published_or_final_version / abstract / Dentistry / Doctoral / Doctor of Philosophy

The aim of this thesis was to investigate socio-economic status in relation to morbidity and mortality, in particular cardiovascular disease among women using data from two population based studies from Sweden. The secondary aim was to explore mechanisms potentially linking socio-economic status to health, assessing for example dental, dietary, and lifestyle factors. Samples: The Population Study of Women in Gothenburg Sweden was begun in 1968-69. A representative random sample of 1,622 women was selected according to date of birth and within the strata 38, 46, 50, 54, and 60 years of age; the participation rate was 90 percent. The Gerontological and Geriatric Population Studies in Gothenburg (H-70) are based on representative samples of 70-year olds from Göteborg, Sweden who participated in a series of cross sectional and longitudinal studies between1971 and 2000. Participation rates ranged from 86 percent for men and 83 percent for women in the 1901/2 birth cohort to 65 percent for men and 69 percent for women in the 1930 birth cohort. Main results: High socio-economic status was associated with a decreased risk for cardiovascular disease [RR 0.49; CI 0.24 – 0.99] in middle aged women independently of risk factors such as smoking and obesity;moreover opposing monotonic trends were seen for mortality from cancer and cardiovascular disease in relation to socio-economic status. Tooth loss, a proxy for cumulative lifetime oral infection was also associated with an increased risk for cardiovascular disease in women independently of socio-economic factors such as the husband’s occupational category, income, and educational level. Among 70-year old cohorts, later-born women were heavier and had higher body mass index than earlier-born women within the high education group only. However, secular increases in waist-hip ratio were seen in both educational groups. Compared to earlier-born cohorts of 70-year old men, later-born cohorts had higher body mass index and cholesterol levels across social strata, and heart disease and diabetes mellitus became more prevalent. Among the elderly, secular trends indicated greater improvements in cardiovascular risk factors among women than men, with exception to smoking and alcohol consumption. Diet quality and food selection were assessed in relation to socio-economic status in the youngest cohort of 70-year olds born in 1930. Socio-economic disparities in diet quality were detected in men but not in women. Conclusions: From a public health perspective, it is suggested that risk factor patterns should be investigated in association with socio-economic status in order to expose health inequalities, and to develop more equitable interventions for cardiovascular disease prevention.

Objetivo: Estudos demonstram progressos na promoção da equidade em certos níveis da provisão de serviços no SUS. O objetivo deste trabalho foi verificar a aplicação deste princípio constitucional na provisão de serviços públicos odontológicos no Estado do Paraná, partindo do conceito de equidade vertical descrito na legislação brasileira. Método: Este estudo ecológico analisou indicadores de alocação de recursos, oferta e utilização dos serviços odontológicos para municípios do Paraná, 2003. Os dados foram obtidos através de relatórios administrativos, referências bibliográficas, e bancos oficiais disponibilizados na Internet. Utilizando estatísticas não paramétricas, através do programa SPSS 8.0 1997, analisou-se a associação entre indicadores de serviços odontológicos e de condição socioeconômica. Resultados: Identificou-se tendência redistributiva dos recursos federais transferidos aos municípios para Atenção Básica, intensificada a partir do lançamento do Programa Saúde da Família. Observou-se ainda tendência pró-equidade na oferta e utilização dos serviços odontológicos em Atenção Básica. Porém, quando um indicador de capacidade de resposta do sistema de saúde foi considerado, duas situações ocorreram: para municípios com sistemas de saúde melhor avaliados, a provisão de serviços odontológicos associou-se positivamente com os indicadores socioeconômicos; para os demais verificou-se associação negativa. O PSF apresentou características mais equânimes do que outras políticas de saúde bucal. Conclusões: Foram identificados progressos quanto à equidade na provisão de serviços públicos odontológicos no Paraná, associados principalmente com a implantação do PSF com equipes de saúde bucal. Argumenta-se que estes progressos estão relacionados com a capacidade de alguns municípios com piores condições de vida desenvolverem boas respostas dos sistemas de saúde. / Objective: Studies have shown progresses on the promotion of equity in the provision of some health services in the context of SUS. This study aimed to verify if this constitutional principle has been applied to the provision of dental public services in the state of Paraná, considering the concept of vertical equity as described in the Brazilian law. Methods: This ecological study assessed resources, supply and utilization of dental services in towns of Paraná, 2003. Data were obtained from administrative reports, bibliographic references, and official databases available on web. The appraisal of association between indices assessing dental services and socioeconomic status used non parametric statistics, performed by the SPSS 8.0 1997 software. Results: A redistributive trend was identified for federal resources addressed to municipalities for primary health care. The supply and utilization of dental services in units of primary health care also presented a pro-equity trend. However, when considering an index of responsiveness of health systems, two situations were identified: for towns with better-off health systems, the provision of dental services was positively associated with socioeconomic indices; while the remaining towns presented a negative association. The Health Family Program (PSF) presented a more equitable feature than other dental health policies. Conclusions: Progresses on the promotion of equity in the provision of dental public services at Paraná were identified, mainly associated to the implementation of PSF with dental teams. They were discussed as associated with the ability of some municipalities presenting poorer life conditions developing good answers for their health systems.

