International Journal of

Environmental Research
and Public Health

Article
Oral Health of Australian Adults: Distribution and Time Trends
of Dental Caries, Periodontal Disease and Tooth Loss
Najith Amarasena * , Sergio Chrisopoulos, Lisa M. Jamieson and Liana Luzzi

Australian Research Centre for Population Oral Health (ARCPOH), Adelaide Dental School, Faculty of Medical
and Health Sciences, The University of Adelaide, Adelaide 5000, Australia;
sergio.chrisopoulos@adelaide.edu.au (S.C.); lisa.jamieson@adelaide.edu.au (L.M.J.);
liana.luzzi@adelaide.edu.au (L.L.)
* Correspondence: najith.amarasena@adelaide.edu.au

Abstract: This study was conducted to describe the distribution and trends in dental caries, peri-
odontal disease and tooth loss in Australian adults based on the findings of the National Study
of Adult Oral Health 2017–18. A cross-sectional study of a random sample of Australians aged
15+ years was carried out, employing a three-stage stratified probability sampling design. Data
were collected via online survey/telephone interviews using a questionnaire to elicit self-reported
information about oral health and related characteristics. Participants were then invited to have an
oral examination, conducted by calibrated dental practitioners following a standardised protocol
in public dental clinics. A total of 15,731 Australians aged 15+ years were interviewed, of which
5022 dentate participants were orally examined. Results showed that nearly one third of Australian
adults had at least one tooth surface with untreated dental caries and, on average, 29.7 decayed,





 missing or filled tooth surfaces per person. Almost 29% of adults presented with gingivitis while
Citation: Amarasena, N.; the overall prevalence of periodontitis was 30.1%. Overall, 4% of adults were edentulous while, on
Chrisopoulos, S.; Jamieson, L.M.; average, 4.4 teeth were lost due to pathology. Poorer oral health was evident in Australians from
Luzzi, L. Oral Health of Australian lower socioeconomic backgrounds, indicating socioeconomic inequalities in oral health. Time trends
Adults: Distribution and Time Trends revealed that dental caries experience and tooth retention of Australian adults has improved over
of Dental Caries, Periodontal Disease 30 years, while periodontal health has deteriorated between 2004–06 and 2017–18. These findings
and Tooth Loss. Int. J. Environ. Res. can be used to assist policy makers in planning and implementing future oral healthcare programs.
Public Health 2021, 18, 11539. https://
doi.org/10.3390/ijerph182111539 Keywords: dental caries; oral health; periodontal disease; tooth loss

Academic Editor: Paul B. Tchounwou

Received: 15 September 2021

1. Introduction
Accepted: 28 October 2021
Published: 2 November 2021 Traditionally, oral health has been defined as “a state of being free from mouth and
facial pain, oral diseases and disorders that limit an individual’s capacity in biting, chewing,
Publisher’s Note: MDPI stays neutral smiling, speaking and psychosocial well-being” [1]. In view of more emphasis given to
with regard to jurisdictional claims in ‘absence of disease’ in this definition, a broader description for oral health has recently been
published maps and institutional affil- suggested [2]. This broader definition advocates the definitions adopted by global and
iations. national organizations and reiterates the importance of recognising dentistry as an arena
providing care and supporting oral health, rather than purely treating disease. According to
the new definition, oral health is multi-faceted and includes the ability to speak, smile, smell,
taste, touch, chew, swallow and convey a range of emotions through facial expressions with
Copyright: © 2021 by the authors.
confidence and without pain, discomfort, and disease of the craniofacial complex, as well as
Licensee MDPI, Basel, Switzerland. being a fundamental component of general health and physical and mental wellbeing [2,3].
This article is an open access article While proponents of this new definition aimed to reach consensus on a universal definition
distributed under the terms and of oral health, this has not eventuated [4]. Global oral health aims to provide optimal
conditions of the Creative Commons oral health for all and to eradicate global health inequalities via health promotion, disease
Attribution (CC BY) license (https:// prevention and appropriate oral care strategies that incorporate common factors and
creativecommons.org/licenses/by/ resolutions, and recognise that oral health is integral to overall health [4].
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 11539. https://doi.org/10.3390/ijerph182111539 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 11539 2 of 14

