Oral Health Inequalities Dr Mohammed Junaid BDS, MDS (Public Health Dentistry), MFDS RCPS (Glasg.), DDPH RCS (Eng.), AFHEA, PhD Seek Wisdom THE UNIVERSITY OF WESTERN AUSTRALIA Oral Health Centre of Western Australia  **Dr Mohammed Junaid** BDS, MDS (Public Health Dentistry), MFDS RCPS (Glasg.), DDPH RCS (Eng.), AFHEA, PhD The University of Western Australia Oral Health Centre of Western Australia Clinical photo: A photograph of a diverse group of people at a demonstration, with the central figure holding a placard that reads 'ORAL HEALTH FOR ALL!', illustrating the concept of advocacy for universal access to oral healthcare. # Acknowledgement of country I would like to acknowledge the traditional custodians of the land, the Whadjuk Noongar people, in whose land, I have recorded this lecture and pay my respects to elder's past, present and emerging. Including to all those with Indigenous heritage who are listening to this recording.  ### Acknowledgement of Country I would like to acknowledge the traditional custodians of the land, the Whadjuk Noongar people, in whose land, I have recorded this lecture and pay my respects to elder's past, present and emerging. Including to all those with Indigenous heritage who are listening to this recording. Labelled diagram: A circular chart illustrating the Noongar Boodja Six Seasons calendar, divided into six colored segments labeled Birak (December-January), Bunuru (January-February), Djeran (March-April), Makuru (May-June), Djilba (July-August), and Kambarang (September-November). The center includes burning regulation labels: 'BURNING PROHIBITED' in red, 'REQUIRED' in yellow, and 'BURNING PERMITTED' in green. **Learning** **outcomes** - Understand the concept of oral health inequalities/inequities and its relevance to dental practice. - What factors are associated with equitable oral health– the unifying framework. - Inequitable burden of oral diseases in Australia. - Knowing a population framework to tackle oral health inequalities. - Understanding the practice of social dentistry and the role of a dental health professional in providing equitable oral health service. **LEARNING OUTCOMES** Image source: https://ser.msu.edu/spartan-experience-record-101/learning-outcomes/ - Understand the concept of oral health inequalities/inequities and its relevance to dental practice. - What factors are associated with equitable oral health – the unifying framework. - Inequitable burden of oral diseases in Australia. - Knowing a population framework to tackle oral health inequalities. - Understanding the practice of social dentistry and the role of a dental health professional in providing equitable oral health service. *Image source: https://ser.msu.edu/spartan-experience-record-101/learning-outcomes/* - ==The distinction between inequalities and inequities.== - ==The enabling factors and barriers that can promote equity or contribute to inequity.== - ==The dentist’s social responsibilities and the role of social determinants in day-to-day dental practice.== ## Synopsis 1. What are oral health inequalities? 2. What are the determinants of oral health? 3. Relationship between social/ structural determinants and oral health inequities? 4. How does existing determinants that impact oral health/service use? 5. Inequitable burden of oral diseases in Australia. 6. Understanding equitable approaches in managing and preventing oral disease and promoting oral health – population level (Ottawa Charter) 7. Adopting practice of social dentistry – dental practice level   1. What are oral health inequalities? 2. What are the determinants of oral health? 3. Relationship between social/structural determinants and oral health inequities? 4. How does existing determinants that impact oral health/service use? 5. Inequitable burden of oral diseases in Australia. 6. Understanding equitable approaches in managing and preventing oral disease and promoting oral health – population level (Ottawa Charter) 7. Adopting practice of social dentistry – dental practice level > [!note] Lecturer — Lecture Structure > This was the final lecture in a series of four lectures for the public health dentistry component of the Dent 5311 unit. > > - The lecture was recorded in three parts: an introduction to inequalities, inequities and the determinants of oral health; population-level approaches to managing oral health inequality, including the Ottawa Charter; and the practice of social dentistry and the social responsibilities of dentists. > - The lecturer emphasised that oral health problems do not arise entirely within the oral cavity, because non-dental factors can strongly influence oral health outcomes. > - The second recording was identified as particularly relevant to planning a community oral health program and to the assessment task