Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2013; 58: 192199
SCIENTIFIC ARTICLE
doi: 10.1111/adj.12060

Will improving access to dental care improve oral

health-related quality of life?
LA Crocombe,* GD Mahoney, AJ Spencer,* M Waller
*Australian Research Centre for Population Oral Health, School of Dentistry, The University of Adelaide, South Australia.
University Department of Rural Health, The University of Tasmania, Hobart, Tasmania.
Centre for Military and Veterans Health, School of Population, The University of Queensland, Queensland.

ABSTRACT
Background: The aim of this study was to determine if Australian Defence Force (ADF) members had better oral health-
related quality of life (OHRQoL) than the general Australian population and whether the difference was due to better
access to dental care.
Methods: The OHRQoL, as measured by OHIP-14 summary indicators, of participants from the Defence Deployed
Solomon Islands (SI) Health Study and the National Survey of Adult Oral Health 200406 (NSAOH) were compared.
The SI sample was age/gender status-adjusted to match that of the NSAOH sample which was age/gender/regional loca-
tion weighted to that of the Australian population.
Results: NSAOH respondents with good access to dental care had lower OHIP-14 summary measures [frequency of
impacts 8.5% (95% CI = 5.4, 11.6), extent mean = 0.16 (0.11, 0.22), severity mean = 5.0 (4.4, 5.6)] than the total
NSAOH sample [frequency 18.6 (16.6, 20.7); extent 0.52 (0.44, 0.59); severity 7.6 (7.1, 8.1)]. The NSAOH respondents
with both good access to dental care and self-reported good general health did not have as low OHIP-14 summary
scores as in the SI sample [frequency 2.6 (1.2, 5.4), extent 0.05 (0.01, 0.10); severity 2.6 (1.9, 3.4)].
Conclusions: ADF members had better OHRQoL than the general Australian population, even those with good access
to dental care and self-reported good general health.
Keywords: Dental care/utilization, dental health surveys, oral health, outcome assessment (health care), quality of life.
Abbreviations and acronyms: ABS = Australian Bureau of Statistics; ADF = Australian Defence Force; ERP = Estimated Residential
Population; NSAOH = National Survey of Adult Oral Health; OHRQoL = oral health-related quality of life; SI Health Study =
Defence Deployed Solomon Islands Health Study.
(Accepted for publication 30 August 2012.)

Not surprisingly research has focused on access to

INTRODUCTION
Dental services are one of the least subsidized areas
of health in Australia,1 and it has been argued that
this has resulted in service rationing by limiting the
access to and the range of dental services supplied by
both private and public dental services.2 Public
funded dental care for adults is limited to those who
hold health concession cards which are issued by Cen-
trelink, an agency of the Australian Governments
Family Assistance Office.2 Health care card holders
are means tested largely by income and include aged
pensioners. Access is limited by triaging for priority
care, waiting times for general dental care and the
scope of services is narrowed to routine dental ser-
vices. Private dental care for adults is rationed by
availability of providers, some queuing and by the fee
of alternative services.
192
dental care in terms of the difficulties encountered
and on associations with poor oral health outcomes.
For example, health care card holders who visit public
dental clinics are at least twice as likely to experience
toothache, to avoid certain foods and to suffer from
the social embarrassment of bad teeth, compared to
non-card holders.3 Low income adults without private
insurance are more likely to have had all their teeth
extracted than high income adults with insurance.4
Longitudinal studies have investigated the association
between routine dental care and oral health-related
quality of life (OHRQoL), but these have been limited
to older adults,58 and/or subjects with an oral disad-
vantage,5,8,9 where an oral disadvantage was defined
as avoiding laughing or smiling because of unattrac-
tive teeth or gums, avoiding talking to someone
because of unattractive teeth or gums or bad breath,
2013 Australian Dental Association