Oral diseases predominantly comprise tooth decay (dental caries), gingival (periodon-
tal) disease and oral cancers [5,6]. Dental caries, which is considered the most prevalent
chronic disease worldwide [7], occur when microorganisms of dental biofilm (a sticky
colourless film of bacteria build-up on the tooth surfaces) start to metabolize fermentable
carbohydrates in the diet, in particular, free sugars, into acidic by-products. These acidic
by-products can locally destroy (demineralise) the hard tooth structure (enamel and den-
tine) and initiate dental caries’ development. Frequent consumption of high free sugar and
insufficient exposure to fluoride are the main contributing factors for dental caries [5–7].
While making enamel more resistant to acid attack, fluoride mainly acts topically to inhibit
demineralisation through its presence at low concentrations in the oral fluids [5,7]. With
periodontal disease, tissues that support and surround the tooth (gums, periodontal liga-
ment and alveolar bone) are affected mainly by dental biofilm accumulated at the neck of
the tooth where the tissues meet the gums (gingival margin), causing gingivitis (bleeding
of the gums) [5,6]. This may lead to a more destructive form of disease, i.e., periodontitis,
in susceptible individuals, particularly among those who are immunocompromised [5,6].
Poor oral hygiene, accompanied by inadequate plaque removal, is the main cause of peri-
odontal disease, while tobacco smoking is a major risk factor associated with periodontal
disease [5,6]. If left untreated, both dental caries and periodontal disease lead to tooth loss,
and these two oral diseases are the major causes of tooth loss. Oral diseases affect nearly
3.5 billion people universally. Of them, approximately 2.3 billion and 530 million present
with dental caries of the permanent and primary (baby) dentitions, respectively [8,9]. In
2010, severe periodontitis was ranked as the sixth-most prevalent health condition, afflict-
ing 743 million people globally with an incidence of 701 cases per 100,000 person years [10].
Although the prevalence of severe tooth loss declined from 4.4% in 1990 to 2.4% in 2010,
158 million people worldwide were edentulous in 2010 [10].
In regard to the oral health status of Australians (based on data published prior
to the National Study of Adult Oral Health 2017–18), 42% and 24% of children aged
5–10 years and 6–14 years, respectively, had experienced dental caries in their primary
teeth and permanent teeth, whereas almost a quarter of Australian dentate adults aged 15
and over had untreated decay [11]. The prevalence of periodontal disease in Australian
dentate adults aged 15 years and over was 22.9%, whilst 4.4% of the adult population were
edentulous [11]. The present study aims at describing the distribution and time trends of
dental caries, periodontal disease and tooth loss in Australian adults based on findings
from the National Study of Adult Oral Health 2017–18 (NSAOH 2017–18).

2. Materials & Methods

Study methodology, including computation of sample size, has been described in
previous studies [12,13]. Briefly, a cross-sectional study of a random sample of Australians
aged 15 years and over was carried out across all Australian states and territories, employ-
ing a three-stage stratified probability sampling design. The first stage of selection included
sampling of postcodes within states/territories, mainly by means of systematic sampling
with probability of selection proportional to the number of households within the postcode,
followed by selecting individuals aged 15 years and over within selected postcodes from
the Medicare database provided by the Australian Government Department of Human Ser-
vices (DHS). Accordingly, the final sample size required 15,200 interviews to be conducted,
in order to complete 7200 oral examinations.
Interviews were conducted online or by telephone (CATI—computer-assisted tele-
phone interview) by trained interviewers using a questionnaire based on previous sur-
veys [11,14]. Self-reported information about oral health and related characteristics such
as age, sex, Indigenous identity, residential location, schooling/educational qualifications,
eligibility for public dental care, dental insurance and usual reason for a visit to the dentist
was collected. Calibrated dental practitioners conducted oral examinations following a
standardised protocol in public dental clinics run by the relevant state or territory dental
health services. Inter-examiner reliability relative to a gold standard examiner was assessed
Int. J. Environ. Res. Public Health 2021, 18, 11539 3 of 14

by conducting replicate pairs of examination with 101 study participants. Dentate partici-
pants who consented to an examination were included for oral examinations. Although
there were nine measures of oral health status, as described in detail elsewhere [15], the
current analysis was confined to assessment of coronal caries (dental decay in tooth crown),
gingivitis and periodontal destruction, and presence/absence of teeth (tooth loss).

2.1. Dental Caries (Coronal Caries)

All teeth present were subdivided into five tooth surfaces and assessed for dental
caries using visual criteria without an explorer. The five tooth surfaces were mesial, buccal,
distal, lingual and occlusal (for back teeth: premolars and molars)/incisal (for front teeth:
incisors and canines). The mean number of decayed tooth surfaces per person denotes the
severity, or burden, of untreated dental caries in people. The number of decayed, missing
and filled tooth surfaces (DMFS) indicates lifetime experience of dental caries in a given
person, since it has been regarded that cavities in enamel cannot heal and treatment of
dental decay, either as a filling or extraction, leaves a permanent sign of disease [12].