A problemática deste trabalho foi originada pela recente criação do Hospital de Ensino Odontológico da Faculdade de Odontologia da Universidade Federal do Rio Grande do Sul. Para tanto, foram pesquisadas quais formas de caracterização jurídica poderiam ser mais adequadas para a gestão do HEO visando apurar alternativas de desburocratização de processos de aquisições e contratação de pessoal. A partir dessa pesquisa são discutidas três alternativas: Organizações Sociais, Fundações de Apoio e Órgão Auxiliar com destaque orçamentário. Também é proposta uma sistemática para apoiar a gestão de custos do hospital com a finalidade de manter a instituição sustentável econômico e financeiramente. A sistemática preliminarmente proposta está estrutura num roteiro com 7 fases: (i) Compreensão da estrutura organizacional da empresa; (ii) Identificação dos centros de custos; (iii) Identificação dos recursos consumidos pelos centros de custos e distribuição dos custos pelos centros de custos; (iv) Identificação das atividades desenvolvidas na instituição; (v) Quantificação dos recursos consumidos pelas atividades desenvolvidas detalhando os insumos e custos fixos; (vi) Análise dos resultados; (vii) Proposição de melhorias. Por fim são apresentados os resultados possíveis de serem implementados, conclusões e propostas de melhorias e de trabalhos futuros sobre o tema. / The problematic of this work was originated by the recent creation of the Dental Teaching Hospital of the Faculty of Dentistry of the Federal University of Rio Grande do Sul. For this purpose, it was investigated which forms of juridical characterization could be more adequate for the management of HEO in order to determine alternatives of debureaucratization of procurement processes and hiring of personnel. Based on this research, three alternatives were discussed: Social Organizations, Support Foundations and Auxiliary Organ with budgetary emphasis. A system was also proposed to support the hospital's cost management in order to keep the institution economically and financially sustainable. The systematics preliminarily proposed is structure in a script with 7 phases: (i) Understanding of the organizational structure of the company; (ii) Identification of cost centers; (iii) Identification of resources consumed by cost centers and distribution of costs by cost centers; (iv) Identification of the activities carried out at the institution; (v) Quantification of the resources consumed by the activities developed detailing the inputs and fixed costs; (vi) Analysis of results; (vii) Proposals for improvements. Finally, this study presents the possible results to be implemented, conclusions and proposals for improvements and future work on the theme.

