 0.02
SE
0.25* 0.13* 0.13* 0.10*
0.37* 0.12* 0.11* 0.47* 0.10*
β
DMFT
0.02 0.02 0.02 0.02
0.03 0.02 0.02 0.03 0.02
SE
*P < 0.05. Ref groups: major cities; non-Indigenous; fluoridated areas; rank 5 (highest SES). SE, standard error; SES, socioeconomic status; DMFT, decayed, missing and filled permanent teeth index; dmft, decayed, missing and filled deciduous teeth index.
0.03 0.02 0.02 0.03 0.03
0.18* −0.01 0.04 1.15* 0.24*
SE
β
SE
Filled
β
Missing
Untreated caries
dmft
Missing
Untreated caries
Filled
Permanent teeth of children aged 8–12 years
Deciduous teeth of children aged 5–10 years
Multivariable models of deciduous teeth of children aged 5–10 years old and of permanent teeth of children aged 8–12 years controlled for age and sex
Remoteness Remote/very remote areas Outer regional Inner regional Indigenous Non-fluoridated areas SES Rank 1 (lowest) Rank 2 Rank 3 Rank 4
TABLE 6:
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cavitated caries lesions (either filled or not), which are considered to be quite reliable.20 The difference between rural and metropolitan oral health over time needs to be regularly updated, and further research into why child oral health is poorer outside compared to inside Australia’s major cities needs to be undertaken.
Conclusions Dental caries continued to be common among children who attended the SDS. Even after accounting for Indigenous status, fluoridation status and SES, child oral health was poorer in rural areas than major city areas. Despite children in this study having some access to dental from SDS, the caries level among remote/very remote children was still higher than that among children from major city areas. This suggested that population preventive measures need to be identified and implemented in remote/very remote areas in order to reduce the burden of disease in this subpopulation.
Acknowledgements The Australian Institute of Health and Welfare funded this research. We wish to acknowledge the State and Territory health authorities’ data used in this publication. We would like to thank the staff of the School Dental Services for their cooperation.
References 1 Australian Institute of Health and Welfare (AIHW). Geographic variation in oral health and use of dental services in the Australian population 2004–06. AIHW Dental Statistics and Research Unit Research Report No. 41. AIHW Cat. no. DEN 188. Adelaide: AIHW; 2009. 2 Roberts-Thomson KF, Do LG. Oral health status. In: Slade GDS, Spencer AJ, Roberts-Thomson KF, eds. Australia’s Dental Generation: The National Survey of Adult Oral Health 2004–06. Canberra: Australian Institute of Oral Health and Welfare, 2007; 81–142. AIHW cat.no.DEN165. 3 Adams CS-SL, Larson A, O’Grady M. Edentulism and associated factors in people 60 years and over from urban, rural and remote Western Australia. Australian Dental Journal 2003; 48: 10–14. 4 Adams CS-SL, Larson A, O’Grady M. Dental visits in older Western Australians: a comparison of urban, rural and remote residents. The Australian Journal of Rural Health 2004; 12: 143–149. 5 Crocombe LA, Stewart JF, Brennan DS, Slade GD, Spencer AJ. Is clinical oral health poorer in regional areas compared with major city areas? The Australian Journal of Rural Health 2013; 21: 150–157.