involving development of such a program. Clip art illustration of a yellow emoji face wearing black-rimmed glasses, holding an open brown book, and displaying a surprised expression with wide blue eyes and an open mouth. Clip art illustration of a person lying on a purple rug, reading an open book while holding a green pencil in their mouth. - HEALTH INEQUALITIES - Absolute uneven differences in health outcomes/burden of disease between different population groups or communities - HEALTH INEQUITIES - Subset of inequalities. - Disparities in metrics of health outcomes due to avoidable differences in social, economic, geographical or healthcare resources that are unfair and unjust #### Health Inequalities - Absolute uneven differences in health outcomes/burden of disease between different population groups or communities #### Health Inequities - Subset of inequalities - Disparities in metrics of health outcomes due to avoidable differences in social, economic, geographical or healthcare resources that are unfair and unjust > [!example] Oral Health Differences > Population A may have better oral health, while Population B may have poorer oral health outcomes. > The absolute difference between the two populations represents a health inequality. > [!note] Lecturer — Fairness of Inequalities > The definition of inequality does not, by itself, indicate whether the difference is fair, unfair, avoidable or unavoidable. > [!note] Lecturer — Health Disparities > The term health disparities is commonly used in the United States instead of health inequities. > In the context described in the lecture, disparities and inequities can be used synonymously because both refer to differences in health outcomes resulting from injustice. <font color="black"> 1. <font color="red">Health inequalities vs health inequities – What's the difference?</font> HEALTH INEQUALITIES Absolute uneven differences in health outcomes/ burden of disease between different population groups or communities HEALTH INEQUITIES • Subset of inequalities. • Disparities in metrics of health outcomes due to avoidable differences in social, economic, geographical or healthcare resources that are unfair and unjust Lee H, Kim D, Lee S, Fawcett J. The concepts of health inequality, disparities and equity in the era of population health. Appl Nurs Res. 2020 Dec;56:151367 </font>  #### Health Inequalities - Absolute uneven differences in health outcomes/burden of disease between different population groups or communities #### Health Inequities - Subset of inequalities - Disparities in metrics of health outcomes due to avoidable differences in social, economic, geographical or healthcare resources that are unfair and unjust *Lee H, Kim D, Lee S, Fawcett J. The concepts of health inequality, disparities and equity in the era of population health. Appl Nurs Res. 2020 Dec;56:151367.* Labelled diagram: A Venn-style illustration showing a large outer circle (representing Health Inequalities) containing a smaller, inner shaded circle labeled "HEALTH INEQUITIES". This visualizes the concept from the slide text that health inequities are a subset of health inequalities. # ## 2. Determinants of oral disease | | | | | | | :--- | :--- | :--- | :--- | :--- | | **Structural determinants**<br>(Socioeconomic, political, and environmental context) | **Intermediate determinants**<br>(Social position and circumstances) | **Proximal determinants**<br>(Behaviours and biological factors) | **Outcomes** | | | **Macro-economic policies**<br>**Social and welfare policies**<br>**Trade policies**<br>**Overseas development policies**<br>**Globalisation**<br>**Urbanisation** | **Social class**<br>**Income**<br>**Education**<br>**Gender**<br>**Ethnicity** | **Material circumstances**<br>**Social relationships**<br>**Psychosocial factors**<br>**Health service availability or use**<br>**Environmental setting** | **Diet**<br>**Alcohol consumption**<br>**Tobacco use**<br>**Physical activity**<br>**Hygiene** | **Inflammation**<br>**Infection**<br>**Immune response** | | | | | | **Oral disease and NCD burden** | **Commercial determinants—corporate strategies** Political and economic power and influence &nbsp;&nbsp;&nbsp;&nbsp; Lobbying to influence policy &nbsp;&nbsp;&nbsp;&nbsp; Corporate citizenship &nbsp;&nbsp;&nbsp;&nbsp; Targeted and tailored marketing and promotion strategies &nbsp;&nbsp;&nbsp;&nbsp; Influence on research agenda &nbsp;&nbsp;&nbsp;&nbsp; Influences on social norms and local policies &nbsp;&nbsp;&nbsp;&nbsp; Media influence to distract attention and cause confusion &nbsp;&nbsp;&nbsp;&nbsp; Influence on consumers' choices and behaviours Source: Marco A Peres, Lorna M D Macpherson, Robert J Weyant, Blánaid Daly, Renato Venturelli, Manu R Mathur, Stefan Listl, Roger Keller Celeste, Carol C Guarnizo-Herreño, Cristin Kearns, Habib Benziaan, Paul Allison, Richard G Watt, Oral diseases: a global public health challenge, The Lancet, Volume 394, Issue 10194, 2019, Pages 249-260.  #### Determinants of Oral Disease - **Structural determinants** (Socioeconomic, political, and environmental context): - Macro-economic policies - Social and welfare policies - Trade policies - Overseas development policies - Globalisation - Urbanisation - **Intermediate determinants** (Social position and circumstances): - Social class - Income - Education - Gender - Ethnicity - **Proximal determinants** (Behaviours and biological factors): - Material circumstances - Social relationships - Psychosocial factors - Health service availability or use - Environmental setting - Diet - Alcohol consumption - Tobacco use - Physical activity - Hygiene - Inflammation - Infection - Immune response - **Outcomes**: - Oral disease and NCD burden #### Commercial Determinants — Corporate Strategies - Political and economic power and influence - Lobbying to influence policy - Corporate citizenship - Targeted and tailored marketing and promotion strategies - Influence on research agenda - Influences on social norms and local policies - Media influence to distract attention and cause confusion - Influence on consumers' choices and behaviours *Source: Marco A Peres, Lorna M D Macpherson, Robert J Weyant, Blánaid Daly, Renato Venturelli, Manu R Mathur, Stefan Listl, Roger Keller Celeste, Carol C Guarnizo-Herreño, Cristin Kearns, Habib Benziaan, Paul Allison, Richard G Watt, Oral diseases: a global public health challenge, The Lancet, Volume 394, Issue 10194, 2019, Pages 249-260.* > [!example] Aboriginal Australians and Social Circumstances > Aboriginal Australians have experienced significant challenges and poorer health outcomes, but this should not be attributed simply to being Aboriginal or to biological susceptibility. > > - Abject poverty and intergenerational trauma influence material conditions and other factors affecting health outcomes. > [!note] Lecturer — Material Circumstances > Knowledge alone does not ensure that a person can perform recommended oral health behaviours. > > - During a cost-of-living crisis, purchasing food and keeping dinner on the table may take priority over buying fluoridated toothpaste. > - Living in a remote area may make dental services unavailable, limiting a person’s ability to act on oral health knowledge. - ==Extrinsic sugar and sticky foods== - ==Toothbrushing and use of interdental aids== - ==Deep tooth fissures== > [!note] Lecturer — Oral Disease Origins > Oral diseases do not arise only because of conditions within the mouth. The lecturer cautioned that highly biomedical undergraduate training can create the impression that both oral health problems and their solutions are located entirely within the mouth. > > - Oral health outcomes reflect an interplay of biological, behavioural, social, economic, political, environmental and healthcare factors. > [!note] Lecturer — Commercial Food Promotion > Commercial influences can make less healthy foods appear more affordable and attractive than healthier alternatives. > > - Grocery-store promotions may favour chocolates and biscuits over apples, spinach and other healthier foods. > - It may be unrealistic to advise a person experiencing poverty to purchase healthier foods when less healthy products are cheaper and more heavily promoted. > - Political donations do not necessarily determine policy, but commercial and political influence forms part of the context in which policies are developed. A labelled diagram illustrating the determinants of oral disease through a cascading flowchart of blue boxes leading to an outcome circle, overlaid by a yellow section representing commercial determinants. The columns are labeled: Structural determinants (Socioeconomic, political, and environmental context), Intermediate determinants (Social position and circumstances), Proximal determinants (Behaviours and biological factors), and Outcomes. Dental caries – Keyes triad-Does it explain everything?? Personal factors Oral environmental factors Factors that directly contribute to caries development Sociodemographic status Education Behaviour •Oral hygiene •Snacking Saliva •Buffer capacity •Composition •Flow rate Protein Dental sealants Fluoride Oral health literacy Attitudes Chewing gum Plaque pH Microbial species Income Protein Dental insurance coverage Sugars •Clearance rate •Frequency Ca²⁺ PO₄³⁻ Time Bacteria in biofilm Antibacterial agents Tooth Diet •Amount •Composition •Frequency Caries Source: Selwitz, R. H., et al. (2007). "Dental caries." The Lancet 369(9555): 51-59.   