Establishment of risk factors, and mechanisms involved in preterm (premature) birth is important for society. Despite efforts to find the cause(s), a significant proportion of preterm birth is of unknown aetiology. Maternal infection has been implicated and oral infection in the form of periodontal (gum) disease has also been suggested as a risk factor for preterm birth (OPenbacher et at, 1996). The aim of this study was to examine the possible relationship between maternal periodontal disease and the delivery of preterm infants with associated low birthweight in East London. This was an unmatched case-control study with 187 cases (mothers whose infant weighed < 2500g, gestational age < 37 weeks (preterm low birthwieght (PLBW)), and 532 controls (mothers whose infant weighed z 2500g, gestational age z 37 weeks). Risk factor information for prematurity and low birthweight were collected from Maternity notes and a structured questionnaire. Maternal periodontal disease levels were measured by: Community Periodontal Index, periodontal probing pocket depths and a bleeding index. Analysis was by logistic regression. The study population was derived from a multiethnic inner city population the predominant groups being Bangladeshi (51.9%) and white Caucasian (25.9%). No differences were found between the periodontal status of the case and control mothers for any of the periodontal indices. The risk for PLBW decreased significantly (p=0.02) with increasing mean periodontal probing pocket depth (crude OR 0.83[95% CI 0.68, 1.00]). After controlling for pre-pregnancy hypertension, smoking, alcohol consumption, maternal age, ethnic group and mother's education this risk decreased further (OR 0.78[95% CI 0.63, 0.96]). No evidence was found for increased risk of PLBW with maternal periodontal disease as measured in this study population. Promotion of oral health by healthcare workers is important, but these results did not support a specific drive to improve the periodontal health of pregnant women as a means of decreasing adverse pregnancy outcomes.

Submitted by Jean Medeiros (jeanletras@uepb.edu.br) on 2016-03-17T12:20:28Z No. of bitstreams: 1 PDF - Iris Sant´Anna Araujo Rodrigues.pdf: 1428280 bytes, checksum: c5f3406ca09ecfd863453aaab7889ec0 (MD5) / Approved for entry into archive by Secta BC (secta.csu.bc@uepb.edu.br) on 2016-07-22T13:33:31Z (GMT) No. of bitstreams: 1 PDF - Iris Sant´Anna Araujo Rodrigues.pdf: 1428280 bytes, checksum: c5f3406ca09ecfd863453aaab7889ec0 (MD5) / Made available in DSpace on 2016-07-22T13:34:19Z (GMT). No. of bitstreams: 1 PDF - Iris Sant´Anna Araujo Rodrigues.pdf: 1428280 bytes, checksum: c5f3406ca09ecfd863453aaab7889ec0 (MD5) Previous issue date: 2013-05-13 / The oral health of individuals deprived of liberty has been proven to be unsatisfactory due to the negligence prior to prison, as well as to the limited dental care provided in the prison environment. OBJECTIVE: To assess the oral health statuses of individuals deprived of liberty in prisons in the state of Paraíba by analyzing dental caries experience, tooth loss, use and need for prosthetic rehabilitation as well as use of dental services. METHODS: This was a cross sectional study carried out in two prisons of the state of Paraíba in the period between June and August 2012. The sample, selected for convenience, consisted of 192 subjects, being 127 males (66,5%). The data collection instrument was prepared as an adaptation for the population under study of the form used in the 2010 Oral Health National Survey (SB Brazil). Data were statistically analyzed by means of the Pearson’s chi-square test, Fisher’s exact test, and Kruskal-Wallis test with comparisons. In order to evaluate the association between categorical variables, a 5% significance level (p <0.05) and 95% CI were adopted. RESULTS: In the female population analyzed, the mean tooth loss was found to be 11 (36 teeth), which was the DMFT component showing the highest mean. Significant association was verified tooth loss with satisfaction with oral health (p=0,049), self-perception of needing use dental prosthesis (p=0,001), the hassle of brushing teeth (p=0,005), difficulty speaking (p=0,002) and difficulty in performing dayto-day activities (p=0,025). Regarding the use and need for prosthesis, it was observed that 29.2% of prisoners wore any type of prosthesis, all considered unsuitable for use, and 78.5% of them were in need of prosthetic rehabilitation. As to the use of dental services, only one of the prisoners said that had never visited a dentist in her lifetime. Of those who underwent consultation, 71.9% had had the last dental appointment less than a year, being half of the consultations