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6 Mejia G, Amarasena N, Ha D, Roberts-Thomson KF, Ellershaw A. Child dental health survey Australia 2007: 30-year trends in child oral health. Dental statistics and research series no. 60. Cat. no. DEN 217. Canberra. AIHW; 2012. 7 Australian Institute of Health and Welfare and Dental Statistics and Research Unit (AIHW). Urban and rural variations in child oral health. DSRU Research Report No. 28, Cat. no. DEN 154. Canberra: AIHW. 2006. 8 Jamieson LM, Roberts-Thomson KF. Dental general anaesthetic trends among Australian children. BMC Oral Health 2006; 6: 16. 9 Endean C, Roberts-Thomson K, Wooley S. Anangu oral health: the status of the Indigenous population of the Anangu Pitjantjatjara lands. The Australian Journal of Rural Health 2004; 12: 99–103. 10 Jamieson LM, Armfield JM, Roberts-Thomson KF. Indigenous and non-indigenous child oral health in three Australian states and territories. Ethnicity and Health 2007; 12: 89–107. 11 Slade GD, Spencer AJ, Davies MJ, Stewart JF. Caries experience among children in fluoridated Townsville and unfluoridated Brisbane. Australian and New Zealand Journal of Public Health 1996; 20: 623–629. 12 National Advisory Committee on Oral Health. Healthy mouths, healthy lives: Australia’s National Oral Health Plan 2004–2014. Adelaide, Government of South Australia on behalf of the Australia’s Health Minister’s Conference; 2004. 13 Australian Bureau of Statistics (ABS). Census paper 03/01. ASGC remoteness classification: purpose and use. Canberra: Commonwealth of Australia, 2003. 14 ARCPOH (Australian Research Centre for Population Oral Health). Water fluoridation map of Australia updated to 2008. The University of Adelaide. Viewed 16 November 2011, 2008. 15 Palmer JD, Anderson RJ, Downer MC. Guidelines for prevalence studies of dental caries. Community Dental Health 1984; 1: 55–66. 16 World Health Organization. Oral Health Survey Basic Methods. Geneva: WHO, 1998. 17 Brennan D, Spencer AJ. Trends in private dental service provision in major city and other Australian locations. The Australian Journal of Rural Health 2007; 15: 189–195. 18 Slade GD, Bailie RS, Roberts-Thomson KF et al. Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial. Community Dentistry and Oral Epidemiology 2011; 39: 29–43. 19 Humphreys JS, Mathews-Cowey S, Weinand HC. Factors in accessibility of general practice in rural Australia. The Medical Journal of Australia 1997; 166: 577–580. 20 Evans DJ, Rugg-Gunn AJ, Tabari ED. The effect of 25 years of water fluoridation in Newcastle assessed in four surveys of 5-year-old children over an 18-year period. British Dental Journal 1995; 178: 60–64.
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Aust. J. Rural Health (2014) 22, 316–322
Original Research Clinical oral health of Australia’s rural children in a sample attending school dental services Diep Hong Ha, DDS, PhD,1 Leonard A. Crocombe, DDS, PhD,1,2,3 and Gloria C Mejia, DDS, PhD1 1
Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Adelaide, South Australia, 2University Department of Rural Health, University of Tasmania, Hobart, Tasmania, and 3School of Dentistry, University of Western Australia, Perth, Western Australia, Australia
Abstract Objective: To examine the association between children’s clinical oral health status and their residential location using the latest available data (2009) and to ascertain whether poor oral health among rural children is related to being Indigenous, having less access to fluoridated water or being of lower socioeconomic status (SES), than children from urban areas. Design: Cross-sectional survey. Setting and participant: Data were collected on 74 467 children aged 5–12 years attending school dental services in Australia (data were not available for Victoria or New South Wales). Main outcome measures: Clinical oral health was determined by the mean number of permanent teeth with untreated caries, missing and filled permanent teeth, and the mean decayed, missing and filled permanent teeth index (DMFT) of 8 to 12-year-old-children and the mean number deciduous teeth with untreated caries, missing and filled deciduous teeth, and the mean decayed, missing and filled deciduous teeth index (dmft) of 5–10-year-olds. Results: The multivariable models that included coefficients on whether the child was Indigenous, from an area with fluoridated water and SES, were controlled for age and sex. The mean DMFT of 8–12-year-old children and the mean dmft of 5–10-year-old-children were significantly higher in rural areas compared with urban centres after accounting for Indigenous status, fluoridated water and SES. Conclusion: Children’s oral health was poorer in rural areas than in major city areas. Correspondence: Dr Diep Hong Ha, Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Level 1 122 Frome Road, Adelaide, South Australia, 5005, Australia. Email: [email protected] Accepted for publication 27 February 2014. © 2014 National Rural Health Alliance Inc.
KEY WORDS: allied health, dental health, health outcomes research, oral epidemiology, rural health.
