Data source: National Health Survey: Summary of Results, 2007–2008 (Reissue), Table 1.1 Long-term conditions, 43640DO003_20072008 Persons and Appendix 4 State/territory populations, by whether condition current and long-term, Persons.
Chronic disease and use of dental services in Australia
Article first published online: 28 AUG 2011
© 2011 Australian Dental Association
Australian Dental Journal
Volume 56, Issue 3, pages 336–340, September 2011
How to Cite
Australian Research Centre for Population Oral Health, The University of Adelaide, South Australia., . (2011), Chronic disease and use of dental services in Australia. Australian Dental Journal, 56: 336–340. doi: 10.1111/j.1834-7819.2011.01354.x
- Issue published online: 28 AUG 2011
- Article first published online: 28 AUG 2011
Oral and chronic diseases are linked in many ways (Fig 1). They share social determinants in the way people grow, work and live. They also share common risk factors in diet, tobacco use and alcohol consumption.1 This leads to the frequent co-occurrence of both oral and chronic disease, known as co-morbidity. There are a number of direct associations between oral and chronic disease. Associations exist which hypothesize that one can lead to the other, with oral health alternatively being the ‘cause’ or the subsequent ‘event’. This is captured in the now widely recognized phrases from the US Surgeon General’s report on oral health: the mouth as a portal of entry of infection; and the mouth as a mirror of systemic health.2
Dental services are important for people with poor general health, both for their positive impact on oral health and for any contribution they might make to the management of underlying medical conditions. Dental services might be regarded as forming a necessary part of direct management of the medical conditions, or as an indirect component of health care through their contribution to a person’s ability to chew and make good choices about food and nutrition, which then, in turn, affects quality of life, resilience and self-efficacy.
Therefore, there is interest in learning about the extent to which adults with chronic disease face difficulties in accessing dental services. This report uses self-reported information on chronic disease, oral health and dental visiting to determine whether adults with chronic disease report poorer oral health compared to adults without chronic disease.
Data presented in this report were sourced from the National Dental Telephone Interview Survey (NDTIS) 2010. The target population for NDTIS 2010 was Australian residents aged two years and over in all states and territories. To select a representative sample of residents, a two-stage stratified sampling design was implemented. In the first stage, a random sample of households was selected from the Electronic White Pages (EWP). To be able to access the latest version of the EWP, the Australian Institute of Health and Welfare’s Dental Statistics and Research Unit (AIHW DSRU) requested the Australian Electoral Commission (AEC) extract a sample of Australian adults aged 18 years and over from the electoral roll. These data were matched against the Sensis MacroMatch database to append a residential telephone number. Matched records that returned either a landline or mobile telephone number formed the basis of the sample frame for the 2010 NDTIS. The sample frame was stratified by state and region, where region was defined as metropolitan or non-metropolitan. Households were randomly selected from each stratum using the inbuilt features of the WINCATI software programme (WinCati 4.2 Sawtooth Technologies, Inc.) and contacted by telephone.
If telephone contact was made with a household, the interviewer established whether the telephone number served a residential dwelling. If the household was in-scope of the survey, an adult aged 18 years or older usually resident in the household was randomly selected. If there was only one adult usually resident in the household then that person was selected as the target adult. If there were two or more adults usually resident in the household, the householder was asked to identify the person who was due to have the next birthday as well as the person who had the last birthday. The WINCATI programme then randomly selected one of the nominated adults as the target adult to complete the telephone interview. Once the interview was completed with the target adult, if there were children aged 2–17 years usually residing in the household, one child was randomly selected to participate in the survey. A total of 10 237 people aged two or more years were interviewed and asked a range of questions relating to their oral health, access to dental care, dental treatment received and affordability of dental care.
Data were weighted to account for the different probabilities of selection to reflect the 2009 estimated resident population.3
This report presents findings from 6284 adults aged 18 years or older who were directly interviewed, and excludes 481 adults whose information was obtained by proxy (or third party) interview. The telephone interview proceeded in a set order of questions with participants initially asked whether they had attended a general medical practitioner (GP) in the previous 12 months. Further questions about self-reported chronic disease were only asked of those who had a recent GP attendance as such attendance was seen as important in establishing the veracity of self-reported chronic disease experience. The 5537 adults who had made a recent GP visit were asked whether they had experienced a particular chronic condition for at least the previous six months. Chronic diseases included were asthma, cancer, heart disease, diabetes, arthritis, stroke, kidney disease, high blood pressure and depression. Categories of response for each individual disease were ‘Yes’, ‘No’ or ‘Don’t know’. Figure 2 presents the flow diagram of adults interviewed and the sequencing of these adults through questions relating to chronic disease.