held in prison, and dental extraction was the reason for the last visit in 40.6% of the cases. With regard to the male population the value of DMFT was 19.72. About to its components, it was observed that the decay component had the highest mean (11.06 ± 5.37), followed by the missing (7.20 ± 7.23) and filled (1.45 ± 2.45) components respectively. Significant association verified between DMFT with value 22-32 and the oral health variables (p=0,002), difficulty speaking (p=0,024), ashamed to speak (p=0,004) and smile (p=0,001). Only two prisoners affirmed that had never visited a dentist in their lifetimes. Of those who underwent dental consultation, 80% had had their last appointment less than a year, being the majority of visits held in prison (80%), and restorative treatment (32%), followed by odontogenic pain (26.4%) and extraction (17.6%) were the major reasons for such appointments. CONCLUSION: The oral health status of the population studied was found to be precarious, with high number of missing teeth and untreated caries, although most of these individuals had used dental services. The results allowed concluding that dental care for this population was insufficient, thus requiring attention focused on health promotion and problem-solving, in order to improve these individuals’ oral health and consequently quality of life and health. / A saúde bucal de indivíduos em privação de liberdade tem se apresentado de forma precária, como resultado da negligência com a saúde bucal, anteriormente a prisão, bem como pelos escassos serviços odontológicos prestados, quando no ambiente prisional. OBJETIVO: Avaliar a condição bucal de privados de liberdade, em penitenciárias do Estado da Paraíba, analisando a experiência de cárie dentária, perda dentária, o uso e a necessidade de reabilitação protética, bem como a utilização de serviços odontológicos. MÉTODO: Tratou-se de um estudo transversal, realizado em duas penitenciárias do Estado da Paraíba, no período de junho a agosto de 2012. A amostra, selecionada por conveniência, foi composta por 192 indivíduos, sendo 127 do sexo masculino (66,1%). O instrumento de coleta de dados foi elaborado a partir de uma adaptação, para a população em estudo, do formulário utilizado na Pesquisa Nacional de Saúde Bucal (SB Brasil) de 2010. Foram utilizados os testes estatísticos Qui-quadrado de Pearson, Exato de Fisher, e o Kruskal-Wallis. Para avaliar a associação entre as variáveis categóricas adotou-se o nível de significância de 5% (p<0,05) e IC95%. RESULTADOS: Na população feminina, a média geral da perda dentária foi de 11, 36 dentes, representando o componente do índice CPOD com a média mais elevada. Foi verificada associação significativa da perda dentária com a satisfação com a saúde bucal (p= 0,049), autopercepção da necessidade de uso de prótese (p < 0,001), incômodo ao escovar os dentes (p = 0,005), dificuldades em falar (p = 0,002) e dificuldades em realizar tarefas rotineiras (p = 0,025).Com relação ao uso e necessidade de prótese, verificou-se que 29,2% das presidiárias utilizavam algum tipo de prótese, todas consideradas inadequadas para uso, e que 78,5% das reclusas necessitavam de reabilitação protética. Quanto à utilização de serviços odontológicos, apenas uma das presidiárias afirmou nunca haver consultado um dentista durante toda a vida. Das que se consultaram, 71,9% realizou a última consulta odontológica há menos de um ano, com metade destas realizadas no presídio, e a extração dentária sendo o motivo da última consulta para 40,6% das consultadas. Na população masculina, o valor médio do índice CPOD foi de 19,72. Com relação aos seus componentes, observa-se que o componente cariado apresentou a maior média (11,06 ± 5,37), seguido dos componentes perdido (7,20 ± 7,23) e obturado (1,46 ± 2,45), respectivamente. Foi verificada associação estatisticamente significativa entre CPOD com o valor entre 22 a 32, e as variáveis satisfação com saúde bucal (p =0,002), dificuldade para falar (p=0,024), vergonha ao falar (p=0,004) e sorrir (p<0,001). Quanto a utilização de serviços odontológico, apenas dois presidiários afirmaram nunca haver consultado um dentista durante toda a vida. Dos que se consultaram, 80% realizou a última consulta odontológica há menos de um ano, com a maioria dos atendimentos ocorrendo no presídio (80%), sendo o tratamento restaurador (32%), seguido da dor odontogênica (26,4%) e exodontia (17,6%), os principais motivos destes atendimentos CONCLUSÃO: A condição bucal da população estudada revelou-se precária, com elevado número de dentes perdidos e com cárie não tratada, muito embora grande parte destes indivíduos tenha utilizado serviços odontológicos no último ano.

