Special Feature

doi:10.1038/nindia.2017.25 Published online 17 March 2017

Oral health inequalities in Australia

[Nature India Special Issue: Oral Health Inequalities and Health Systems in Asia-Pacific]

Marco A Peres1 & Liana Luzzi2

Policy Recommendations

• Universal water fluoridation should be maintained as a key public health intervention to prevent dental caries and reduce its socioeconomic inequalities.

• Universal water fluoridation should be maintained as a key public health intervention to prevent dental caries and reduce its socioeconomic inequalities.

• Access to dental care should not be dependent only on an individual’s capacity to pay.

• Improving availability of dental care in rural areas is needed to address the rural-urban gap.

• Population oral health research should continue to inform policy makers and health providers on the best way of delivering dental care.

Marco Peres & Liana Luzzi

Australia is a high-income, multicultural country, ranked as having the second highest Human Development Index in 20151, and is the sixth largest country in by land size. However, it has a small population relative to its area, with nearly 24 million people, 89% concentrated in urban areas. Despite high levels of socio and economic development and the country experiencing a marked improvement in oral health indicators in the last dec­ades, oral health inequalities exist and are persistent between sub-groups of the population and across geographic areas.

Burden of oral diseases

The 2011 Australian Burden of Disease Study Report2 revealed that oral dis­eases have a considerable impact on non-fatal disease burden (4.4%) and are among the leading causes of total burden among females and males aged 5-14 years. Among non-fatal burden, tooth decay is the 4th highest among females and the 7th highest among males aged 5-14 years, and severe tooth loss is the 7th and 8th highest among females aged 65-74 years and 75-94 years respec­tively and the 10th highest among males aged 75-84 years.

It has been estimated that dental care comprises approximately 6% of na­tional healthcare expenditures accounting for nearly AU$9 billion3, with dental diseases constituting one of the four most expensive disease categories to treat.

Australia’s health system

Medicare is Australia’s universal health system, established to ensure all cit­izens have affordable access to healthcare. However, since its implementa­tion routine dental care was excluded from the system based on a rationale beyond health reasons4. Dental healthcare in Australia is delivered through a complex mix of service providers, including fee-for-service private practice, corporate dental practices, various forms of managed care (such as dental practices linked to private health dental insurers), staff-model dental clinics, run by insurers, and a public dental service in each state and territory, the latter particularly for children5

Therefore, affordability is a key determinant of dental care use, which in turn is an indication of inequalities in oral health in the country. In the last decades, there has been some debate about the in­clusion of dental services within Medicare and two main issues emerged: cost and willingness of the dental professional to be involved6.

Epidemiological evidence of socioeconomic inequalities in oral health

Australia has regular and rich sources of epidemiological data in oral health. The National Dental Telephone Interview Survey (NDTIS) is a source of na­tionally representative population data on dental health and use of dental services in Australia which has been conducted every 30 months since 1994. 

Since 1989 the ongoing Child Dental Health Survey (CDHS) is an annual, national time-series surveillance activity covering children attending public dental services. The first National Oral Health Survey Australia (NOHSA) was conducted in 1987-88, the second in 2004-06 (National Survey of Adult Oral Health (NSAOH)) and the third one, the National Study of Adult Oral Health (NSAOH) 2016-18, is underway. 

NSAOH 2016-18 includes a follow-up com­ponent of all examined participants from NSAOH 2004-06. The first national survey of child oral health was conducted in 1987–1988 (NOHSA) and a com­prehensive nationwide population-based National Child Oral Health Survey (NCOHS) was carried out in 2012-14. These studies revealed:

1. A remarkable decline in caries experience, both in primary and perma­nent teeth, between 1977 and 1983. For primary teeth, there was an in­crease between 1995 and 2001. In permanent teeth, there was a contin­ued decline in caries experience until 20017

2. There was a gradient in dental caries experience in primary and perma­nent teeth across household income groups. Overall children from most disadvantaged socioeconomic areas have higher dental caries experience and prevalence than more affluent peers (NCOHS preliminary report, 2016).

3. Indigenous have worse oral health and dental care indicators than non-in­digenous in all age groups.

4. Adults and children living in remote/very remote areas have higher rates of untreated dental caries than those in major cities.