or being embarrassed by the appearance of teeth or
gums.9
Little attention has been paid to investigating if good
access to dental care is associated with positive OHR-
QoL outcomes. Beck et al.10 defined dental access as the
opportunity for each individual to enter into the dental
care system and to make use of dentists services as the
best way of preventing and controlling oral disease.
The Australian Defence Force (ADF), in maintaining
its members dentally fit to fight, requires each mem-
ber undergo a compulsory annual dental assessment
and any treatment deemed necessary by the treating
dental officer (a qualified dentist). This service is pro-
vided at no charge to the ADF member. Any necessary
treatment whilst on leave is also free.11,12 Outside the
ADF, one would expect that people with good access
to dental care would not have difficulty paying a $100
dental bill, would not have to avoid or delay dental
treatment because of cost, would not be eligible for
public dental care, would have dental insurance, and
would usually visit a dentist for a check-up as opposed
to a problem. The difference between the ADF mem-
bers and people in the community at large with good
access to dental care is that oral health care for ADF
members is institutionalized and enforced. Those ADF
members who do not attend for a dental appointment
without good reason may be fined and a dental officer
needs to sign off that an ADF member is dentally fit
before he/she can be deployed, promoted or undergo
further training. ADF members may have access to
dental care that they may never be able to afford out-
side the ADF. Therefore, access to dental care for ADF
members may be regarded as optimum.
It is important that policy makers, dental health
administrators and dental clinicians know if good
access to dental care is associated with good OHR-
QoL, so that positive outcomes can be expected from
improved access in an environment where health
resources are scarce and needed to be allocated effi-
ciently. It is one thing to know that people with poor
access to dental care are more likely to have poor
OHRQoL. It is quite another to investigate if people
with good access to dental care have good OHRQoL.
The objectives of this study were to determine if ADF
members have better OHRQoL than the general Aus-
tralian population, and if so, whether ADF members
have similar or better OHRQoL as Australians with
good access to dental care.
METHODS
Data sources
The OHRQoL of the survey participants from two
cross-sectional surveys were compared: the Defence
Deployed Solomon Islands Health Study (SI Health
2013 Australian Dental Association
Dental care access and quality of life
Study)13 and the National Survey of Adult Oral
Health 200406 (NSAOH).14
The Solomon Islands (SI) is a Melanesian nation
east of Papua New Guinea. In 2003, SI was in a polit-
ical and security crisis, as a result of longstanding
internal conflicts. The ADF deployed Operation
ANODE in 2003 as part of the Regional Assistance
Mission to the Solomon Islands.
The SI Health Study aimed to determine whether
the health of the veterans of Operation ANODE dif-
fered significantly from similar non-deployed ADF
members. Both current and former ADF members
were invited to participate. A nominal roll included
4089 individuals who were deployed to the Solomon
Islands as part of Operation ANODE and a compari-
son group of 4092 ADF personnel frequency matched
to the deployed group on gender, age group, service
(Navy, Army or Air Force) and service type (Perma-
nent or Reserve), from which 500 deployed and 500
comparison individuals were randomly selected.13
The self-report questionnaire, from which OHIP-14
was obtained, was completed between March and
December 2007. The mean OHIP-14 scores were
similar between the deployed and non-deployed
groups.13
The NSAOH14 used a clustered, stratified, random
sampling design to select a representative sample of
people aged 15 years or more. NSAOH consisted of a
computer-aided telephone interview, an oral epidemi-
ological examination and a questionnaire. Full details
of sampling, examination protocol have been
described elsewhere.15
Dependent variables
The dependent variables were the summary measures
for the OHIP-14. The OHIP-14 has seven content
areas of functional limitation, physical pain, psycho-
logical discomfort, physical disability, psychological
disability, social disability and handicap. Each of the
seven OHIP dimensions consists of two items (or
questions). Each item could have one of five
responses: never, hardly ever, occasionally, fairly
often or very often.
The definitions for summary OHIP-14 measures
were proposed by Slade.16 Frequency of OHIP14
impacts (previously known as prevalence) was defined
as the percentage of subjects who reported one or
more items fairly often and very often. Extent was
summarized for each survey participant by the num-
ber of items reported fairly often or very often.
Severity was the sum of the ordinal responses where