Introduction The oral health of Australian adults residing outside capital cities is poorer than that of those living in capital cities.1 Non-capital city residents are more likely to suffer complete tooth loss, have an inadequate dentition (less than 21 teeth), wear dentures, have untreated coronal dental caries and a higher mean DMFT (untreated caries, missing due to caries and filled permanent teeth) than capital city residents.2 People aged over 60 years in rural areas are more likely to be edentulous than those from urban areas.3 Geographical location is also a major factor in the frequency of use of dental services and reason for dental visits.4 The difference in dental caries indicators between capital city and non-capital city residents is still present after accounting for differences in socioeconomic status (SES), preventive dental behaviours and access to dental care.5 The inequalities in oral health between urban and rural adult residents suggest that there might be an inequality in child oral health as well. Although child oral health improved between 1977 and 2009,6 the Australian Institute of Health and Welfare7 reported that in 2001 children from rural and remote areas had higher prevalence and higher mean caries experience than children from metropolitan areas. Likewise, children who live in rural locations are disproportionally represented among those receiving dental treatment under a general anaesthetic.8 It is well known that Indigenous children or children living in non-fluoridated areas have worse dental health than their counterparts.9–11 The differences in oral health might be explained by the fact that more Indigenous children live in rural areas and most of rural areas are not fluoridated. There is a lack of research doi: 10.1111/ajr.12107
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What is already known on this subject: • The oral health of Australian children and adults residing outside capital cities is poorer than that of those living in capital cities. • The difference between rural and urban residential status is still present after controlling for other covariate such as SES, Indigenous status or water fluoridation among Australian adults. • The evidence on the differences in oral health between rural and urban when controlling for other characteristics in children has been lacking.
What this study adds: • The latest available data (2009) indicated that the oral health of Australian children residing outside capital cities continues to be poorer than that of those living in capital cities. • This study suggests that the differences in oral health between rural and urban children still exist after controlling for SES, Indigenous status and water fluoridation.
Remoteness determining whether the inequality in oral health between rural and urban still exists after controlling for water fluoridation, and Indigenous and SES statuses. Reducing inequalities in oral health was a major focus of the Australia’s National Oral Health Plan.12 Monitoring clinical oral disease might shed light on regional differences in child oral health, is a critical part of the assessment of public health and is important for the planning of oral health service provision. Thus, the information is essential for guiding current and future efforts to improve population oral health. The aims of this study were to update the information on the association between children’s oral health status and their residential location using the latest available data and to examine the association between the residential remoteness status and child oral health after controlling for being Indigenous, access to the benefits of water fluoridation and SES.
Methods
Remoteness areas were defined using the Australian Standard Geographical Classification – Remoteness Areas system that divides Australia into five regions: ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’.13 The postcode of the child’s residence, or of the clinic attended, was used to classify the child’s remoteness. Because of the low numbers, children from remote and very remote areas were considered as one group.
Putative confounders The Socio-Economic Indexes for Areas indices use information from 2006 Census to assign a measure of SES to all geographic areas (postcode) in Australia. Water fluoridation status was defined by postcode. If the fluoride level in drinking water was greater than 0.3 ppm, the water was defined as fluoridated.14 The categories of ‘Aboriginal’ or ‘Torres Strait Islander’ or ‘Aboriginal and Torres Strait Islander’ or ‘South Sea Islander’ were grouped as Indigenous.
Child Dental Health Survey 2009
Dependent variables
The Child Dental Health Survey (CDHS) monitors the oral health of children enrolled in school dental services (SDS) in Australia. Data were derived from routine examinations of children attending SDS in 2009. All children enrolled in SDS in South Australia, the Australian Capital Territory, Tasmania and the Northern Territory were selected for this study. Queensland and Western Australia adopted a systematic sampling procedure based on a random sample of children using date of birth. More specifically, at the time of examination, children were sampled at random by selecting those born on a specific day of the month. Victoria and New South Wales data were not included as the data were not available.
Clinical oral health status was measured by the mean number teeth with untreated caries, and by the mean number of missing or filled deciduous teeth of children aged 5–10 years, and of permanent teeth of children aged 8–12 years. Deciduous tooth caries experience in children aged 5–10 years was recorded as the number of deciduous teeth that had untreated caries, or were missing or filled because of dental caries (dmft) based on the coding scheme of Palmer et al.15 For children aged 8–12 years, permanent caries experience was reported as the number of permanent teeth that had untreated caries, or were missing or filled because of dental caries (DMFT), based on the World Health Organization protocol.16
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Analysis
TABLE 2:
To quantify the level of advantage and disadvantage for areas in which the child lived, the Australian Bureau of Statistics’ Socioeconomic Indices for Areas dataset was merged with CDHS dataset. Data sourced from the annual CDHS were weighed at the regional level. Population counts by age and postcode were based on the ‘2009 Estimated Resident Population of Australia by postal area by age’. Bivariate and multivariable regression analyses were used to determine associations with child oral health. The difference in the relative change in the clinical oral health outcome indicators between groups was considered statistically significant if the 95% confidence intervals did not overlap. Analysis was conducted with SAS 9.3 (SAS Institute Inc., Cary, NC, USA).
