Melbourne Dental School - Theses
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ItemScreening for Type 2 Diabetes Mellitus initiated through the dental setting: a cost-effectiveness analysis( 2019)Background. Diabetes Mellitus (DM) is the fastest growing chronic condition in Australia. Approximately, 30% of DM in Australia is undiagnosed. Early identification may delay or prevent the onset of DM with minimal complication. In the Western Pacific (WP) region, Australia has the highest per capita spending on DM. With the rising cost of healthcare, increasing emphasis is being made to ensure that health interventions are not only practical but also cost-effective that can save resources which otherwise may have to be spent on complication and hospital admission. By stretching the number of contact points between health care providers and individuals seeking care, there is plenty of opportunity for early identification of asymptomatic individuals with Type 2 Diabetes Mellitus (T2DM). With this link between DM and periodontal disease, dentists may have an unrealized opportunity to identify risk groups and refer them to physicians for further care. For any screening activity in the dental setting, the participation of Oral Health Professionals (OHP) is important. Little is known as to how well oral health professionals incorporate into practice on the evidence supporting the link between DM and periodontal disease. Besides that, no previous studies have reported the cost-effectiveness of opportunistic screening using a diabetes risk assessment tool in the dental setting. As such, the aim of the thesis is twofold. To explore the Victorian oral health professionals (OHP) knowledge, attitude and practice (KAP) around DM and to evaluate the overall economic justification of screening for diabetes and pre-diabetes in the dental setting. Methods. A cross-sectional survey of Victorian OHP was conducted. The questionnaire consisted of sociodemographic, practice characteristics and diabetes-related KAP. Descriptive statistics with frequencies and percentages were used to summarize the variables. A Mann-Whitney and Kruskal-Wallis test was performed to determine differences in OHP response to the KAP questions. The screening model consists of a decision tree and a disease progression Markov model to identify the risk of T2DM over a ten-year period. Literature data were used for the risk categorisation and disease transition for health states. The cost-effectiveness of screening was compared to no screening option. A hypothetical population of 40 to 74-year-old Victorian dental patients with no previous history of DM were screened with the Australian type 2 Diabetes Risk Assessment Tool (AUSDRISK). Those identified as high-risk follow-up with the physician for screen diagnosis using Fasting Plasma Glucose (FPG). Based on the previous finding from two-step screening in the dental setting the model made an assumption that 21.5% of the dental patient identified as high risk follow up with the physician. The cost-effectiveness was analysed from a societal perspective. The main outcome measure includes cost per case detected as undiagnosed T2DM, new cases of T2DM. A univariate sensitivity analysis was performed to determine the effect of different physician follow-up rate from the dental setting to identify undiagnosed T2DM. Results. The survey analysis included 197 OHP. General and specialist dentist constitute 65% and 11% of the response and the remainder were dental hygienist and therapist. Around 86% of the OHP showed adequate knowledge of DM. Further 93% and 81% of the OHP expressed positive attitude and practice behaviour towards T2DM screening and management. For OHP to perform chair-side screening for DM, 58% felt it was essential, and 70% felt it was appropriate. More female (67%) and public sector OHP (79%) felt it is important to conduct chair-side screening for T2DM. The majority (65.4%) of the OHP agreed on consent as the most important and insurance coverage as the least important (43%) consideration for T2DM screening. Under model assumption, the number of dental patients identified as undiagnosed T2DM and pre-diabetes were 4,108 (0.3%) and 10,072 (0.8%). The cost incurred for one new case of undiagnosed T2DM and pre-diabetes were AUD 15,508 and AUD 6,325. The Number Needed to Screen (NNS) to identify one new case of undiagnosed T2DM and pre-diabetes were 288 and 117. Among those followed up with the physician, at the end of five years, 81.5% had Normal Glucose Tolerance (NGT), 8.1% had Impaired Fasting Glucose (IFG), 6.9% had T2DM, and the all-cause mortality was 3.5%. At the end of the ten-year period, 10% had T2DM. The overall and disease-free survival was 92.8% and 82.8%. Discussion. Majority of OHPs had adequate knowledge and a positive attitude towards T2DM screening in the dental setting. The survey identified patient willingness as the most important consideration among the OHPs for implementing T2DM screening in the dental setting. The screening model identified several methodological challenges due to incongruent data and unsuitable comparator. Despite that, opportunistic screening with AUSDRISK was found to be neither clinically effective nor cost-effective compared to screening in the medical setting. High screening cost, poor predictive ability of AUSDRISK, low prevalence of the disease, unnecessary physician referral besides uncertain benefits, fear of over diagnosis and poor patient compliance makes screening for T2DM in the dental setting difficult to justify. The model findings are in line with previous estimates on AUSDSRISK as a screening tool. In financially constrained health system resource allocation will need to be based on favourable evidence that screening can reduce disease levels in the community, demonstrate health benefits at an acceptable cost. A two-step opportunistic screening that includes a risk assessment followed by a Point-of-Care (PoC) HbA1c may offer some benefits in the low- and middle-income countries.