never was coded as 0, hardly ever as 1, occasion-
ally as 2, fairly often as 3 and very often as 4. A
person could have an OHIP-14 severity ranging from
0 to 56. The severity measure using all response cate-
193
LA Crocombe et al.
gories attempts to overcome limitations that may be
inherent in restricting summary scores to arbitrary
thresholds of impacts. A lower OHIP-14 summary
score equates to better OHRQoL.
General health
As general and oral health may be linked, NSAOH
participants were asked to rate their general health as
either excellent, very good, good, fair or poor. Australian Bureau of Statistics (ABS) Estimated Resi-
Respondents who answered either excellent, very
good, good were considered to have good self-per-
ceived general health.
Access to dental care
From the NSAOH, seven putative measures that may
be associated with good access to dental care were
selected: not being eligible for public dental care, not
having a lot of trouble paying a $100 dental bill, not
avoiding or delaying dental care due to cost, usually
visiting a dentist for a check-up, visiting at least annu-
ally, having visited a dentist in the last 12 months and
having private dental insurance.
Demographic covariates
From both surveys, five demographic variables were
selected: gender (male/female), age (18<35, 35<45,
4565 years), country of birth (Australia, elsewhere),
highest education level (degree/teacher/nurse, trade/
diploma/certificate, no post-secondary education),
occupational status (employed or not). The three age
groups chosen were those usually reported by the
ADF. The questionnaire date of 15 September 2007
(mid-term of the survey) was used to calculate the age
for all SI respondents because the date when the ques-
tionnaire was completed was not given for many SI
respondents. People in part-time employment (less
than 35 hours) were categorized as employed.
Statistical analysis
Participants in the NSAOH who were under 18 years
and over 65 years were excluded from the analysis
because the SI sample did not contain anyone in these
age groups. As there was no statistically significant
difference in OHIP-14 severity between members
deployed to the Solomon Islands and the comparison
group of ADF members who were not deployed,13 the
two SI Health Study subgroups were combined into
one for the analysis.
The participation rates, descriptive data and bivari-
ate analysis for each survey are presented. The puta-
tive access variables that were significantly associated
with OHIP-14 summary scores in bivariate and multi-
194
variate analysis were defined as access to dental care
variables. This is not to say that putative access
variables that were not significantly associated with
OHIP-14 summary scores were not related to access
to care, but as they were not related to OHRQoL,
these factors were not able to explain the difference in
OHRQoL between the NSAOH and SI samples. The
NSAOH sample was age/gender/regional location
weighted to that of the Australian population to the
dential Population (ERP) of 2005. To rule out the
possibility that age or gender could be playing a role
in the outcome, the SI sample was also age/gender-
adjusted to ABS ERP 2005. The age/gender-adjusted
SI sample was stratified by those independent vari-
ables shown to be significantly associated with the
OHIP-14 summary indicators in bivariate and multi-
variate analysis with generalized least squares estima-
tion using element-wise regression to ascertain if
factors, other than access to dental care, were influ-
encing the outcome. The SI sample was further
adjusted for these non-access to dental care factors.
OHIP-14 summary indicators were compared with
that from a total NSAOH sample of respondents, then
with a NSAOH subsample with good access to dental
care. A further comparison was made with the OHIP-
14 summary scores of a subsample of NSAOH
respondents with both good access to dental care and
good self-perceived general health.
SUDAAN (Research Triangle Institute, Research
Triangle Park, NC, USA) was used to adjust for com-
plex analytical design and to weight for sampling
probability and non-response in the NSAOH sample.
Ethics approval
NSAOH was reviewed and approved by The Univer-
sity of Adelaides Human Research Ethics Committee.
Approval was received for the data collection stage of
the SI Health Study from Australian Defence Human
Research Ethics Committee.
RESULTS
Participation
Response to the SI self-report health questionnaire was
obtained from 44% (n = 435) of the living sample.
Five were deceased and 19% of individuals could not
be located and contacted in the time available. The
largest proportion of those who could not be located
was ex-ADF members. An overall response rate of
54% was achieved for those who could be contacted.13
There were 14 123 respondents to the NSAOH who
completed the interview and 5505 adults underwent
an oral examination. Of those aged over 18 and
2013 Australian Dental Association
 Dental care access and quality of life