Results The surveillance covered over 57 000 (57 118) children aged 5–10 years, and 46 114 children aged 8–12 years. There were 74 020 children aged 5–12 years (Table 1). Of those, 2219 were from Queensland, 9748 from Western Australia, 38 276 from South Australia, 15 313 from Tasmania, 5463 from the Australian Capital Territory and 3001 from the Northern Territory (data are not shown).
Descriptive data Over half the children of both age groups were from major city areas, with the number of children examined decreasing with increasing remoteness (Tables 1,2). Age
TABLE 1: Distribution of children in the sample by their remoteness, 2009
Age (years)
Number of children sampled (n)
Major cities (%)
Inner regional (%)
Outer regional (%)
Remote/ very remote (%)
5 6 7 8 9 10 11 12 Total
8675 9472 9759 9787 9728 9697 9122 7780 74 020
53.6 52.9 51.8 53.1 52.0 51.7 50.8 49.8 52.01
22.7 22.5 23.7 22.7 22.3 22.9 22.6 23.8 22.87
19.2 19.9 19.6 19.8 21.2 20.8 21.6 21.5 20.41
4.6 4.8 4.9 4.4 4.6 4.6 5.0 4.9 4.71
Unweighted number.
Distributions of children by age and region Aged 5–10 years
Aged 8–12 years
Region
n
%
n
%
Major cities Inner regional Outer regional Remote/very remote Total
29 987 13 018 11 463 2650 57 118
52.50 22.79 20.07 4.64 100.00
23 782 10 521 9657 2154 46 114
51.57 22.82 20.94 4.67 100.00
Unweighted number.
and sex distribution of the children was similar between the regions (data not shown). Remote/very remote areas had the highest proportion of Indigenous and low SES children in both age groups (Table 3). It was much more likely that both 5–10-yearolds and 8–12-year-olds from major city areas lived in areas with water fluoridation than their same-aged counterparts in regional areas.
Bivariate analysis The mean number of untreated caries deciduous teeth in 5–10-year-olds was higher in remote/very remote areas than in outer or inner regional areas, which in turn was higher than in major city areas (Table 4). There was a higher mean number of missing deciduous teeth in outer regional and remote/very remote areas compared with the inner regional and major city areas and a higher mean number of filled deciduous teeth in outer regional than in the other areas. Children from remote/very remote and outer regional areas had a higher dmft than children from inner regional areas, who had a higher dmft than children from capital cities. Among 8–12-year-old children (Table 5), there was a higher mean number of missing permanent teeth in inner regional than the other areas, but the mean number of untreated caries and filled teeth was highest in the remote/very remote areas, resulting in the DMFT score being highest in the remote/very remote areas.
Multivariable analysis In the multivariable models that controlled for being Indigenous, from a fluoridated area, of low SES, and for age and sex, the mean dmft of 5–10 year old children and the mean DMFT of 8–12-year-old children were significantly higher in the areas outside major city areas than within major city areas (Table 6). © 2014 National Rural Health Alliance Inc.
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TABLE 3:
Distribution of children characteristics by remoteness among 5–10- and 8–12-year-old children
Characteristics Among 5–10-year-olds Indigenous Non-fluoridated areas Lowest SES areas Among 8–12-year-olds Indigenous Non-fluoridated areas Lowest SES areas
Major cities (%) (95% CI)
Inner regional (%) (95% CI)
Outer regional (%) (95% CI)
Remote/very remote (%) (95% CI)
2.14 (2.08–2.2) 8.33 (8.25–8.42) 10.32 (10.22–10.41)
2.56 (2.43–2.69) 55.04 (54.77–55.32) 9.79 (9.63–9.96)
8.05 (7.83–8.27) 49.15 (48.85–49.45) 23.25 (23–23.51)
38.37 (37.77–38.96) 25.54 (24.99–26.1) 46.10 (45.49–46.71)
2.09 (2.02–2.15) 8.65 (8.56–8.74) 10.76 (10.66–10.86)
2.51 (2.51–2.37) 55.06 (55.06–54.76) 10.19 (10.19–10.01)
7.67 (7.6–7.44) 45.61 (45.61–45.28) 25.17 (25.17–24.88)
37.41 (36.75–38.08) 25.64 (25.00–26.28) 45.94 (45.26–46.62)
Weighted percentage. CI, confidence interval; SES, socioeconomic status.