2.2. Periodontal Disease

Clinical assessment for periodontal disease was conducted among those who had no
medical contraindications for periodontal probing. Gingivitis and periodontitis were the
two types of diseases assessed, as per the following criteria:
Gingivitis: Inflammation of the marginal gingival tissues around six index teeth
(if present: the most anterior molar tooth in each dental quadrant + right upper central
incisor + left lower central incisor) were assessed using the gingival index of Loe and
Silness [16].
Periodontitis: The US National Health and Nutrition Examination Survey (NHANES)
methods were employed to assess periodontal tissue destruction [17]. Assessments were
made on three aspects (mesio-buccal, mid-buccal and disto-buccal) of all teeth present,
except third molars (wisdom teeth), using a periodontal probe. To describe the prevalence
of moderate and severe periodontitis, a case definition developed by the US Centers for
Disease Control and Prevention (CDC) and the American Academy of Periodontology
(AAP) was used [17]. Accordingly, moderate periodontitis was defined as the presence of
either at least two proximal sites not on the same tooth with attachment loss of 4 mm or
more, or at least two such sites that had pockets of 5 mm or more. Severe periodontitis was
defined as having at least two proximal sites not on the same tooth with attachment loss of
6 mm or more, plus at least one periodontal pocket with a depth of 5 mm or more.
Tooth loss: Complete tooth loss (edentulism) was assessed based on the answer
to the following interview question: ‘Do you have any natural teeth?’, with response
categories of ‘Yes’/’No’. Existing natural teeth included crowns and caps, while dental
implants were not considered natural teeth. For participants aged less than 45 years, the
examiners distinguished between missing teeth that had been removed due to dental decay
or periodontal disease and teeth missing due to any other reason. For participants aged
45 years or more, a removed or an absent tooth was recorded as missing.
To ensure representativeness of the target population, all data were weighted to
population benchmarks [13]. Data files were managed and summary variables were
computed using SAS software version 9.4 (SAS 9.4; SAS Institute Inc., Cary, NC, USA).
Proportions, means and their 95% confidence were calculated where relevant.

3. Results
A total of 15,731 Australians aged 15 years and over completed an interview, and of
them, 5022 dentate participants were orally examined. This resulted in overall participation
rates of 39.7% (interview) and 33.6% (examination). Intra-class correlation coefficients (ICC)
calculated to assess inter-examiner reliability were above 0.9 and 0.7 for diagnosing dental
caries and periodontal disease, respectively. Weighting ensured that, approximately, an
equal proportion of males (49.2%) and females (50.8) participated in the study. Given that
Int. J. Environ. Res. Public Health 2021, 18, 11539 4 of 14

oral health status varies considerably with age, population estimates were calculated for
four age groups—15–34 years, 35–54 years, 55–74 years and ≥75 years. Tables 1–7 present
the distribution of dental caries, periodontal disease and tooth loss, and Figures 1–3 depict
the time trends of these three conditions.

Table 1. Proportion of Australian dentate adults aged 15 years and over with untreated coronal caries.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
% (95% CI)
All people 5022 32.1 (29.6, 34.7) 30.3 (25.7, 35.2) 35.4 (31.1, 40.0) 32.2 (28.2, 36.6) 24.5 (18.8, 31.3)
Sex
Male 2249 49.6 (46.9, 52.2) 34.7 (31.2, 38.4) 32.1 (25.1, 40.0) 37.1 (30.9, 43.7) 38.5 (33.2, 44.2) 22.3 (14.8, 32.2)
Female 2773 50.4 (47.8, 53.1) 29.5 (26.3, 32.9) 28.4 (23.2, 24.2) 33.8 (28.3, 39.8) 26.0 (20.3, 32.6) 26.2 (18.3, 36.0)
Indigenous identity
Non-Indigenous 4937 98.3 (97.4, 98.9) 32.1 (29.5, 34.7) 30.6 (26.0, 35.6) 35.4 (31.1, 40.0) 31.6 (27.6, 35.9) 24.5 (18.8, 31.3)
Indigenous 84 1.7 (1.1, 2.6) * 27.8 (15.0, 45.5) * 17.6 (6.8, 38.3) * 36.1(15.5, 63.4) 72.8 (45.1, 89.7) * 22.4 (2.6, 75.9)
Residential location
Major cities 2969 72.7 (69.1, 76.0) 31.8 (28.7, 35.1) 28.0 (23.4, 33.2) 35.3 (29.9, 41.2) 34.9 (29.4, 40.7) 25.7 (18.2, 34.9)
Rural/remote 2053 27.3 (24.0, 30.9) 32.6 (28.4, 37.1) 35.9 (26.0, 47.1) 35.6 (29.3, 42.6) 28.0 (22.4, 34.4) 22.5 (14.9, 32.5)
Year level of schooling
Year 10 or less 1190 25.5 (23.5, 27.8) 36.9 (32.0, 42.1) 32.8 (22.4, 45.3) 51.4 (41.1, 61.6) 35.0 (28.0, 42.7) 25.3 (17.7, 34.7)
Year 11 or more 3793 74.5 (72.2, 76.5) 30.2 (27.3, 33.2) 29.6 (25.0, 34.7) 31.7 (27.1, 36.8) 29.7 (25.1, 34.9) 22.5 (14.3, 33.7)
Highest qualification
attained
Degree or higher 2026 29.3 (26.9, 31.8) 30.4 (26.3, 34.8) 33.1 (26.4, 40.4) 29.3 (23.6, 35.7) 27.6 (21.4, 34.7) * 14.5 (7.7, 25.5)
Other/None 2931 70.7 (68.2, 73.1) 32.6 (29.5, 35.8) 28.6 (22.9, 35.0) 39.0 (33.2, 45.1) 32.6 (27.9, 37.6) 24.9 (18.7, 32.3)
Eligibility for public
dental care
Eligible 1634 30.7 (28.3, 33.1) 34.5 (30.1, 39.1) 29.3 (18.8, 42.6) 54.2 (45.5, 62.7) 32.9 (26.6, 39.8) 24.1 (18.1, 31.5)
Ineligible 3373 69.3 (66.9, 71.7) 31.1 (28.1, 34.2) 30.8 (26.0, 36.0) 31.4 (26.9, 36.3) 31.4 (26.3, 37.0) * 26.7 (13.8, 45.4)
Dental insurance
Insured 2548 45.3 (42.5, 48.1) 24.4 (21.3, 27.7) 22.3 (17.3, 28.4) 25.1 (19.8, 31.3) 25.9 (21.3, 31.1) 24.9 (17.0, 34.8)
Uninsured 2385 54.7 (51.9, 57.5) 38.6 (35.2, 42.1) 35.9 (29.8, 42.5) 45.7 (39.9, 51.6) 37.8 (31.5, 44.5) 24.3 (16.3, 34.6)
Usually visit dentist
For a check-up 3135 61.5 (58.8, 64.1) 24.3 (21.4, 27.5) 24.2 (19.3, 29.9) 25.4 (20.3, 31.3) 24.4 (19.6, 30.0) 19.5 (13.1, 28.0)
For a dental problem 1796 38.5 (35.9, 41.2) 43.5 (39.3, 47.9) 43.7 (35.6, 52.2) 49.2 (42.5, 56.0) 39.4 (32.5, 46.7) 30.9 (20.1, 44.3)

* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution.

Table 2. Mean number of decayed tooth surfaces per person in the Australian dentate adults aged 15 years and over.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
Mean (95% CI)
All people 5022 1.4 (1.2, 1.6) 1.3 (0.9, 1.7) 1.4 (1.1, 1.7) 1.8 (1.3, 2.3) 1.1 (0.6, 1.5)
Sex
Male 2249 49.6 (46.9, 52.2) 1.7 (1.4, 2.0) 1.3 (0.8, 1.7) 1.6 (1.1, 2.1) 2.8 (1.9, 3.6) 1.1 * (0.3, 1.9)
Female 2773 50.4 (47.8, 53.1) 1.2 (0.9, 1.4) 1.4 (0.8, 1.9) 1.3 (0.9, 1.7) 0.8 (0.5, 1.0) 1.1 (0.6, 1.6)
Indigenous identity
Non-Indigenous 4937 98.3 (97.4, 98.9) 1.4 (1.2, 1.6) 1.3 (0.9, 1.6) 1.4 (1.1, 1.7) 1.8 (1.3, 2.2) 1.1 (0.6, 1.6)
Indigenous 84 1.7 (1.1, 2.6) 2.7 * (0.5, 4.9) 2.5 * (0.0, 5.7) 3.2 * (0.2, 6.3) 2.8 * (0.0, 6.5) 0.9 * (0.0, 2.6)
Residential location
Major cities 2969 72.7 (69.1,76.0) 1.4 (1.1,1.6) 1.3 (0.8,1.7) 1.4 (1.0,1.8) 1.6 (1.0,2.1) 1.3 (0.6,1.9)
Rural/remote 2053 27.3 (24.0,30.9) 1.6 (1.3,2.0) 1.4 (0.9,1.9) 1.5 (1.1,2.0) 2.2 (1.3,3.2) 0.7 (0.4,1.0)
Year level of schooling
Year 10 or less 1190 25.5 (23.5,27.8) 2.1 (1.6,2.6) 2.6 * (1.0,4.2) 2.2 (1.5,2.9) 2.2 (1.4,3.0) 1.3 * (0.6,2.0)
Year 11 or more 3793 74.5 (72.2,76.5) 1.2 (1.0,1.4) 1.1 (0.8,1.4) 1.3 (0.9,1.6) 1.3 (0.9,1.6) 0.7 (0.4,1.0)
Highest qualification
attained
Degree or above 2026 29.3 (26.9,31.8) 0.9 (0.7,1.2) 0.9 (0.6,1.3) 0.9 (0.5,1.2) 1.1 (0.6,1.7) 0.9 * (0.2,1.7)
Other/None 2931 70.7 (68.2,73.1) 1.7 (1.4,1.9) 1.5 (0.9,2.1) 1.7 (1.3,2.2) 2 (1.4,2.5) 1.1 (0.5,1.6)
Eligibility for public
dental care
Eligible 1634 30.7 (28.3,33.1) 2.1 (1.6,2.5) 1.8 * (0.6,3.0) 2.9 (2.1,3.8) 2.3 (1.4,3.1) 1.1 (0.6,1.7)
Ineligible 3373 69.3 (66.9,71.7) 1.2 (1.0,1.4) 1.2 (0.8,1.5) 1.1 (0.8,1.4) 1.3 (0.9,1.8) 0.8 * (0.3,1.3)
Dental insurance
Insured 2548 45.3 (42.5,48.1) 0.8 (0.6,1.0) 0.7 (0.4,0.9) 0.8 (0.5,1.1) 1.1 (0.7,1.6) 0.6 (0.4,0.9)
Uninsured 2385 54.7 (51.9,57.5) 1.9 (1.6,2.2) 1.6 (1.1,2.1) 2 (1.6,2.5) 2.3 (1.6,3.1) 1.4 * (0.6,2.3)
Usually visit dentist
For a check-up 3135 61.5 (58.8,64.1) 0.7 (0.6,0.9) 0.7 (0.5,0.9) 0.8 (0.5,1.2) 0.6 (0.5,0.8) 0.5 (0.3,0.7)
For a dental problem 1796 38.5 (35.9,41.2) 2.3 (1.9,2.6) 2.4 (1.5,3.3) 2.1 (1.7,2.6) 2.4 (1.7,3.2) 1.8 * (0.7,2.9)
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution.
Int. J. Environ. Res. Public Health 2021, 18, 11539 5 of 14