Does the Keyes triad explain everything? #### Personal Factors - Sociodemographic status - Education - Income - Dental insurance coverage - Oral health literacy - Attitudes - Behaviour: - Oral hygiene - Snacking #### Oral Environmental Factors - Saliva: - Buffer capacity - Composition - Flow rate - Protein - Dental sealants - Fluoride - Chewing gum - Plaque pH - Microbial species - Antibacterial agents #### Factors Directly Contributing to Caries Development - Bacteria in biofilm - Tooth - Time - Ca²⁺, PO₄³⁻ - Sugars: - Clearance rate - Frequency - Diet: - Amount - Composition - Frequency - Caries *Source: Selwitz, R. H., et al. (2007). "Dental caries." The Lancet 369(9555): 51-59.* > [!note] Lecturer — Beyond the Keyes Triad > Dental caries cannot be explained solely by the presence of Streptococcus mutans, low salivary flow or deep fissures. These factors may be necessary or may accelerate progression, but they are not sufficient on their own to explain all dental caries. > > - The development of caries also involves biological, behavioural, social and structural factors. > [!note] Lecturer — Life Course Effects > Social determinants are not static; they change as people grow and experience different life circumstances. Earlier experiences can continue to affect oral health later in life. > > - Severe childhood poverty may be followed by financial wealth, while teeth still show the effects of caries during tooth development and eruption, limited dental care and inadequate access to fluoridated toothpaste. A cartoon illustration showing anthropomorphized teeth and bacteria, where smiling white teeth represent healthy structures and purple spiky characters with mischievous expressions represent the cariogenic bacteria mentioned in the slide text. This figure is a labelled diagram consisting of three concentric layers and a central Venn diagram to illustrate the multifactorial nature of dental caries. The outermost pink layer represents 'Personal factors' (e.g., Sociodemographic status, Income), the middle green layer represents 'Oral environmental factors' (e.g., Saliva, Fluoride), and the inner blue section displays 'Factors that directly contribute to caries development' as four intersecting circles: Tooth, Diet, Time, and Bacteria in biofilm. Social determinants of oral health  Social determinants of oral health. Labelled diagram: A conceptual model of social determinants of oral health, depicted as nested concentric ovals representing influences at the community level (e.g., dental care system characteristics, physical safety), family level (e.g., socioeconomic status, culture), and child level (e.g., biologic endowment, development). These layers surround a central 'Oral Health' outcome, which is linked to a Venn diagram showing the intersection of Microflora, Host and teeth, and Substrate (diet). 3. What has this got to do with oral health equity/inequality? – The unifying framework **Enabling Processes** Rights Empowerment Opportunities Resources Autonomy Respect Supportive family environment Social inclusion Access to support **Structural Determinants** (Socioeconomic, political and environmental context) | Macro economic policies | | Social, welfare and education policies | | Cultural and social norms | | Early life | **Intermediate Determinants** (Social Position and circumstances) | Social class | Material circumstances | | Income | Social relationships | | Education | Psychosocial factors | | Social standing | Health services | **Proximal Determinants** (Behavioural and biological factors) | Diet | Inflammation | | Alcohol | Infection | | Tobacco | Immune response | | Hygiene | | **Disabling Processes** Adverse childhood events Lack of opportunities Abuse & violence Stress Marginalisation Discrimination Stigma Harassment Social exclusion Poor self esteem Oral Health Source: Watt, R., Venturelli, R. & Daly, B. Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream. *Br Dent J* **227**, 49–54 (2019)  #### Enabling Processes Rights, empowerment, opportunities, resources, autonomy, respect, supportive family environment, social inclusion, access to support. #### Framework Components - **Structural Determinants** (Socioeconomic, political and environmental context): - Macro-economic policies - Social, welfare and education policies - Cultural and social norms - Early life - **Intermediate Determinants** (Social position and circumstances): - Social class - Income - Education - Social standing - Material circumstances - Social relationships - Psychosocial factors - Health services - **Proximal Determinants** (Behavioural and biological factors): - Diet - Alcohol - Tobacco - Hygiene - Inflammation - Infection - Immune response #### Disabling Processes Adverse childhood events, lack of opportunities, abuse & violence, stress, marginalisation, discrimination, stigma, harassment, social exclusion, poor self-esteem. #### Outcome - Oral Health *Source: Watt, R., Venturelli, R. & Daly, B. Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream. Br Dent J 227, 49–54 (2019)* > [!note] Lecturer — Framework Connections > The lecturer stated that a unifying framework explaining the determinants of oral disease and oral health was published in 2019 in the *Lancet*. > > - The structural, intermediate and proximal categories are connected rather than separate: structural determinants influence intermediate determinants, which influence proximal determinants. > - These determinants combine to influence oral health outcomes. > - Commercial determinants may also affect the structural, intermediate and proximal levels. Labelled diagram: A conceptual framework illustrating the determinants of oral health, organized into three tiers of influence—Structural Determinants (e.g., Macro economic policies), Intermediate Determinants (e.g., Social class, Income), and Proximal Determinants (e.g., Diet, Tobacco)—which flow towards an 'Oral Health' outcome. The model is flanked by 'Enabling Processes' at the top (including Rights, Empowerment) and 'Disabling Processes' at the bottom (including Adverse childhood events, Discrimination), with arrows indicating their impact on the central determinants. # 4. Factors that influence access to dental services - **First phase** - **Lay referrals and interventions** - **Health care organization** - **Geographic availability** - **Ability to pay** - **Self-care, self-help** - **Geographical availability** - **Second phase** ## Process Boxes | Perception of need | Identify a source of care | Gain entry to health care | Obtain health care | Achieve a desirable outcome | | :--- | :---: | :---: | :---: | :---: | ## Factors (Left Column) - Cultural variation - Presentation and knowledge of disease - Triggers - Perceptions of costs and benefits ## Factors (Right Column - Under "Obtain health care") - Fit between health care and patient: - Availability - Affordability - Acceptability - Accessibility - Accommodation Source: Daly B, Batchelor P, Treasure ET, Watt RG, Essentials in Dental Public Health, Second Edition, Oxford university press  #### Influencing Phases - **First phase**: - Lay referrals and interventions - Health care organization - Geographic availability - Ability to pay - Self-care, self-help - **Second phase** #### Process Continuum 1. Perception of need 2. Identify a source of care 3. Gain entry to health care 4. Obtain health care 5. Achieve a desirable outcome #### Modifying Factors - **Pre-entry factors**: - Cultural variation - Presentation and knowledge of disease - Triggers - Perceptions of costs and benefits - **Care acquisition factors (Fit between health care and patient)**: - Availability - Affordability - Acceptability - Accessibility - Accommodation *Source: Daly B, Batchelor P, Treasure ET, Watt RG, Essentials in Dental Public Health, Second Edition, Oxford university press.* > [!note] Lecturer — Intention to Seek Care > Physical access to a dental service is not sufficient for someone to obtain care. > - A person must develop an intention and willingness to seek care. > - This behaviour is influenced by the combined effect of the determinants discussed throughout the lecture. > [!note] Lecturer — Barriers to Access > Access to dental care is a process in which multiple factors operate together. > > - Decisions to seek care may be affected by knowledge, social circumstances, income, education and social relationships. > > - Geographic location, service availability, affordability and perceived need can also influence the decision. > > - Even when a person wants to seek care, structural or practical barriers may interrupt the process. > [!note] Lecturer — Service Availability > Geographic and financial barriers can substantially restrict access to dental care. > > - Remote residence may limit access because services are unavailable or insufficient, particularly in outback areas. > > - Financial hardship may prevent a person from visiting a dentist, and the cost is especially important because most dental care is paid for by individuals. > > - Dentistry is outside Medicare, while public dental services for adults are sparse, limited and unevenly distributed. Labelled diagram: A flowchart illustrating a two-phase model of access to dental services. The First phase includes factors such as 'Lay referrals and interventions', 'Health care organization', 'Geographic availability', 'Ability to pay', and 'Self-care, self-help' which influence the initial steps of 'Perception of need', 'Identify a source of care', and 'Gain entry to health care'. The Second phase focuses on 'Obtain health care' and 'Achieve a desirable outcome', influenced by the 'Fit between health care and patient' (Availability, Affordability, Acceptability, Accessibility, Accommodation). Figure 2: Proportion of children aged 6–14 who have experienced decay in permanent teeth by selected population groups, 2012–14 | | | | :--- | :--- | | **Indigenous status** | | | Australia | | | Indigenous | | | Non-Indigenous | | | **Remoteness** | | | Major cities | | | Inner regional | | | Outer regional | | | Remote/very remote | | | **Household income** | | | Low | | | Medium | | | High | | | | | 0 | 5 | 10 | 15 | 20 | 25 | 30 | Per cent | 35 | 40 | 45 | | | | Source: National Child Oral Health Study 2012–14, published in Ha et al. 2016. | | Australian Institute of Health and Welfare (2023) **_Oral health and dental care in Australia_**, AIHW, Australian Government, accessed 15 January 2024.  #### Proportion of Children Aged 6–14 with Decay in Permanent Teeth (2012–14) *Unit: Percent (0–45%)* - **Indigenous status**: - Australia - Indigenous - Non-Indigenous - **Remoteness**: - Major cities - Inner regional - Outer regional - Remote/very remote - **Household income**: - Low - Medium - High *Source: National Child Oral Health Study 2012–14, published in Ha et al. 2016.* *Australian Institute of Health and Welfare (2023) Oral health and dental care in Australia, AIHW, Australian Government, accessed 15 January 2024.* > [!note] Lecturer — Untreated Decay > Untreated decay is particularly useful for understanding oral health inequality. > > - It reflects both disease experience and whether treatment has been obtained. > - Measuring oral health burden may also include permanent tooth decay, primary tooth decay, periodontal disease, and tooth loss. Chart: A horizontal bar chart illustrating the proportion of children aged 6–14 who have experienced decay in permanent teeth, categorized by Indigenous status (Indigenous, Non-Indigenous), Remoteness (Major cities, Inner regional, Outer regional, Remote/very remote), and Household income (Low, Medium, High). The x-axis represents percentages ranging from 0 to 45. **Who bears the cost for dental care?** In 2011-12, individuals were responsible for 57% of the total cost of dental care compared with only 12% of the cost of all other health services (Figure 5).⁴⁶ Figure 5: Total expenditure by source⁴⁶ Source: Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.  In 2011–12, individuals were responsible for 57% of the total cost of dental care compared with only 12% of the cost of all other health services. *Figure 5: Total expenditure by source.* *Source: Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.* > [!note] Lecturer — Dental Costs > Most dental care in Australia is paid for by the individual because dentistry is outside Medicare. > > - These arrangements create challenges for people who cannot afford private dental care. > - The current cost-of-living crisis may cause dental care to be prioritised below food and household expenses. > [!note] Lecturer — Service Distribution > Adult public dental services in Australia are sparse, particularly in outback areas. > > - Services may be limited and sporadic. > - Uneven distribution can make appropriate dental care unavailable or difficult to reach, contributing to poorer oral health. Chart: Two pie charts titled 'All other health' and 'Dental' compare total expenditure by source, with a shared legend identifying six categories: Individuals (light green), Health insurance funds (pale green), Australian Government insurance premium rebates (medium green), Australian Government (teal), State, territory and local government (dark blue), and Other (navy). The visual illustrates that individuals bear a much larger share of dental care costs compared to all other health services. Distribution of adult public dental services— Australia  Distribution of adult public dental services — Australia. Map of Australia illustrating the geographic distribution of adult public dental services, where dark red shaded regions represent State Suburbs (SSC 2016) containing these facilities and a red circle marks the location of Alice Springs. Inequalities in oral health care eventually lead higher preventable hospitalisations Number of Acute potentially preventable hospitalisations per 100,000 population 2012-13 Pyelonephritis (kidney infection) 2.87 Dehydration and gastroenteritis 2.83 Dental conditions 2.76 Cellulitis 2.00 Ear, nose and throat infections 1.63 Convulsions and epilepsy 1.50 Appendicitis with generalised peritonitis 0.37 Gangrene 0.31 Perforated/bleeding ulcer 0.23 Pelvic inflammatory disease 0.20 Figure 6: Number of acute PPH separations per 100,000 population² # of Potentially Preventable Dental Hospitalisations FY11 – FY21, Australia-wide +14% Covid-19 lockdown delayed Dental care FY16 FY17 FY18 FY19 FY20 FY21 Source: Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA’S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016. Parliament of Australia, Senate