under 65 years, there were 3295 NSAOH Table 2. Percentage of respondents answering very
questionnaire respondents. This was 31.1% of those often, fairly often or occasionally
in the same age group who responded to the tele-
OHIP-14 items SI NSAOH
phone interview. Full details of the survey participa-
tion have been described elsewhere.15 n % n %

Trouble pronouncing words 17 4.4 228 7.8

Taste affected 18 4.7 358 9.5
Descriptive statistics Painful aching 55 14.4 989 29.3
Uncomfortable to eat 49 12.8 1361 39.0
Compared to the NSAOH sample, the SI sample had Been self-conscious 60 15.7 1092 33.0
more males, younger people, more people born in Felt tense 35 9.2 762 21.6
Australia, more trade qualifications but less degree Diet unsatisfactory 8 2.1 246 6.9
Interrupted meals 12 3.2 294 9.3
qualifications, and were more likely to be employed Difficult to relax 20 5.3 443 12.9
(Table 1). Compared to the SI sample, the NSAOH Been embarrassed 34 8.9 774 21.9
sample had a much higher proportion of respondents Been a bit irritable 17 4.5 316 9.8
Difficulty doing jobs 7 1.9 138 4.3
between the ages of 45 and 65 years, and a much Life less satisfying 16 4.2 401 11.9
lower proportion of respondents between the ages of Unable to function 2 0.5 83 2.5
25 to 34 years.
In the NSAOH sample, about one-fifth (22.3%)
were eligible for public dental care, 15.5% had a lot
of difficulty paying a $100 dental bill, over one-third birth (Table 3). Age was not significantly associated
(36.8%) avoided or delayed dental treatment due to with the OHIP-14 severity in either sample. Gender,
cost, just under half (48.2%) had private insurance, education level and occupational status were not sig-
half (50.6%) visited a dentist at least once a year, nificantly associated with OHIP-14 severity in the SI
over 40% (43.1%) usually visited a dentist for a sample, while they were in the NSAOH sample.
problem, over half (57.7%) had visited a dentist Within the NSAOH, being eligible for public dental
within the last 12 months, and the majority (89.9%) care, having a lot of difficulty paying a $100 dental
reported that their general health was either excel- bill, avoiding or delaying dental care due to cost, not
lent, very good or good. having private dental insurance, usually visiting a den-
The NSAOH sample had a consistently higher per- tist for a problem, and having poor self-perceived gen-
centage of respondents who answered very often, eral health were all significantly associated with
fairly often or occasionally experiencing negative higher OHIP-14 severity scores than their counter-
impacts from their teeth, gums or dentures on the 14 parts. However, frequency of, and time since last den-
OHIP-14 items than the SI sample (Table 2). The more tal visit, were not associated with OHIP-14 severity.
common items that were answered as being a problem Hence, people from the NSAOH sample who were
were: uncomfortable to eat, been self conscious, not eligible for public dental care, did not have a lot
painful aching, felt tense and been embarrassed. of trouble paying a $100 dental bill, had not avoided
or delayed dental care due to cost, usually visited a
dentist for a check-up and had dental insurance were
Bivariate analysis
defined as having good access to dental care.
There was a statistically significant difference in Although not shown here, in the NSAOH multivari-
OHIP-14 severity within both samples for country of ate analysis for OHIP-14 severity, the same access to
dental care variables that were statistically significant
in bivariate analysis continued to be statistically sig-
Table 1. Study participant compositions nificant (p < 0.05) with poorer access being associated
Variable SI NSAOH* with higher OHIP-14 severity. The removal of these
dental care access variables decreased the percentage
n % n %
of variation (R2) of the model explained from 0.16 to
Male 376 86.4 1191 50.3 0.06 while the model stayed statistically significant
Age 18<35 years 236 54.2 656 38.2
35<45 years 143 32.9 837 23.7
(p < 0.01).
4565 years 56 12.9 1802 38.1
Country of birth: Australia 355 90.6 2570 79.4
Education: Degree/Teacher/Nurse 97 24.8 1214 37.9 OHIP-14 summary indicators
Trade/Diploma/Certificate 140 35.9 929 29.9
No post secondary education 151 38.7 1025 32.2 The SI sample had much better, i.e. lower, OHIP-
Not employed 14 3.6 1002 26.7 14 summary indicators than the NSAOH sample.
*% but not n were weighted for age, gender and regional location Age and gender-adjustment of the SI Health Study
to ABS ERP 2005. sample resulted in a slight reduction in frequency of
2013 Australian Dental Association 195
LA Crocombe et al.