Table 3. Mean number of decayed, missing or filled tooth surfaces per person in Australian dentate adults aged 15 years
and over.

Age (Years)
N Weighted % Total 15–34 35–54 55–74 ≥75
Mean (95% CI)
All people 5022 29.7 (28.4, 31.1) 7.7 (6.9, 8.5) 24.9 (23.3, 26.5) 57.1 (54.8, 59.4) 75.3 (72.2, 78.4)
Sex
Male 2249 49.6 (46.9,52.2) 27.1 (25.2, 29.1) 7.3 (6.0, 8.5) 22.2 (19.8, 24.5) 53.5 (50.5, 56.4) 71.5 67.1, 76.0)
Female 2773 50.4 (47.8,53.1) 32.3 (30.5, 34.1) 8.1 (6.9, 9.4) 27.6 (25.6, 29.6) 60.7 (57.3, 64.2) 78.3 (74.5, 82.1)
Indigenous identity
Non-Indigenous 4937 98.3 (97.4,98.9) 29.9 (28.5, 31.3) 7.7 (6.9, 8.6) 24.9 (23.3, 26.5) 57.1 (54.8, 59.5) 75.4 (72.3, 78.5)
Indigenous 84 1.7 (1.1,2.6) 18.7 (10.3, 27.1) * 6.9 (1.1, 12.7) 27.5 (22.7, 32.3) 63.9 (54.9, 72.8) NP
Residential location
Major cities 2969 72.7 (69.1,76.0) 28.5 (26.9, 30.1) 7.8 (6.8, 8.9) 24.4 (22.5, 26.3) 57 (53.6, 60.4) 77.8 (73.8, 81.7)
Rural/remote 2053 27.3 (24.0,30.9) 32.3 (29.8, 34.8) 7.3 (5.9, 8.8) 26 (23.1, 28.9) 57.2 (54.7, 59.7) 71.1 (66.9, 75.4)
Year level of schooling
Year 10 or less 1190 25.5 (23.5,27.8) 43.9 (41.1–46.8) 7.6 (4.6, 10.6) 29.9 (26.1, 33.8) 57 (53.4, 60.7) 75.6 (71.2, 80.0)
Year 11 or more 3793 74.5 (72.2,76.5) 24.8 (23.4, 26.2) 7.6 (6.8, 8.5) 23.9 (22.1, 25.6) 57.3 (54.3, 60.3) 74.8 (71.2, 78.4)
Highest qualification
attained
Degree or higher 2026 29.3 (26.9,31.8) 20.9 (19.2, 22.5) 8.4 (7.2, 9.6) 19 (17.1, 20.8) 55.8 (52.9, 58.7) 76.3 (72.0, 80.6)
Other/None 2931 70.7 (68.2,73.1) 33.4 (31.8, 35.1) 7.3 (6.2, 8.4) 28.3 (26.1, 30.5) 58 (55.4, 60.5) 75.7 (72.1, 79.2)
Eligibility for public
dental care
Eligible 1634 30.7 (28.3,33.1) 44.8 (42.0, 47.6) 8.8 (6.8, 10.7) 32.5 (28.6, 36.4) 58.9 (55.2, 62.5) 75.5 (72.0–79.0)
Ineligible 3373 69.3 (66.9,71.7) 23.2 (21.8, 24.5) 7.5 (6.6, 8.4) 23.3 (21.6, 25.0) 55.4 (52.5, 58.3) 74.1 (69.2, 79.0)
Dental insurance
Insured 2548 45.3 (42.5,48.1) 30.6 (28.8, 32.4) 7.5 (6.2, 8.7) 23.2 (21.1, 25.4) 59.4 (57.0, 61.8) 76.4 (72.8, 79.9)
Uninsured 2385 54.7 (51.9,57.5) 29.9 (27.9, 31.8) 7.9 (6.8, 9.1) 27.1 (24.6, 29.5) 55.3 (51.6, 59.0) 74.6 (69.8, 79.3)
Usually visit dentist
For a check-up 3135 61.5 (58.8,64.1) 26.6 (25.0, 28.1) 6.5 (5.6, 7.3) 21.9 (19.8, 23.9) 56.7 (54.3, 59.2) 75.5 (71.1, 79.8)
For a dental problem 1796 38.5 (35.9,41.2) 35.7 (33.4, 37.9) 10.8 (8.9, 12.7) 29.8 (27.2, 32.4) 57.7 (53.5, 61.9) 75.3 (71.1, 79.4)
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution. NP: Not publishable due to small cell counts.