TABLE 4: Mean number of untreated caries, missing, filled deciduous teeth and dmft among 5–10-year-old children by their characteristics
Characteristics Regional location Major cities Inner regional Outer regional Remote/very remote areas Indigenous Non-Indigenous Indigenous Fluoridation status Non-fluoridated areas Fluoridated areas Socioeconomic status Rank 1 (lowest) Rank 2 Rank 3 Rank 4 Rank 5 (highest)
Untreated caries Mean (95% CI)
Missing Mean (95% CI)
Filled Mean (95% CI)
dmft Mean (95% CI)
0.89 1.20 1.16 1.37
0.07 0.17 0.30 0.27
0.95 1.01 1.23 1.05
1.91 2.38 2.69 2.69
(0.87–0.91) (1.17–1.24) (1.12–1.20) (1.30–1.45)
(0.07–0.08) (0.15–0.18) (0.29–0.32) (0.23–0.30)
(0.93–0.97) (0.98–1.04) (1.19–1.27) (0.97–1.12)
(1.88, (2.33, (2.63, (2.57,
1.94) 2.44) 2.75) 2.81)
0.73 (0.72–0.75) 2.01 (1.95–2.07)
0.13 (0.12–0.13) 0.31 (0.29–0.34)
0.91 (0.89–0.92) 1.10 (1.04–1.16)
1.77 (1.75, 1.79) 3.42 (3.33, 3.52)
1.51 (1.48–1.54) 0.85 (0.83–0.87)
0.20 (0.18–0.21) 0.12 (0.11–0.12)
1.21 (1.18–1.24) 0.95 (0.93–0.96)
2.91 (2.87, 2.96) 1.91 (1.89, 1.94)
1.25 1.21 1.09 0.95 0.63
0.40 0.13 0.15 0.06 0.05
1.12 1.12 1.01 0.97 0.87
2.77 2.46 2.25 1.97 1.55
(1.20–1.29) (1.18–1.25) (1.05–1.12) (0.92–0.97) (0.60–0.67)
(0.38–0.42) (0.11–0.14) (0.14–0.17) (0.04–0.07) (0.03–0.07)
(1.08–1.16) (1.08–1.16) (0.98–1.04) (0.94–1.00) (0.84–0.90)
(2.71, (2.40, (2.20, (1.93, (1.50,
2.84) 2.52) 2.30) 2.02) 1.61)
Age and sex adjusted, weighted number. CI, confidence interval; dmft, decayed, missing and filled deciduous teeth index.
The mean number of untreated carious deciduous teeth in 5–10-year-olds was very high in remote/very remote areas, as was the mean number of deciduous filled teeth in outer regional areas. The mean DMFT of 8–12-year-olds living in remote/very remote areas was © 2014 National Rural Health Alliance Inc.
much higher (0.37) than for those children living in inner (0.12) or outer regional (0.11) or in major city areas, and the largest component explaining this fact was the much higher mean number of filled teeth in children from remote/very remote areas.