Table 3. Bivariate comparison of mean OHIP-14 Stratied analysis

severity scores for the SI Health Study and NSAOH
As good access to dental care could be a marker for
by other variables and access to dental care variables
other factors and as country of birth, highest
Variable SI Health Study NSAOH education level and employment status were signifi-
OHIP-14 p OHIP-14 p
cantly associated with the OHIP-14 summary indica-
Severity Severity tors in bivariate analysis, a stratified analysis by these
three variables was undertaken (Table 5). Stratifica-
Gender: 0.85 0.02
Male 2.8 7.0 tion for age and gender was not undertaken because
Female 2.9 8.2 the SI Health Study had been adjusted for age and
Age: 0.34 0.11 gender to match the NSAOH sample and Australian
18<35 years 2.7 7.0
35<45 years 2.6 8.1 population.
4565 years 3.7 8.0 Stratification for country of birth or highest educa-
Country of birth: 0.02 <0.01 tion level did not significantly change any of the
Australia 2.8 7.1
Elsewhere 0.0 8.5 OHIP summary scores, other than in the trade/
Education: 0.68 <0.01 diploma/certificate strata where there was a statisti-
Degree/Teacher/Nurse 2.3 6.0 cally significant increase in OHIP-14 severity in the
Trade/Diploma/Certificate 3.3 8.4
No post secondary 3.0 8.8 age and gender adjusted SI Health Study sample.
education There were only 13 respondents in the age and gender
Employment status: 0.91 0.01 adjusted SI Health Study not employed group and so
Employed 2.9 7.1
Not employed 1.1 9.1 not surprisingly, there was not a significant change in
Eligible for public dental care: <0.01 the OHIP-14 summary scores with stratification for
Yes 10.5 employment status.
No 6.8
A lot of diff. pay $100 <0.01
dental bill:
Yes 12.5 Effect of good access and good general health
No 6.7
Avoid/delayed treatment <0.01 Further adjustment of the SI sample in bivariate anal-
due cost: ysis for country of birth, highest education level and
Yes 10.4 employment status did not appreciably alter the
No 6.0
Have private dental insurance: <0.01 OHIP-14 summary results (Table 6). People in the
Yes 6.6 NSAOH with good access to dental care had statisti-
No 8.7 cally significant lower OHIP-14 summary measures
Frequency of dental visits: 0.52
!12 mths 7.6 than the total NSAOH sample although the summary
12+ mths 7.7 measures were still not as low as that in the age/gen-
Time since last visit: 0.25 der/country of birth/education and employment sta-
!12 /months 7.8
12 + months 7.4 tus-adjusted SI Health Study sample. There was a
Usual reason for dental visit: <0.01 strong connection between self-perceived better
Check-up 5.8 general health and improving OHIP-14 summary mea-
Problem 10.0
Self-perceived general health: <0.01 sures. The NSAOH respondents with good access to
Good 7.1 dental care who also reported good general health had
Poor 13.4 slightly lower OHIP-14 summary scores again. The
OHIP-14 frequency of impacts and severity measures
of NSAOH respondents with both good access to den-
tal care and self-reported good general health were
OHIP-14 impacts and severity scores, though in the not as low as that in the age/gender/country of birth/
case of OHIP-14 extent the reduction was clearer education and employment status-adjusted SI Health
(Table 4). Study sample, but OHIP-14 extent was less clear.