Table 4. Percentage of people with gingival inflammation in the Australian dentate population.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
% (95% CI)
All people 4401 28.8 (26.1, 31.6) 31.3 (27.1, 35.8) 29.5 (25.2, 34.2) 24.4 (20.7, 28.6) 20.9 (15.0, 28.2)
Sex
Male 1906 48.9 (46.0,51.8) 34.7 (30.7,39.0) 34.9 (28.5,41.8) 35.6 (29.3,42.4) 34.1 (28.0,40.8) 27.4 (17.0,41.1)
Female 2496 51.1 (48.2,54.0) 23.1 (20.3,26.1) 27.6 (22.7,33.0) 23.7 (18.8,29.3) 15.7 (12.1,20.3) 16.7 (10.3,26.0)
Indigenous identity
Non-Indigenous 4330 98.4 (97.4,99.0) 28.7 (26.0,31.5) 31.3 (27.0,35.9) 29.1 (24.8,33.8) 24.6 (20.8,28.9) 20.9 (15.1,28.2)
Indigenous 71 1.6 (1.0,2.6) 38.6 (19.9,61.4) 30.5 * (11.1,60.7) 63.3 (36.2,84.0) 9.9 * (1.2,49.2) NP
Residential location
Major cities 2607 73.8 (70.3,77.0) 30.1 (26.8,33.5) 31.5 (26.8,36.6) 31.6 (26.2,37.5) 26.0 (21.0,31.7) 21.9 (14.9,30.8)
Rural/remote 1795 26.2 (23.0,29.7) 25.2 (20.6,30.4) 30.4 (21.8,40.6) 24.2 (18.1,31.4) 21.1 (16.3,26.9) 18.2 * (9.2,32.9)
Year level of schooling
Year 10 or less 943 23.2 (21.2,25.4) 28.6 (24.0,33.8) 40.2 (27.5,54.3) 30.4 (22.1,40.1) 23.3 (17.5,30.2) 18.6 (11.4,28.8)
Year 11 or more 3427 76.8 (74.6,78.8) 28.9 (25.9,32.1) 29.9 (25.5,34.7) 29.3 (24.6,34.6) 25.6 (21.0,30.9) 24.5 (15.7,36.0)
Highest qualification
attained
Degree or above 1865 30.6 (28.1,33.3) 24.0 (20.5,28.0) 21.3 v 27.3 (21.2,34.3) 24.2 (17.5,32.5) 22.2 * (11.3,39.1)
Other/None 2477 69.4 (66.7,71.9) 31.2 (27.9,34.6) 36.7 (31.1,42.7) 31.0 (25.6,37.0) 25.2 (20.9,30.0) 20.7 (14.1,29.3)
Eligibility for public
dental care
Eligible 1264 27.3 (24.9,29.9) 30.4 (26.0,35.3) 31.9 (22.8,42.5) 38.1 (29.1,48.0) 28.4 (22.2,35.5) 19.6 (13.5,27.6)
Ineligible 3123 72.7 (70.1,75.1) 28.3 (25.3,31.5) 31.3 (26.7,36.4) 27.8 (23.3,32.8) 21.4 (17.0,26.4) 29.6 * (14.1,51.8)
Dental insurance
Insured 2261 46.1 (43.0,49.2) 25.2 (22.0,28.8) 29.9 (24.0,36.5) 25.0 (19.8,31.1) 20.4 (16.2,25.3) 14.9 (9.1,23.6)
Uninsured 2058 53.9 (50.8,57.0) 31.1 (27.5,34.9) 30.1 (24.6,36.1) 34.8 (28.6,41.6) 28.4 (22.5,35.1) 25.8 (16.9,37.3)
Usually visit dentist
For a check-up 2775 62.3 (59.5,65.1) 25.2 (22.0,28.7) 27.5 (22.5,33.1) 25.2 (20.2,31.1) 20.7 (16.7,25.3) 20.5 (13.6,29.9)
For a dental problem 1548 37.7 (34.9,40.5) 33.2 (29.3,37.4) 35.4 (27.9,43.6) 35.7 (29.3,42.8) 28.7 (22.6,35.8) 21.4 * (12.2,34.9)
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution. NP: not publishable due to small cell counts.
Int. J. Environ. Res. Public Health 2021, 18, 11539 6 of 14