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TABLE 5: Mean number of untreated caries, missing, filled permanent teeth and DMFT among 8–12-year-old children by their characteristics
Characteristics Regional location Major cities Inner regional Outer regional Remote/very remote areas Indigenous Non-Indigenous Indigenous Fluoridation status Non-fluoridated areas Fluoridated areas Socioeconomic status Rank 1 (lowest) Rank 2 Rank 3 Rank 4 Rank 5 (highest)
Untreated caries Mean (95% CI)
Missing Mean (95% CI)
Filled Mean (95% CI)
DMFT Mean (95% CI)
0.29 0.36 0.28 0.45
0.03 0.07 0.03 0.04
0.29 0.37 0.34 0.63
0.61 0.80 0.65 1.12
(0.28–0.30) (0.34–0.38) (0.26–0.29) (0.41–0.49)
(0.02–0.04) (0.06–0.08) (0.02–0.04) (0.03–0.06)
(0.28–0.30) (0.35–0.39) (0.32–0.36) (0.59–0.67)
(0.59, (0.77, (0.62, (1.06,
0.62) 0.83) 0.68) 1.19)
0.21 (0.21–0.22) 0.59 (0.57–0.62)
0.03 (0.03–0.03) 0.06 (0.05–0.08)
0.27 (0.26–0.28) 0.54 (0.51–0.58)
0.51 (0.50, 0.53) 1.20 (1.16, 1.25)
0.40 (0.39–0.42) 0.27 (0.27–0.28)
0.07 (0.07–0.08) 0.03 (0.02–0.03)
0.36 (0.34–0.37) 0.31 (0.31–0.32)
0.83 (0.81, 0.86) 0.61 (0.60, 0.63)
0.43 0.37 0.27 0.26 0.25
0.03 0.09 0.03 0.02 0.03
0.40 0.36 0.36 0.31 0.22
0.86 0.82 0.66 0.59 0.49
(0.41–0.45) (0.35–0.39) (0.26–0.29) (0.24–0.27) (0.23–0.27)
(0.02–0.04) (0.08–0.09) (0.03–0.04) (0.02–0.03) (0.02–0.03)
(0.38–0.42) (0.34–0.38) (0.34–0.37) (0.29–0.32) (0.20–0.23)
(0.83, (0.79, (0.64, (0.57, (0.46,
0.90) 0.85) 0.69) 0.61) 0.52)
Age and sex adjusted, weighted number. CI, confidence interval; DMFT, decayed, missing and filled permanent teeth index. Statistical significant when 95%CIs do not overlap.
Discussion Deciduous teeth caries experience among children 5–10 years and the permanent teeth caries experience of 8–12-year-old children were significantly higher outside the major cities, and this was not explained by being Indigenous, living in an area without water fluoridation or being of low SES. The higher mean number of untreated deciduous teeth in remote/very remote areas might reflect the amount of disease with which these younger children present to the clinic, the very limited access to dental care or a different treatment philosophy in remote/very remote areas compared with other regions for children under the age of five years. Among children aged 8–12 years, the large mean number of filled permanent teeth in remote/very remote areas suggested that children had higher disease patterns in remote/very remote settings. These study findings are in accordance with the existing studies that indicate dentists from non-capital city areas supply more patient visits per year and might be busier than capital city dentists.17 Given that deciduous and permanent dentition caries levels remained high in remote/very remote children, the current predominant focus on treatment with inadequate resources, the problems with high levels of dental caries cannot be expected to reduce. More emphasis should be given on preventive measures including oral health promotion, oral health
checks by other health professionals, simple and effective applications of fluoride varnish and, where feasible, water fluoridation.18 Some of the results might, in part, be explained by different concepts of oral health. Humphreys19 suggested that people in rural areas might have a different concept of health. In the area of oral health, this is indicated by the fact that people in rural areas have a different dental visiting pattern, being more likely to have a problem-orientated pattern of dental attendance, less likely to make an annual dental visit and less likely to have a regular dentist than city-based people.7 The limitations of the study are that living in an area with water fluoridation may not be representative of lifetime fluoride exposure. For example, a child could have just moved into the area, or children might, or might not, use fluoridated toothpaste. As the child population of New South Wales and Victoria represent a sizeable proportion of the Australian child population, comparisons with national estimates should be made with caution. This was a large survey with over 74 000 participants, allowing the estimate to be quite precise. The study used dental caries data based on the clinical judgement of the examining dental therapist or dentist, which might vary between the clinicians, but to overcome this limitation, detailed instructions on data collection were provided to all clinics. Also, analyses were based on the presence/absence of © 2014 National Rural Health Alliance Inc.
© 2014 National Rural Health Alliance Inc.