Table 4. Comparison of age/gender adjusted SI Health Study OHIP-14 summary measures with NSAOH
OHIP-14 summary measures SI Health Study Age/gender adjusted SI Health Study NSAOH

Freq. of impacts:
% (95% CI) 7.1 (4.7, 9.5) 2.6 (1.2, 5.4) 18.6 (16.6, 20.7)
Extent:
Mean (95% CI) 0.23 (0.12, 0.34) 0.05 (0.01, 0.10) 0.52 (0.44, 0.59)
Severity:
Mean (95% CI) 2.8 (2.2, 3.4) 2.6 (1.9, 3.4) 7.6 (7.1, 8.1)

196 2013 Australian Dental Association

 Dental care access and quality of life

Table 5. OHIP-14 summary measures stratied by country of birth, level of education and employment status
Socio-demographic variables OHIP-14 summary measures Age/gender adjusted SI Health Study NSAOH: Good access*

Country of Birth:
Australia Freq. of impacts:% (95% CI) 2.1 (1.0, 4.3) 8.3 (4.8, 11.7)
Extent: Mean (95% CI) 0.04 (0.00, 0.07) 0.15 (0.09, 0.20)
Severity: Mean (95% CI) 3.2 (2.1, 4.3) 4.8 (4.2, 5.4)
Elsewhere Freq. of impacts:% (95% CI) 4.6 (0.8, 22.3) 9.9 (2.6, 17.2)
Extent: Mean (95% CI) 0.05 (0.03, 0.12) 0.25 (0.06, 0.44)
Severity: Mean (95% CI) 1.5 (0.5, 2.6) 6.2 (4.5, 7.9)
Education:
Deg./Teach/Nurse Freq. of impacts:% (95% CI) 0.8 (0.2, 3.2) 5.1 (2.2, 7.9)
Extent: Mean (95% CI) 0.00 (0.00, 0.02) 0.09 (0.04, 0.15)
Severity: Mean (95% CI) 2.3 (1.6, 2.9) 4.31 (3.6, 5.0)
Trade/Dip./Cert. Freq. of impacts:% (95% CI) 1.0 (0.4, 2.8) 14.0 (6.7, 21.3)
Extent: Mean (95% CI) 0.02 (0.00, 0.03) 0.27 (0.12, 0.42)
Severity: Mean (95% CI) 4.2 (2.0, 6.4) 6.0 (4.6, 7.4)
No Post Sec. Edu. Freq. of impacts:% (95% CI) 5.5 (2.0, 13.8) 9.0 (1.1, 17.0)
Extent: Mean (95% CI) 0.14 (0.00, 0.27) 0.18 (0.05, 0.30)
Severity: Mean (95% CI) 2.9 (1.7, 4.1) 5.3 (4.0, 6.7)
Employment status:
Employed Freq. of impacts:% (95% CI) 3.3 (1.5, 7.0) 9.9 (6.0, 13.7)
Extent: Mean (95% CI) 0.06 (0.01, 0.11) 0.18 (0.12, 0.25)
Severity: Mean (95% CI) 2.9 (1.7, 4.0) 5.0 (4.3, 5.8)
Not employed Freq. of impacts:% (95% CI) 0.00* 4.0 (0.8,7.2)
Extent: Mean (95% CI) 0.00 (0.00, 0.00)* 0.09 (0.02, 0.17)
Severity: Mean (95% CI) 1.4 (0.8, 2.0)* 5.0 (4.1, 5.9)

*Only 13 in the SI not employed group.