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ItemExploring the oral health curriculum in Australian pharmacy schools( 2019)Introduction Poor oral health continues to be prevalent in Australia despite ongoing advancements in oral health knowledge and care. Without innovative strategies to improve the oral health of the population, the quality of life for an increasing number of Australians will be negatively affected as poor oral health extends beyond the mouth and can affect general health and well-being. Beyond the dental clinic setting, pharmacists have been recognised in the literature to have an important role in oral health care. The potential to expand the role of pharmacists as oral health advisors has also been acknowledged. While previous studies explored the knowledge and opinions of pharmacists regarding oral health, no research has been completed to explore the extent of oral health content that is currently included in Australian pharmacy schools’ curricula or on the knowledge and opinions of the pharmacy students who are about to graduate as health professionals. Aim The aim of this study was to investigate the knowledge, attitudes and perceptions towards the role of pharmacists in oral health among final year pharmacy students in Australia, and to investigate the extent of the oral health content in Australian pharmacy curricula. Methods A cross sectional study of pharmacy students across 8 Australian pharmacy courses was undertaken using an anonymous online survey. In addition, semi-structured interviews were conducted with pharmacy course coordinators or convenors to discuss the oral health content in their course curricula. Survey results were analysed using SPSS software (SPSS 25.0, Chicago Il, USA) and the findings summarised using descriptive statistics. Phone interviews were recorded, transcribed verbatim and analysed thematically. Results A total of 45 pharmacy students across the nation completed the online survey. Almost half of the students (48.9%) reported that oral health was not included in their course. Many believed that pharmacists have an important role in oral healthcare, however only 38.9% perceived that pharmacists were appropriately trained to provide oral health education. Most students (91.7%) believed that professional relationships between pharmacists and dental practitioners could be improved, and that pharmacists had the potential to be more involved with preventing oral health issues (86.1%). Three main themes emerged from the course convenor interview study: (1) That pharmacists have a role in oral healthcare, (2) That oral health is being taught in pharmacy courses, however each did so in a varied manner, (3) Lack of space in course curricula is the key barrier for further inclusion of oral health care content in pharmacy courses. Conclusion Overall, the findings of this study provide evidence that the oral health content in pharmacy curricula in Australia is inconsistent, with students indicating that they wanted more education on oral health topics. Both students and course convenors recognised that pharmacists have an important role in oral healthcare. Therefore, pharmacy courses in Australia should consider expanding the coverage of oral health content to provide graduates with the confidence and skills they need to improve the oral health of the community.
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ItemAustralian weightings for the PAR Index( 1994)Critical review of orthodontic treatment results is a necessary procedure in the quest for quality control in orthodontic treatment provision. In order for valid information to be collected in such a review, a reliable method must be utilised. Traditionally, occlusal indices have been the method of choice. The index employed should however be reliable and utilised specifically for the purpose it was designed. This has not been the case in the few early attempts at assessing treatment standards. The PAR Index is an occlusal index designed specifically to fulfil such a purpose. The occlusal features comprising the components of the PAR Index have been weighted to reflect British and American orthodontic opinion. This study validates the PAR index using contemporary Australian orthodontic opinion in terms of the degree an occlusion deviates from the ideal. The resultant weightings may be used to allow valid data collection in quality control studies conducted in Australia.
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ItemEvaluation of changing normative needs for dental care in planning for the delivery of dental care to the Australian adolescent population( 1984)Normative needs represent a potential requirement for the use of dental resources. Therefore, changing normative needs should be anticipated in planning for the delivery of dental care. The aim of this study was to evaluate changing normative needs of the Australian adolescent population for restorative and exodontic treatment over the period 1980 to 1990. A predictive model composed of a population sub-model, disease sub-model, and resource requirements sub-model was developed. The disease sub-model was developed around the prediction of severity of dental caries (DMFT index). The severity of dental caries was predicted to decrease by 33.5 percent over the period. The backlog of untreated dental caries was found to be related to the severity of dental caries. Incidence of dental caries was calculated directly from the predicted severity of dental caries. Cross-sectional incidence overestimated the longitudinal incidence. The backlog and longitudinal incidence of dental caries decreased by 23.6 and 31.2 percent over the period. Backlog was two to three times the longitudinal incidence of dental caries. Backlog and incremental streams of needs were predicted on the basis of backlog and incidence of dental caries. In both streams the total number of teeth in need of treatment (TINOT) was equal to the number of teeth with dental caries plus a proportion of the previously restored teeth at risk of retreatment. In the backlog stream, previously restored teeth were related to the severity and backlog of dental caries. In the incremental stream, previously restored teeth were assumed to approximate the severity of dental caries (DMFT). In both streams a 0.10 proportion of restored teeth at risk one year and age earlier were indicated as requiring retreatment. Backlog TINOT was one-and-a-half to two times incremental TINOT. Over the period backlog TINOT decreased by 26.1 percent and incremental TINOT by 33.0 percent. Teeth in need of treatment were apportioned to individual items of treatment on the basis of a probable case-mix of treatment associated with the predicted severity of dental caries. As severity of dental caries decreased the case-mix of treatment items tended toward less complex items. Resource supply equivalents, rated skill units and 1980 dollars, were used to combine the need for different treatment items into single measures. The decrease in normative need expressed as resource supply was marginally higher than for TINOT. The predicted needs were multiplied by population number at each age and time to represent total population needs, demonstrating the "political-arithmetic" of the measurement and comparison of changing normative needs. The distribution of needs in the Australian adolescent population was investigated by the prediction of the prevalence of dental caries which represented the maximum percentage of the population with any need, and the percentage of the population with active caries in any one year who potentially require treatment. Approximately half the adolescent population have active caries in anyone year. The study demonstrated that changing needs must be correctly defined, predicted, and applied in planning for the delivery of dental care to the Australian adolescent population.