5. More adults without dental insurance had untreated decay than those with insurance8.·         Prevalence of moderate and severe periodontitis was 22.9% in the Aus­tralian population in 2004-06. Among people of all ages those with less education had a higher prevalence than the more educated9.

6. Uninsured adults and those living outside major cities had a higher prev­alence of periodontitis than uninsured and those living in major cities8.

7. There was a gradient in the average number of missing teeth across household income groups8.

8. Adults with dental insurance had fewer missing teeth than those without insurance8.

Water fluoridation

Water fluoridation is considered to be a cost-effective, safe, and socially just public health intervention. Water fluoridation was first implemented in Aus­tralia in 1953 in Tasmania and was later expanded to almost all cities with the significant exception of the northeast state of Queensland. Following Queens­land’s decision of mandating water fluoridation in 2008, the country is now almost completely covered by fluoridation10. It is expected that this almost universal policy would reduce socioeconomic inequalities, by state, in dental caries10.

Dental workforce

The supply of all registered dental professionals is unevenly distributed across geographic regions, with the distribution of the dental labour force in Australia heavily skewed in favour of metropolitan areas. The supply of dental practi­tioners is highest in major cities (63.1 per 100,000 people) and lower in all other areas. The pattern is similar for dental hygienists, but less pronounced for dental prosthetists and oral health therapists. The exception is dental ther­apists, where major cities have the lowest number per 100,000 people8.

In addition to the geographic imbalance, there is an imbalance between the public and private sectors with public dental services unable to recruit and retain practitioners in proportion to the size of the eligible population.

According to population density (major cities, inner and outer regional, remote and very remote), adults who live in major cities are more likely to visit a dentist, visit for a check-up and visit a private practice than those in other areas8. Overall, adults living in major city areas are more likely to have a fa­vourable dental visiting pattern (usually visit at least once a year, usually visit for a check-up, and have a regular source of dental care), than in other areas8.

Adults who live outside of major cities are less likely to have private dental insurance11. The disadvantage in visiting for rural and remote adults is reflected in their oral health. Adults who live outside major cities are more likely (at all ages except the oldest) to have had all of their teeth extracted, and more likely to have insufficient teeth for good oral function12. They are also more likely to have dental care needs unmet12.


1. United Nations Development Programme (UNDP). Human Development Report 2015 Work for Human Development. New York: the United Nations Development Pro­gramme (2015)

2. Australian Institute of Health and Welfare (AIHW). Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series 3, BOD 4. Canberra: AIHW (2016)

3. Australian Institute of Health and Welfare (AIHW). Health expenditure Australia 2013–14. In: Health and welfare expenditure series. Australian Institute of Health and Welfare (2015)

4. Russel, L. Closing the dental divide. Med. J. Australia 201, 641-642 (2014)

5. Brennan, D. S. et al. Trends in dental service provision in Australia: 1983-1984 to 2009-2010. Int. Dent. J. 65, 39-44 (2015)

6. Spencer, J & Harford, J. Inequality in oral health in Australia. Australian Review of Pub­lic Affairs (2007)

7. Mejia, G. C. & Ha, D. H. Dental caries trends in Australian school children. Aust. Dent. J. 56, 227-230 (2011)

8. Chrisopoulos, S. et al. Oral health and dental care in Australia: key facts and figures 2015. Cat. no. DEN 229. Canberra: AIHW (2016)

9. Slade, G. D. et al eds. Australian’s dental generations: The National Survey of Adult Oral Health 2004-06. Vol. AIHW cat. No. DEN 165. Australian Institute of Health and Welfare: Canberra (2007)

10. Do, L. G. & Spencer, A. J. Contemporary multilevel analysis of the effectiveness of wa­ter fluoridation in Australia. Aust. NZ J. Pub. Health 39, 44-50 (2015)

11. Harford, J. et al. Trends in access to dental care among Australian adults 1994–2008. Canberra: AIHW (2011)

12. Roberts-Thomson K. D. &  Do, L. Oral health status. Australia’s dental generations: the National Survey of Adult Oral Health 2004-2006. Adelaide: AIHW (Dental Statistics and Research No. 34) 81-142 (2007)