Objetivo: Estudos demonstram progressos na promoção da equidade em certos níveis da provisão de serviços no SUS. O objetivo deste trabalho foi verificar a aplicação deste princípio constitucional na provisão de serviços públicos odontológicos no Estado do Paraná, partindo do conceito de equidade vertical descrito na legislação brasileira. Método: Este estudo ecológico analisou indicadores de alocação de recursos, oferta e utilização dos serviços odontológicos para municípios do Paraná, 2003. Os dados foram obtidos através de relatórios administrativos, referências bibliográficas, e bancos oficiais disponibilizados na Internet. Utilizando estatísticas não paramétricas, através do programa SPSS 8.0 1997, analisou-se a associação entre indicadores de serviços odontológicos e de condição socioeconômica. Resultados: Identificou-se tendência redistributiva dos recursos federais transferidos aos municípios para Atenção Básica, intensificada a partir do lançamento do Programa Saúde da Família. Observou-se ainda tendência pró-equidade na oferta e utilização dos serviços odontológicos em Atenção Básica. Porém, quando um indicador de capacidade de resposta do sistema de saúde foi considerado, duas situações ocorreram: para municípios com sistemas de saúde melhor avaliados, a provisão de serviços odontológicos associou-se positivamente com os indicadores socioeconômicos; para os demais verificou-se associação negativa. O PSF apresentou características mais equânimes do que outras políticas de saúde bucal. Conclusões: Foram identificados progressos quanto à equidade na provisão de serviços públicos odontológicos no Paraná, associados principalmente com a implantação do PSF com equipes de saúde bucal. Argumenta-se que estes progressos estão relacionados com a capacidade de alguns municípios com piores condições de vida desenvolverem boas respostas dos sistemas de saúde. / Objective: Studies have shown progresses on the promotion of equity in the provision of some health services in the context of SUS. This study aimed to verify if this constitutional principle has been applied to the provision of dental public services in the state of Paraná, considering the concept of vertical equity as described in the Brazilian law. Methods: This ecological study assessed resources, supply and utilization of dental services in towns of Paraná, 2003. Data were obtained from administrative reports, bibliographic references, and official databases available on web. The appraisal of association between indices assessing dental services and socioeconomic status used non parametric statistics, performed by the SPSS 8.0 1997 software. Results: A redistributive trend was identified for federal resources addressed to municipalities for primary health care. The supply and utilization of dental services in units of primary health care also presented a pro-equity trend. However, when considering an index of responsiveness of health systems, two situations were identified: for towns with better-off health systems, the provision of dental services was positively associated with socioeconomic indices; while the remaining towns presented a negative association. The Health Family Program (PSF) presented a more equitable feature than other dental health policies. Conclusions: Progresses on the promotion of equity in the provision of dental public services at Paraná were identified, mainly associated to the implementation of PSF with dental teams. They were discussed as associated with the ability of some municipalities presenting poorer life conditions developing good answers for their health systems.