enquiry 2023-24: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Dental_Services_in_Australia/DentalServices/Final_report/Chapter_2_-_A_system_in_decay   Inequalities in oral health care eventually lead to higher preventable hospitalisations. #### Number of Acute Potentially Preventable Hospitalisations (PPH) per 100,000 Population (2012–13) - Pyelonephritis (kidney infection): 2.87 - Dehydration and gastroenteritis: 2.83 - Dental conditions: 2.76 - Cellulitis: 2.00 - Ear, nose and throat infections: 1.63 - Convulsions and epilepsy: 1.50 - Appendicitis with generalised peritonitis: 0.37 - Gangrene: 0.31 - Perforated/bleeding ulcer: 0.23 - Pelvic inflammatory disease: 0.20 #### Potentially Preventable Dental Hospitalisations (FY11–FY21, Australia-wide) - Overall increase: +14% - COVID-19 lockdown delayed dental care (tracked across FY16, FY17, FY18, FY19, FY20, FY21) *Source: Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA’S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.* *Parliament of Australia, Senate enquiry 2023-24: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Dental_Services_in_Australia/DentalServices/Final_report/Chapter_2_-_A_system_in_decay* > [!note] Lecturer — Preventable Hospitalisations > Potentially preventable hospitalisations can indicate how effectively primary care is functioning. > > - When dental conditions lead to hospitalisation, this may indicate that earlier or more accessible primary dental care was not obtained. > - The lecturer also stated that dental conditions ranked even higher among chronic conditions. > [!example] Covid Cavities > The COVID-19 pandemic and associated lockdowns restricted people’s ability to attend dental appointments, but did not stop oral bacteria or existing caries from progressing. > > - Existing caries could worsen while people were unable to see a dentist. > - Potentially preventable dental hospitalisations subsequently increased, a situation referred to as “Covid cavities”. > - The example illustrates how government policies and broader structural conditions can directly affect oral disease and hospitalisation. > [!note] Lecturer — Oral Health Determinants > Health inequalities are uneven differences in health outcomes or disease burden, whereas health inequities are inequalities produced by injustice and avoidable unfair circumstances. > > - Oral health is shaped by proximal, intermediate, structural, commercial, enabling, and disabling determinants. > - Social determinants include non-dental factors that contribute to poor oral health or promote good oral health. > - Access depends on a person’s propensity and ability to seek care, as well as the availability and affordability of services. > - Despite overall improvements, the burden of oral disease in Australia remains inequitable. > [!note] Lecturer — Next Recordings > The next recording was to address positive and population-level approaches to tackling oral health inequalities, including the Ottawa Charter and its principles. > > - The Ottawa Charter was identified as important for planning a community oral health program. > - A later recording would address social dentistry and the dentist’s role in responding to existing inequalities. > - This would include social responsibilities and incorporating social determinants of health into daily dental practice. Chart: A horizontal bar chart ranking acute potentially preventable hospitalisations per 100,000 population in 2012-13. The conditions are listed by frequency, with 'Dental conditions' highlighted in light green at a rate of 2.76, placing it third highest behind Pyelonephritis (kidney infection) at 2.87 and Dehydration and gastroenteritis at 2.83. Chart: A line graph titled '# of Potentially Preventable Dental Hospitalisations FY11 – FY21, Australia-wide' displays a trend from FY16 to FY21. The data shows a steady increase until FY19, followed by a sharp decline in FY20 and a steep rise to the highest point in FY21. A pink shaded region highlights the period labeled 'Covid-19 lockdown delayed Dental care,' with an annotation indicating a '+14%' increase between FY19 and FY21. #Lets revise..|**Image OCR: Extract all text from this PDF page image. Use the PDF text for context to enhance accuracy. Prioritize image text but use PDF text to resolve ambiguities. If the text is in a different colour, format it as bold. Errors may occur with the pdf text — if it is obviously corrupted or error-ridden then ignore it.