0.02 0.02 0.02 0.02
0.48* 0.28* 0.24* 0.16*
0.23* 0.08* 0.04* 0.02*
−0.01 0.10* 0.20* −0.14* −0.14* 0.01 0.01 0.01 0.01
0.01 0.01 0.01 0.01 0.01 0.20* 0.14* 0.14* 0.06*
0.04 0.17* −0.02 0.08* 0.08*
β
0.02 0.02 0.02 0.02
0.04 0.02 0.03 0.03 0.03
SE
0.91* 0.50* 0.43* 0.25*
0.22* 0.26* 0.22* 1.37* 0.18*
β
0.04 0.04 0.04 0.03
0.05 0.03 0.04 0.06 0.05
SE
0.16* 0.09* 0.05* 0.03*
0.06* −0.00 0.07* 0.32* 0.07*
β
0.01 0.01 0.01 0.01
0.02 0.01 0.01 0.02 0.01
SE
0.00 −0.00 0.00 −0.00
−0.00 0.15* 0.00 0.01 −0.00
β
0.00 0.00 0.00 0.00
0.01 0.00 0.00 0.01 0.01
SE
0.08* 0.04* 0.09* 0.06*
0.31* 0.11* 0.04* 0.13* 0.03*
β
0.01 0.01 0.01 0.01
0.02 0.01 0.01 0.02 0.02
SE
0.25* 0.13* 0.13* 0.10*
0.37* 0.12* 0.11* 0.47* 0.10*
β
DMFT
0.02 0.02 0.02 0.02
0.03 0.02 0.02 0.03 0.02
SE
*P < 0.05. Ref groups: major cities; non-Indigenous; fluoridated areas; rank 5 (highest SES). SE, standard error; SES, socioeconomic status; DMFT, decayed, missing and filled permanent teeth index; dmft, decayed, missing and filled deciduous teeth index.
0.03 0.02 0.02 0.03 0.03
0.18* −0.01 0.04 1.15* 0.24*
SE
β
SE
Filled
β
Missing
Untreated caries
dmft
Missing
Untreated caries
Filled
Permanent teeth of children aged 8–12 years
Deciduous teeth of children aged 5–10 years
Multivariable models of deciduous teeth of children aged 5–10 years old and of permanent teeth of children aged 8–12 years controlled for age and sex
Remoteness Remote/very remote areas Outer regional Inner regional Indigenous Non-fluoridated areas SES Rank 1 (lowest) Rank 2 Rank 3 Rank 4
TABLE 6:
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cavitated caries lesions (either filled or not), which are considered to be quite reliable.20 The difference between rural and metropolitan oral health over time needs to be regularly updated, and further research into why child oral health is poorer outside compared to inside Australia’s major cities needs to be undertaken.
Conclusions Dental caries continued to be common among children who attended the SDS. Even after accounting for Indigenous status, fluoridation status and SES, child oral health was poorer in rural areas than major city areas. Despite children in this study having some access to dental from SDS, the caries level among remote/very remote children was still higher than that among children from major city areas. This suggested that population preventive measures need to be identified and implemented in remote/very remote areas in order to reduce the burden of disease in this subpopulation.
Acknowledgements The Australian Institute of Health and Welfare funded this research. We wish to acknowledge the State and Territory health authorities’ data used in this publication. We would like to thank the staff of the School Dental Services for their cooperation.
References 1 Australian Institute of Health and Welfare (AIHW). Geographic variation in oral health and use of dental services in the Australian population 2004–06. AIHW Dental Statistics and Research Unit Research Report No. 41. AIHW Cat. no. DEN 188. Adelaide: AIHW; 2009. 2 Roberts-Thomson KF, Do LG. Oral health status. In: Slade GDS, Spencer AJ, Roberts-Thomson KF, eds. Australia’s Dental Generation: The National Survey of Adult Oral Health 2004–06. Canberra: Australian Institute of Oral Health and Welfare, 2007; 81–142. AIHW cat.no.DEN165. 3 Adams CS-SL, Larson A, O’Grady M. Edentulism and associated factors in people 60 years and over from urban, rural and remote Western Australia. Australian Dental Journal 2003; 48: 10–14. 4 Adams CS-SL, Larson A, O’Grady M. Dental visits in older Western Australians: a comparison of urban, rural and remote residents. The Australian Journal of Rural Health 2004; 12: 143–149. 5 Crocombe LA, Stewart JF, Brennan DS, Slade GD, Spencer AJ. Is clinical oral health poorer in regional areas compared with major city areas? The Australian Journal of Rural Health 2013; 21: 150–157.
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