Estudos epidemiológicos são a única forma de propiciar uma visão do estado de saúde bucal e necessidades de tratamento de uma população, e as possíveis relações entre os fatores ambientais e a prevalência de cárie. Estudos desta natureza, no Brasil e no mundo, tem sido dirigidos a grupos de estudantes da rede pública ou trabalhadores da indústria ou comércio. Estretanto, face à situação atual de alto desemprego e um grande número de crianças fora da rede escolar, usou-se uma metodologia que permitiu o sorteio de quarteirões de todos os bairros urbanos da cidade de Bauru. Todas as residências dos quarteirões sorteados foram visitadas e 1839 foram examinadas. No levantamento epidemiológico foram examinados 6.539 indivíduos de mais de 3 anos de idade, que foram classificados quanto à idade, sexo, classe socio-economica, nível de escolaridade e atenção odontológica recebida nos últimos doze meses prévios ao exame. Baseados na análise estatística dos resultados, pode-se concluir que: 1 - O padrão de saúde bucal nas faixas etárias testadas, em relação ao número de pacientes isentos de cárie, CPOD, última visita ao dentista, dentes restaurados e cariados mostrou não have diferenças estatisticamente significantes entre os sexos. Entretanto, houve diferenças estatisticamente significantes entre os sexos em relação ao número de dentes perdidos no sub-grupo de 35-44 anos, tendo o sexo feminino perdido mais dentes que o masculino. 2 - O padrão de saúde bucal na faixa etária de 3-4 anos de idade mostrou diferenças estatisticamente significantes entre as classes sociais, tendo as de nível sócio-econômico mais elevado mostrado maior número de crianças com CPOD igual a zero. Já nas faixas etárias de 5-6 e 12-13 anos, esta diferenã não foi observada. Quando o CPOD e o número de dentes perdidos foram considerados para o grupo 12-13 anos, não houve diferença estatisticamente significante entre as distintas classes sociais. Para a faixa etária de 35-44 foi observada uma diferença estatisticamente significante quando ao número de dentes perdidos, sendo que as classes mais privilegiadas perderam menos dentes que as demais. No sub-grupo de 12-13 anos houve diferença estatisticamente significante, tanto para dentes perdidos, sendo que as classes mais privilegiadas perderam menos dentes que as demais. No sub-grupo de 12-13 anos houve diferença estatisticamente significante, tanto para dentes restaurados, quando para dentes cariados. As classes mais privilegiadas mostraram maior número de dentes restaurados, enquanto as demais mostraram maior número de cariados. As comparações entre os nossos dados e as metas estabelecidas pelo OMS para o ano 2.000 apontam para a necessidade do aumento de 38% para 50% de crianças isentas de cárie, a diminuição do CPOD aos 12 anos, de 4,87 para 3 e o aumento do percentual de indivíduos com todos os dentes aos 18 anos, de 51% para 85%. Certamente estes índices não serão conseguidos dentro do modelo atual de atendimento. Atitudes firmes necessitam ser tomadas para reverter o quadro atual. / A sampling survey may be the only feasible method of collecting the relevant data on disease distribution for use in planning and evaluating the communities dental status, dental need and how these states are influenced by the enviroment. Epidemiological investigations in the world and Brazil have been generally directed to more accessible population groups such as school age children or organized groups like factory workers. Howevwe, with the particular situations wich face the population nowadays such as high inflation rate, unemplyment, and a great number of children out of the school system, the sampling selection as performed in two stages. In the first stage, blocks of all the urban districts that divide the city were randomly selected. In the second stage, all the dwellings in each block were selected. Of the 1,927 families visited, 1,839 agreed to be examined, representing a response rate of 95,4 per cent. Examinations were provided for 6,598 individuals from 1,839 families. The subjects were between the ages of 3 and 92 years-old. The individuals were classified according to sex, age, educational level, socio-economic status and having received dental treatment in the last 12 months previous to the examination. To assess the oral health of each individual, information about dentition status and treatment need, prosthetic status and denture requirements as well as conditions needing immediate attention were obtained according the criteria proposed by WHO. According to the experimental conditions of this investigation and based upon on the statistical analysis of the data, the following conclusions were drawn: 1- No significant difference was found by sex in the DMFT score, last visit to the dentist, caries free children, filled or decay score. However, significant differences were detected by sex in the M-D score among the 35-44 age goup, and females presented higher numbers of missing teeth than males. 2 - Significant differences was found among children aged 3-4 in the number of caries free by socio economic status. In the same way, among people of 35-44 years of age, significant difference was found in the number of missing teeth by socio economic status and the M-T is inversely related to the social class; the higher social class the lower the mean number. Significant differences were detected in both the number of filled and decayed teeth among people aged 12-13. With higher social class, the number of filled teeth was higher and the number of decayed teeth was lower. However, no significant differences were found by socio economic status in both DMFT score and missing teeth among the age-groups 5-6, 12-13. 3 - By the comparasion between our data and the WHO\'s desire for the year 2000 to achieve their goals, it will be necessary to improve both the number of carie free children from 38% to 50%, and the number of people who had all of their teeth from 51% to 85%. It will also be necessary at the same time to decrease the DMFT from 4,87 to 3 for 12 years-old people. These goals will not be achieved with the dental care system available nowadays. A change in attitude must be taken to improve the current situation.