** **FORMAT RULES:** - Format tables in HTML (only tables, NOTHING ELSE). - Format flowcharts as tables as best as possible. - All other formatting must be in Markdown. **FIGURE/IMAGE RULES (CRITICAL):** - If a figure is an image with only labels or sparse text, output ONLY a brief 2-5 word description wrapped in tags. Example: - If the text on the page only makes sense in the context of a figure or image (labels, names with no context), treat the whole page as a figure: wrap a single brief description in tags and output NOTHING ELSE. - NEVER output image descriptions as plain text outside of tags. - NEVER output standard HTML image tags like <img src="...">. - NEVER output <div>, <figure>, <section>, or other HTML wrapper tags (except tables). - NEVER explain your reasoning, reference the instructions, or include meta-commentary. Output ONLY the OCR text and/or descriptions. **DO NOT ADD ANYTHING TO THE TEXT ITSELF. YOU ARE ONLY TRANSCRIBING/FORMATTING. DO NOT SAY ANYTHING ELSE** **FIGURE CAPTION EXTRACTION:** This page has detected figure regions. Each is given an arbitrary LABEL (BOX_A, BOX_B, BOX_C, ...) followed by the exact box it occupies (grounding coords 0-1000, top-left origin) and a rough position: BOX_A: [51,54,210,246] (left half, upper area) BOX_B: [11,279,241,598] (left half, middle area) BOX_C: [6,661,267,950] (left half, lower area) These labels (BOX_A, BOX_B, ...) are internal identifiers ONLY. They have NO relationship to any number, letter, or ordering printed on the slide (for example a "1., 2." list, or "A) B)" panel letters). Do NOT match a label to the slide's own numbering or panel letters. After transcribing ALL of the OCR text above, append a JSON object mapping each LABEL to the CAPTION of the figure occupying THAT label's box — the verbatim on-screen text that physically labels the figure at that location (usually directly beneath or beside it: a diagnosis name, a before/after descriptor, or a caption line). - Match strictly by the box location/coordinates, NOT by any number or letter printed on the slide. - Copy the caption verbatim from the page (preserve casing and punctuation). - Do NOT use unrelated body bullets, definitions, or headings; do NOT invent or summarize the image. - If a figure has no on-screen caption, use "" (many figures legitimately have none). - Captions are TEXT ONLY — never coordinates, never labels. Wrap the JSON object between these EXACT markers (on their own lines): Continue to transcribe ALL on-page text normally, including any caption sentences — the captions stay in the OCR transcription; this JSON is an additional copy.    Let's revise. Illustration of an open book and pen Cartoon of a boy reading Cartoon cat reading a book [^1]: Original PDF page 1: [[L4 Oral health inequalities_recording 1_slides.pdf#page=1|L4 Oral health inequalities recording 1 slides, p.1]] [^2]: Original PDF page 2: [[L4 Oral health inequalities_recording 1_slides.pdf#page=2|L4 Oral health inequalities recording 1 slides, p.2]] [^3]: Original PDF page 3: [[L4 Oral health inequalities_recording 1_slides.pdf#page=3|L4 Oral health inequalities recording 1 slides, p.3]] [^4]: Original PDF page 4: [[L4 Oral health inequalities_recording 1_slides.pdf#page=4|L4 Oral health inequalities recording 1 slides, p.4]] [^5]: Original PDF page 5: [[L4 Oral health inequalities_recording 1_slides.pdf#page=5|L4 Oral health inequalities recording 1 slides, p.5]] [^6]: Original PDF page 6: [[L4 Oral health inequalities_recording 1_slides.pdf#page=6|L4 Oral health inequalities recording 1 slides, p.6]] [^7]: Original PDF page 7: [[L4 Oral health inequalities_recording 1_slides.pdf#page=7|L4 Oral health inequalities recording 1 slides, p.7]] [^8]: Original PDF page 8: [[L4 Oral health inequalities_recording 1_slides.pdf#page=8|L4 Oral health inequalities recording 1 slides, p.8]] [^9]: Original PDF page 9: [[L4 Oral health inequalities_recording 1_slides.pdf#page=9|L4 Oral health inequalities recording 1 slides, p.9]] [^10]: Original PDF page 10: [[L4 Oral health inequalities_recording 1_slides.pdf#page=10|L4 Oral health inequalities recording 1 slides, p.10]] [^11]: Original PDF page 11: [[L4 Oral health inequalities_recording 1_slides.pdf#page=11|L4 Oral health inequalities recording 1 slides, p.11]] [^12]: Original PDF page 12: [[L4 Oral health inequalities_recording 1_slides.pdf#page=12|L4 Oral health inequalities recording 1 slides, p.12]] [^13]: Original PDF page 13: [[L4 Oral health inequalities_recording 1_slides.pdf#page=13|L4 Oral health inequalities recording 1 slides, p.13]] [^14]: Original PDF page 14: [[L4 Oral health inequalities_recording 1_slides.pdf#page=14|L4 Oral health inequalities recording 1 slides, p.14]] [^15]: Original PDF page 15: [[L4 Oral health inequalities_recording 1_slides.pdf#page=15|L4 Oral health inequalities recording 1 slides, p.15]] [^16]: Original PDF page 16: [[L4 Oral health inequalities_recording 1_slides.pdf#page=16|L4 Oral health inequalities recording 1 slides, p.16]] [^17]: Original PDF page 17: [[L4 Oral health inequalities_recording 1_slides.pdf#page=17|L4 Oral health inequalities recording 1 slides, p.17]]