Prevalence of chronic diseases
Nearly 47% of adults who had visited a GP in the previous 12 months reported they had at least one of the chronic diseases listed in Table 1. This estimate also included 1.3% of adults who nominated another chronic disease that was not specifically asked by interviewers. Chronic diseases with the highest survey prevalence (>10% prevalence) were high blood pressure, arthritis, depression and asthma. Kidney disease (0.9%) and stroke (0.7%) were the lowest prevalence diseases.
|Self-reported chronic disease status||Prevalence %||95% CI||Comparison with population prevalence estimates|
|No chronic disease||53.1||51.2, 54.9|
|One or more chronic disease||46.9||45.1, 48.8|
|– Asthma||11.1||9.9, 12.4||9.8|
|– Cancer||2.6||2.1, 3.2||2.3|
|– Heart disease||5.1||4.4, 5.9||5.1|
|– Diabetes||6.7||5.9, 7.5||4.9|
|– Arthritis||18.6||17.3, 20.0||23.0|
|– Stroke||0.7||0.5, 1.1||1.7|
|– Kidney disease||0.9||0.7, 1.3||0.7|
|– High blood pressure||20.6||19.2, 22.1||14.1|
|– Depression||11.4||10.3, 12.6||12.6|
There are no directly comparable population estimates available for the percentage of adults with at least one of the chronic diseases listed in Table 1. However, the prevalence of each chronic disease can be compared with population estimates sourced from the 2007–2008 National Health Survey4 for all diseases except kidney disease. Population estimates for kidney disease were sourced from the AIHW report ‘Chronic diseases and associated risk factors in Australia, 2006’.5 The estimates from the National Health Survey are based on younger ages for an adult than those used for this report. The estimates of chronic disease levels within the NDTIS were reasonably aligned with the population estimates, but some important variation existed. Just less than half the survey point estimates and their 95% confidence interval encompass the closest comparative population estimate. Others like asthma and diabetes are reasonably close. The survey estimate for arthritis and stroke were lower, while the estimate for blood pressure was considerably higher.
Self-rated general and oral health
Adults were asked to rate their general health and oral health on a five-point Likert-type scale. Responses were grouped into ‘Excellent/Very good/Good’ and ‘Fair/Poor’. Table 2 presents the percentage of adults rating their health as either ‘Excellent’, ‘Very good’ or ‘Good’ by reported presence of chronic disease. Adults with no chronic disease were more likely to rate their general health as ‘Excellent/Very good/Good’ than adults with at least one chronic disease (96.1% vs. 78.3%). Among those reporting chronic disease, the percentage reporting their general health as ‘Excellent/Very good/Good’ was lowest for stroke (40.3%), kidney disease (46.8%) and heart disease (55.7%), with percentage estimates for all diseases (except asthma and high blood pressure) significantly lower than the overall percentage for adults with at least one chronic condition.
|Self-reported chronic disease status||General health||Oral health**|
|Prevalence %||95% CI||Prevalence %||95% CI|
|All||87.8||86.5, 88.9||81.4||79.9, 82.9|
|No chronic disease||96.1||94.9, 97.0||86.9||84.9, 88.7|
|Chronic disease||78.3||76.1, 80.4||74.7||72.1, 77.1|
|– Asthma||79.2||74.5, 83.3||77.7||72.3, 82.3|
|– Cancer||62.1||50.8, 72.3||85.1||76.1, 91.1|
|– Heart disease||55.7||48.2, 63.0||73.0||65.2, 79.6|
|– Diabetes||62.9||56.3, 69.0||71.3||64.5, 77.2|
|– Arthritis||70.7||66.9, 74.1||72.4||68.6, 75.8|
|– Stroke||40.3||22.7, 60.9||47.7||26.0, 70.3|
|– Kidney disease||46.8||31.9, 62.4||67.5||51.3, 80.4|
|– High blood pressure||76.5||73.1, 79.5||73.1||69.2, 76.7|
|– Depression||66.7||61.4, 71.6||66.5||60.9, 71.7|
A lower percentage of adults rated their oral health as ‘Excellent/Very good/Good’ than made the same rating for their general health (81.4% vs. 87.8%). Adults reporting no chronic disease were more likely to rate their oral health as ‘Excellent/Very good/Good’ than adults reporting at least one chronic disease (86.9% vs. 74.7%). Among those reporting chronic disease, the percentage rating their oral health as ‘Excellent/Very good/Good’ was lowest for stroke (47.7%), depression (66.5%) and kidney disease (67.5%), with percentage estimates for stroke and depression significantly lower than the overall percentage for adults with at least one chronic condition.