Many people in the United States have untreated dental disease due to a lack of dental insurance, a lack of oral health knowledge, and a lack of priority placed on dental health. Despite an increase in dental service use by Medicaid recipients as a result of local programs, children enrolled in Medicaid often have low rates of use of dental services. Using the health literacy framework of the Paasche-Orlow and Wolf (POW) model, the purpose of this study was to explore to the relationship between oral health literacy of parents and dental service use for children enrolled in Medicaid and the differences in use rates between preventive and restorative services. A cross-sectional research design was employed within a convenience sample of parents who presented to a nonprofit clinic for a medical appointment. Participants completed a demographic profile, an oral health questionnaire, and REALD-30 survey. Responses were correlated with dental claims retrieved from 1 reference child for each parent. Pearson's correlation revealed no significant relationship between oral health literacy and dental service utilization, r = -.056 (p = .490). An ANOVA revealed no difference in utilization between preventive and restorative services, F (2, 149) = .173, p = .841, ç2 = .002. However, high rates of use for restorative services were observed, suggesting a high prevalence of tooth decay in children. Although this study did not find a significant relationship between oral health literacy and dental utilization, barriers continue to exist that contribute to the high rates of tooth decay in children enrolled in Medicaid. This study impacted social change by highlighting the importance of preventive care in reducing the prevalence of tooth decay.

Oral diseases including dental caries and periodontal disease are among the most prevalent and costly diseases in Australia today. Around 5.4% of Australia’s health dollar is spent on dental services totalling around $2.6 billion, 84% of which are delivered through the private sector (AIHW 2001). The other 16% is spent providing public sector services in varied and inadequate ways. While disease rates among school children have declined significantly in the past 20 years the gains made among children are not flowing on to adult dentitions and our aging population will place increasing demands on an inadequate system into the future (AHMAC 2001). Around 50% of adults do not received regular care and this has implications for widening health inequalities as the greatest burden falls on lower income groups (AIHW DSRU 2001). The National Competition Policy agenda has initiated, Australia-wide, reviews of dental legislation applying to delivery of services by dentists, dental specialists, dental therapists and hygienists and dental technicians and prosthetists. The review of the Victorian Dentists Act 1972, was completed first in 1999, followed by the other Australian states with Queensland, the ACT and the Northern Territory still developing legislation. One of the objectives of the new Victorian Act is to ‘…promote access to dental care’. This study has grown out of the need to know more about how dental therapists and hygienists might be utilised to achieve this and the legislative frameworks that could enable such roles. This study used qualitative methods to explore dental health policy making associated with strategies that may increase access to dental care using dental therapists and hygienists. The study used a multiple case study design to critically examine the dental policy development process around the Review of the Dentists Act 1972 in Victoria; to assess legislative and regulatory dental policy reforms in other states in Australia and to conduct a comparative analysis of dental health policy as it relates to dental auxiliary practice internationally. Data collection has involved (I) semi-structured interviews with key participants and stakeholders in the policy development processes in Victoria, interstate and overseas, and (ii) analysis of documentary data sources. The study has taken a grounded theory approach whereby theoretical issues that emerged from the Victorian case study were further developed and challenged in the subsequent interstate and international case studies. A component of this study has required the development of indicators in regulatory models for dental hygienists and therapists that will increase access to dental care for the community. These indicators have been used to analyse regulation reform and the likely impacts in each setting. Despite evidence of need, evidence of the effectiveness and efficiency of dental therapists and hygienists, and the National Competition Policy agenda of increasing efficiency, the legislation reviews have mostly produces only minor changes. Results show that almost all Australian states have regulated dental therapists and hygienists in more prescriptive ways than they do dentists. The study has found that dental policy making is still dominated by the views of private practice dentists under elitist models that largely protect dentist authority, autonomy and sovereignty. The influence of dentist professional dominance has meant that governments have been reluctant to make sweeping changes. The study has demonstrated alternative models of regulation for dental therapists and hygienists, which would allow wider utilisation of their skills, more effective use of public sector funding, increased access to services and a grater focus on preventive care. In the light of theses outcomes, there is a need to continue to advocate for changes that will increase the public health focus of oral health care.