Table 5. Proportion of people with moderate or severe periodontitis in the Australian dentate population.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
% (95% CI)
All people 4402 30.1 (27.9, 32.4) 12.2 (9.5, 15.6) 32.7 (28.5, 37.3) 51.1 (46.2, 56.0) 69.3 (60.5, 76.9)
Sex
Male 1906 48.9 (46.0,51.8) 34.9 (31.2,38.8) 16.6 (11.8,22.8) 38.9 (32.1,46.3) 59.5 (53.3,65.4) 63.1 (48.1,75.9)
Female 2496 51.1 (48.2,54.0) 25.5 (22.7,28.5) 7.8 (5.3,11.3) 26.6 (21.7,32.2) 43.5 (37.1,50.2) 73.0 (62.3,81.6)
Indigenous identity
Non-Indigenous 4330 98.4 (97.4,99.0) 30.3 (28.1,32.7) 12.5 (9.7,15.9) 32.9 (28.6,37.5) 50.8 (46.0,55.6) 69.2 (60.4,76.8)
Indigenous 71 1.6 (1.0,2.6) 11.0 * (5.3,21.3) 3.9 * (0.8,17.2) 21.0 * (8.2,44.1) 49.7 * (15.4,84.3) NP
Residential location
Major cities 2607 73.8(70.3,77.0) 29.4 (26.7,32.2) 12.2 (9.0,16.4) 31.6 (26.4,37.2) 52.9 (46.7,59.1) 71.1 (60.1,80.0)
Rural/remote 1795 26.2 (23.0,29.7) 32.1 (28.1,36.5) 12.3 (8.2,18.2) 35.8 (28.8,43.4) 47.1 (39.6,54.8) 64.4 (49.7,76.9)
Year level of schooling
Year 10 or less 943 23.2 (21.2,25.4) 45.0 (39.6,50.5) 7.7 * (3.3,16.7) 50.0 (39.8,60.3) 55.9 (47.8,63.7) 72.2 (61.0,81.1)
Year 11 or more 3427 76.8 (74.6,78.8) 25.6 (23.2,28.2) 12.9 (9.8,16.8) 29.2 (24.8,34.1) 47.8 (42.3,53.3) 64.7 (49.2,77.7)
Highest qualification
attained
Degree or above 1865 23.2 (21.2,25.4) 21.7 (18.2,25.6) 11.6 (6.7,19.1) 22.7 (18.1,28.1) 49.7 (42.6,56.7) 59.6 (35.9,79.6)
Other/None 2477 69.4 (66.7,71.9) 33.6 (30.6,36.6) 12.6 (9.5,16.5) 38.4 (32.5,44.6) 50.9 (45.3,56.5) 69.9 (60.6,77.8)
Eligibility for public
dental care
Eligible 1264 27.3 (24.9,29.9) 42.5 (37.9,47.2) 15.7 (9.0,25.9) 41.3 (32.1,51.2) 54.8 (47.5,61.9) 70.6 (61.5,78.3)
Ineligible 3123 72.7 (70.1,75.1) 25.5 (22.9,28.2) 11.5 (8.7,14.9) 30.9 (26.2,36.0) 47.7 (41.8,53.7) 59.3 (33.3,80.9)
Dental insurance
Insured 2261 46.1 (43.0,49.2) 25.4 (22.7,28.3) 8.4 (5.1,13.4) 24.5 (19.8,30.0) 45.2 (39.0,51.6) 67.4 (53.1,79.1)
Uninsured 2058 53.9 (50.8,57.0) 35.0 (31.8,38.4) 15.7 (11.5,20.9) 41.1 (34.8,47.7) 56.9 (49.7,63.8) 70.7 (59.7,79.8)
Usually visit dentist
For a check-up 2775 62.3 (59.5,65.1) 26.1 (23.4,29.0) 8.8 (6.0,12.9) 29.5 (23.9,35.8) 49.0 (43.0,55.0) 72.5 (60.4,81.9)
For a dental problem 1548 37.7 (34.9,40.5) 36.8 (32.6,41.3) 18.8 (13.4,25.8) 37.2 (30.4,44.5) 53.0 (45.6,60.2) 64.3 (50.3,76.2)
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution. NP: not publishable due to small cell counts.