Oral health impacting on general health
As noted in the introduction, oral health may impact on general health both directly through the mouth as a portal for infection and indirectly through functional limitations, discomfort and disability. Among adults with at least one chronic disease, 11.6% reported that their oral health impacted on their general health (Table 3). This was highest among those who had experienced a stroke (32.6%) and those with depression (19.0%). The percentage of people from the other chronic disease groups reporting oral health impacts on general health for other chronic diseases ranged from 13.5% for those with diabetes to 8.6% for those with cancer.
|Self-reported chronic disease status||Prevalence %||95% CI|
|Chronic disease||11.6||9.9, 13.5|
|– Asthma||9.5||7.1, 12.6|
|– Cancer||8.6||4.1, 17.0|
|– Heart disease||12.3||8.3, 17.9|
|– Diabetes||13.5||9.7, 18.4|
|– Arthritis||12.3||9.9, 15.1|
|– Stroke||32.6||17.0, 53.2|
|– Kidney disease||11.7||5.5, 23.0|
|– High blood pressure||12.0||9.5, 15.0|
|– Depression||19.0||14.7, 24.2|
Chronic disease and dental visiting behaviour
Tables 4, 5 and 6 compare the dental visiting behaviour of adults by reported presence of chronic disease. Information presented includes the percentage of adults who visited a dental professional in the previous 12 months, the percentage whose last dental visit was for the purpose of a check-up (rather than a dental problem) and the percentage who visited a private practice at their last dental visit.
|Self-reported chronic disease status||Prevalence %||95% CI|
|No chronic disease||59.7||57.0, 62.4|
|One or more chronic disease||58.4||55.8, 60.9|
|– Asthma||53.2||47.2, 59.2|
|– Cancer||56.3||45.3, 66.7|
|– Heart disease||53.8||46.3, 61.1|
|– Diabetes||47.5||41.1, 53.9|
|– Arthritis||57.8||54.0, 61.6|
|– Stroke||18.2||8.8, 33.8|
|– Kidney disease||65.5||49.8, 78.5|
|– High blood pressure||58.5||54.7, 62.2|
|– Depression||58.6||53.5, 63.6|
|Self-reported chronic disease status||Prevalence %||95% CI|
|No chronic disease||62.8||60.0, 65.6|
|One or more chronic disease||54.2||51.3, 57.2|
|– Asthma||58.4||51.4, 65.0|
|– Cancer||57.8||46.5, 68.3|
|– Heart disease||61.8||52.8, 70.0|
|– Diabetes||51.3||43.5, 59.0|
|– Arthritis||48.5||44.1, 52.9|
|– Stroke||41.2||18.3, 68.6|
|– Kidney disease||44.5||28.4, 61.9|
|– High blood pressure||53.1||48.8, 57.3|
|– Depression||49.9||43.7, 56.0|
|Self-reported chronic disease status||Prevalence %||95% CI|
|No chronic disease||91.9||90.2, 93.2|
|One or more chronic disease||84.5||82.5, 86.3|
|– Asthma||82.8||78.0, 86.8|
|– Cancer||77.5||64.9, 86.5|
|– Heart disease||81.5||74.5, 86.9|
|– Diabetes||77.4||71.3, 82.6|
|– Arthritis||77.2||73.6, 80.3|
|– Stroke||67.2||47.5, 82.3|
|– Kidney disease||73.6||58.1, 84.9|
|– High blood pressure||83.6||80.5, 86.2|
|– Depression||79.8||75.5, 83.5|
Adults reporting at least one chronic disease were just as likely to have visited a dental professional in the previous 12 months as those with no chronic disease (58.4% vs. 59.7%) (Table 4). However, among those reporting chronic disease, the percentage that had made a recent dental visit varied significantly by type of disease. Adults who had experienced a stroke (18.2%) were far less likely than adults reporting other chronic diseases to have made a recent dental visit. Visiting was also lower among those reporting diabetes (47.5%). The percentage visiting for both these chronic conditions was significantly lower than the overall prevalence for adults reporting at least one chronic condition (58.4%).