Table 6. Comparison of age/gender adjusted SI Health Study OHIP-14 summary measures with NSAOH
OHIP-14 summary Age/gender adjusted Age/gender/CoB/edu/employ NSAOH NSAOH: Good access* NSAOH: Good
measures SI Health Study adjusted SI Health Study access* and Good
general health**

Freq. of impacts:
% (95% CI) 2.6 (1.2, 5.4) 2.4 (1.6, 3.8) 18.6 (16.6, 20.7) 8.5 (5.4, 11.6) 7.6 (4.7, 10.6)
Extent:
Mean (95% CI) 0.05 (0.01, 0.10) 0.05 (0.01, 0.09) 0.52 (0.44, 0.59) 0.16 (0.11, 0.22) 0.13 (0.09, 0.18)
Severity:
Mean (95% CI) 2.6 (1.9, 3.4) 2.9 (2.2, 3.6) 7.6 (7.1, 8.1) 5.0 (4.4, 5.6) 4.8 (4.2, 5.3)

*Good access = not eligible for public dental care, did not have a lot of trouble paying a $100 dental bill, had not avoided or delayed dental
care due to cost, usually visited a dentist for a check-up and had dental insurance.
**Good general health = excellent, very good or good.

multivariate model, indicated that access to dental

DISCUSSION
Though frequency of, and time since last dental visit,
were not associated with OHIP-14 severity, the
OHIP-14 summary measures of the respondents in the
NSAOH with good access to dental care as measured
by being eligible for public dental care, having a lot
of difficulty paying a $100 dental bill, avoiding or
delaying dental care due to cost, not having private
dental insurance, usually visiting a dentist for a prob-
lem were significantly lower than in the total NSAOH
sample. However, they were not as low as the OHIP-
14 summary measures of the age/gender/country of
birth/highest level of education/employment status
adjusted SI Health Study respondents. These results,
plus the reduction in the percentage of variation
explained (R2 reduced from 0.16 to 0.06) with the
removal of dental access coefficients from the
2013 Australian Dental Association
care was an important factor explaining why ADF
members had lower OHIP-14 severity scores than the
general Australian population. However, other factors
must also be important in the difference in OHRQoL
between ADF members and Australian civilians.
That all three of the age/gender/country of birth/
education and employment status-adjusted SI OHIP-
14 summary scores were lower than the NSAOH
Good Access scores indicated that there was more
influencing the lower SI OHIP-14 summary scores
than good access to dental care. What these additional
influences are remains open to speculation.
One possibility was that ADF members were health-
ier and fitter than the general Australian populace
being subject to ADF physical training and health
care. Supporting this contention was the association
between good general health and good oral health.
197
LA Crocombe et al.
However, the NSAOH respondents who reported
both good access to dental care and good general
health did not have statistically significant better
OHIP-14 summary scores than NSAOH respondents
with good access to dental care, suggesting that a gen-
eral health to oral health association was an unlikely
full explanatory factor. The NSAOH used self-
reported general health which is not as reliable a mea-
sure as a medical examination.
The standout differences between ADF members
and the community at large with good access to den-
tal care is the institutionalized manner of the dental
care and the compulsion for ADF members to take
advantage of the available comprehensive dental ser-
vices.
Access to dental care is a complex issue, many com-
ponents of which have not been measured in this
study. The link of having a lot of difficulty paying a
$100 dental bill, avoiding or delaying dental care due
to cost, and not having private dental insurance with
OHRQoL suggests that for some people cost prevents
them from seeking dental treatment. There are a range
of behavioural, attitudinal, and knowledge-centred
items that impact on access to oral health care ser-
vices. Trust between the operator and recipient and
continuity of care also plays a role as does the avail-
ability, obtainability and comprehensiveness of dental
care. It may be the comprehensiveness component
between dental care received by ADF members and
the Australian population with good obtainability of
dental care that is the difference. The nature of the
dental care supplied to ADF members was not uncon-
strained by dental fees. Although complex treatment
plans are reviewed by senior officers to take into
account the appropriateness of the treatment, the cost