Adults reporting chronic disease were less likely to have visited for the purpose of a check-up, rather than a problem, at their last dental visit than those reporting no chronic disease (54.2% vs. 62.8%) (Table 5). Among those reporting chronic disease, the percentage visiting for a check-up varied significantly by type of disease. Adults who had experienced a stroke (41.2%), had kidney disease (44.5%), arthritis (48.5%) or depression (49.9%) reported the lowest percentage visiting for a check-up. However, percentages for these diseases were not significantly different from estimates for other chronic conditions.
Adults reporting chronic disease were less likely to have visited a private practice at their last dental visit than those reporting no chronic disease (84.5% vs. 91.9%) (Table 6). Among those reporting chronic disease, the percentage visiting privately was similar for the majority of diseases. The percentages were lowest for those who had experienced a stroke (67.2%) and those with kidney disease (73.6%). While these estimates were not significantly different from estimates for other chronic diseases, the estimate for stroke is significantly different from the overall estimate for people reporting chronic diseases (84.5%).
There is a strong theoretical underpinning to the link between oral and general health and disease. There is also increasing discussion on medically necessary dental care, that is where the success of general health care interventions is compromised by a failure to deal with oral health issues as part of the overall health plan.6,7 Yet there is little information available to document whether adults with chronic disease rate their oral health worse and report less favourable dental visiting behaviours than those adults without chronic disease.
This report has identified that fewer adults reporting one or more chronic disease rate their oral health as good and that a small minority of those with chronic disease report that their oral health impacts on their general health. While there was no difference in the percentage of adults who had one or more chronic disease reporting a dental visit in the previous 12 months, a lower percentage had last visited for a check-up and made their last visit to a private practice, the dominant provider of dental services in Australia.
Several groups of adults reporting specific chronic diseases had significantly poorer self-rated oral health, a higher percentage reporting impacts of their oral health on their general health and a lower percentage making a recent last visit for a check-up. A low percentage of those adults with a stroke or depression reported good oral health and a higher percentage reported their oral health impacting on their general health. Those with stroke and diabetes had the lowest percentage reporting having visited in the previous year. Among those with a stroke, kidney disease, arthritis and depression there was a lower percentage reporting last visiting for a check-up and those with a stroke and kidney disease had lower percentages reporting their last visit was to a private dentist. Those with a stroke consistently reported less favourable oral health and less favourable dental visiting behaviours.
These findings relied on self-reported chronic disease status. Only those with a GP visit in the last 12 months were asked about their experience of chronic disease, in the belief that such GP visiting would likely be associated with a person knowing of a diagnosed chronic disease and would be an expected part of its management. The survey prevalence estimates and population estimates recently published for Australian adults were similar, or had small absolute differences. However, given the survey sample size and prevalence of chronic disease, the number of individuals reporting some specific chronic diseases was low and the confidence interval around estimates were subsequently quite wide. This limited the inferences that could be drawn about some chronic conditions.
Adults reporting chronic disease also reported poorer oral health, and nearly one in eight reported that their oral health impacted on their general health. Time since last dental visit was similar for those with and without chronic disease. However, given the links between oral and general health and the potential for medically necessary dental care, a higher percentage of those adults reporting chronic disease making recent dental visits, including for a check-up, might be desirable. Consideration may need to be given to particular chronic diseases which were reportedly more frequently impacted on by oral health and for which a lower percentage of adults reported a recent dental visit. Stroke and depression were two chronic diseases more often associated with poorer self-rated oral health that more frequently impacted on the chronic condition and where fewer adults visited in the previous year and for the purpose of a check-up. Both of these findings highlight the importance of health care providers being aware of the links between oral health and these conditions and of the need to provide support to maintain oral self-care and to work to integrate dental care into the overall health care of the person with either of these conditions.
- 2US Department of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
- 3Australian Bureau of Statistics. Super CUBE dataset Population estimates by age and sex, Australia, by geographical classification (ASGC 2009) at 30 June 2009, Table 1.
- 4Australian Bureau of Statistics. National Health Survey: Summary of Results, 2007-2008 (Reissue). Cat. No. 4364.0. Table 3 – Long term conditions. Canberra: ABS, 2009.
- 5Australian Institute of Health and Welfare. Chronic diseases and associated risk factors in Australia, 2006. AIHW Cat. No. PHE 81. Canberra: AIHW, 2006.
- 7Australian Health Ministers’ Advisory Council, Steering Committee for National Planning for Oral Health. Oral health of Australians: National planning for oral health improvement: Final report. Adelaide, SA: Department of Human Services, 2001.