and maintainability, these constraints may not be as
great as those faced among the NSAOH good access
to dental care subgroup.
The studys shortcomings should be discussed. The
two cross-sectional surveys had different composi-
tions. The different composition in gender and age as
well as country of birth, highest education level and
employment status was handled by age and gender
adjustment of the SI Health Study data, while other
differences in the survey compositions were handled
by stratification and further adjustment of the SI
Health Study data. The SI study authors noted that a
potential limitation of the SI study was the potential
response bias caused by missing data.13 The different
dates of the two surveys (NSAOH in 200406 and
the SI Health Study in 2007) could be a complication
because OHRQoL may change over time. However,
this change would be expected to occur over genera-
tions17 and the dates when the two surveys were held
were close enough to not have had an influence on
the results. The OHIP-14 score was self-assessed and
198
therefore were participants perceptions on the
impacts of oral health on their OHRQoL. More
investigation is required in patient perception of their
treatment and their attitude to oral health.
The demographic variables (age, gender, education
level, highest educational level and occupational sta-
tus) that were associated with the OHIP-14 summary
scores in the NSAOH sample have been shown to
affect OHRQoL in previous studies.17,18 Both the
smaller numbers in the SI sample and the good access
to comprehensive dental care may explain why age,
gender, education level and occupational status were
not significantly associated with OHIP-14 severity in
the SI sample in bivariate analysis. Not being signifi-
cant for age in the NSAOH sample may, at least in
part, be explained by the exclusion of those survey
participants aged older than 65 from the analysis. The
age and gender stratification of the SI Health Study
sample resulted in a non-significant lowering of the
OHIP-14 summary scores. This may reflect the lack
of age and gender variation in access within the ADF.
Compulsion to access to dental care would proba-
bly not be acceptable in a democratic society such as
Australia. However, the institutionalized method of
dental access as utilized by the ADF, such as the
greater comprehensiveness of the dental services sup-
plied, warrants further investigation in its applicability
to the population at large.
CONCLUSIONS
ADF members had better OHRQoL than the general
Australian population. Frequency of, and time since
last dental visit, were not associated with OHIP-14
severity. Access to dental care as measured by being
eligible for public dental care, having a lot of diffi-
culty paying a $100 dental bill, avoiding or delaying
dental care due to cost, not having private dental
insurance, usually visiting a dentist for a problem was
important to OHRQoL, but did not explain all the
difference in OHRQoL between ADF members and
civilian Australians.
ACKNOWLEDGEMENTS
Organizations that supported the National Survey of
Adult Oral Health 200406 were the National Health
and Medical Research Council (Grants #299060,
349514, 349537), the Australian Government Depart-
ment of Health and Ageing Population Health Divi-
sion, the Australian Institute of Health and Welfare,
Colgate Oral Care, the Australian Dental Association,
and the US Centers for Disease Control and Preven-
tion.
The research on which this paper is based was under-
taken as part of the Deployment Health Surveillance
2013 Australian Dental Association

Program (DHSP) conducted by the Centre for Military
and Veterans Health (CMVH) at The University of
Queensland and The University of Adelaide. We thank
the Australian Government Departments of Defence
(DoD) and Veterans Affairs (DVA) for their strategic
direction, and the DoD for project funding and access
to the SI data. We acknowledge the past members of
the CMVH Core Research Team who contributed to
the protocol for the DHSP.
The valuable assistance of Anne Ellershaw in the
adjustments of the SI Health Study is acknowledged.
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Address for correspondence:
Dr Leonard Crocombe
Australian Research Centre for Population Oral Health
School of Dentistry
The University of Adelaide
Adelaide SA 5005
Email: leonard.crocombe@adelaide.edu.au
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