Table 6. Proportion of adults with complete tooth loss in the Australian population.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
% (95% CI)
All people 15,731 4.0 (3.6, 4.4) — 1.1 (0.7, 1.6) 8.1 (7.0, 9.3) 20.5 (18.1, 23.1)
Sex
Male 6781 49.2 (48.1,50.4) 3.4 (2.9,3.9) — 1.1 * (0.6,2.0) 6.5 (5.2,8.1) 19.1 (15.6,23.2)
Female 8950 50.8 (49.6,51.9) 4.7 (4.1,5.3) — 1.0 * (0.6,1.8) 9.6 (8.0,11.5) 21.5 (18.4,25.0)
Indigenous identity
Non-Indigenous 15,392 97.7 (97.3,98.1) 4.0 (3.6,4.4) — 1.1 (0.7,1.6) 7.7 (6.7,8.9) 20.5 (18.1,23.1)
Indigenous 334 2.3 (1.9,2.7) 7.1 (4.3,11.4) — 0.8 * (0.2,2.5) 29.3 (17.8,44.1) 19.5 * (6.5,45.9)
Residential location
Major cities 9372 71.8 (68.6,74.9) 3.5 (3.0,4.0) — 1.0 * (0.6,1.7) 7.4 (6.0,9.0) 18.8 (15.9,22.0)
Rural/remote 6359 28.2 (25.1,31.4) 5.4 (4.7,6.2) — 1.2 * (0.7,2.0) 9.5 (8.1,11.2) 24.2 (20.1,28.7)
Year level of schooling
Year 10 or less 4198 28.9 (27.8,30.1) 9.4 (8.5,10.5) — 3.1 * (1.8,5.2) 11.7 (9.9,13.8) 24.9 (21.6,28.5)
Year 11 or more 11,355 71.1 (69.9,72.2) 1.8 (1.5,2.1) — 0.6 * (0.3,1.1) 5.3 (4.2,6.7) 13.1 (10.2,16.6)
Highest qualification
attained
Degree or higher 5836 26.8 (25.4,28.2) 0.7 (0.5,1.1) — 0.5 * (0.1,1.6) 2.0 (1.3,3.1) 5.3 * (3.0,9.0)
Other/None 9584 73.2 (71.8,74.6) 5.1 (4.6,5.7) — 1.3 (0.8,2.0) 9.4 (8.1,10.8) 22.0 (19.4,24.9)
Eligibility for public
dental care
Eligible 4976 30.2 (29.0,31.4) 10.5 (9.5,11.7) — 3.1 * (1.7,5.3) 13.4 (11.5,15.6) 22.3 (19.6,25.2)
Ineligible 10,686 69.8 (68.6,71.0) 1.2 (1.0,1.5) — 0.7 * (0.4,1.2) 3.7 (2.9,4.9) 11.3 (7.6,16.5)
Dental insurance
Insured 8238 51.1 (49.5,52.8) 1.7 (1.4,2.0) — 0.5 * (0.3,1.1) 3.6 (2.8,4.5) 9.2 (7.0,11.9)
Uninsured 7206 48.9 (47.2,50.5) 6.5 (5.8,7.2) — 1.8 (1.1,2.8) 12.7 (10.9,14.8) 28.3 (24.7,32.3)
Usually visit dentist
For a check-up 9790 63.3 (61.9,64.6) 1.2 (0.9,1.5) — 0.3 * (0.2,0.6) 3.0 (2.1,4.2) 6.1 (4.4,8.4)
For a dental problem 5620 36.7 (35.4,38.1) 7.9 (7.1,8.8) — 2.2 (1.3,3.5) 13.0 (11.2,15.0) 32.5 (28.5,36.7)
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution.
Int. J. Environ. Res. Public Health 2021, 18, 11539 7 of 14

Table 7. Mean number of missing teeth for pathology per person in the Australian dentate population.

Age (Years)
N % (95% CI) Total 15–34 35–54 55–74 ≥75
Mean (95% CI)
All people 5022 4.4 (4.1, 4.7) 0.6 (0.4, 0.7) 3.6 (3.3, 3.9) 8.8 (8.2, 9.4) 13.2 (12.2, 14.2)
Sex
Male 2249 49.6 (46.9,52.2) 4.2 (3.8,4.6) 0.5 (0.3,0.8) 3.4 (3.0,3.9) 8.6 (8.0,9.3) 13.6 (12.5,14.6)
Female 2773 50.4 (47.8,53.1) 4.6 (4.2,5.0) 0.7 (0.4,0.9) 3.8 (3.4,4.2) 9 (8.0,10.0) 12.9 (11.3,14.6)
Indigenous identity
Non-Indigenous 4937 98.3 (97.4,98.9) 4.4 (4.1,4.7) 0.6 (0.4,0.7) 3.6 (3.3,3.9) 8.8 (8.2,9.4) 13.2 (12.2,14.2)
Indigenous 84 1.7 (1.1,2.6) 3.2 (1.6,4.7) 0.9 * (0.0,1.7) 4.9 (3.2,6.7) 11.5 (7.0,16.0) 14 * (1.9,26.0)
Residential location
Major cities 2969 72.7 (69.1,76.0) 4 (3.7,4.4) 0.6 (0.4,0.8) 3.4 (3.0,3.8) 8.4 (7.6,9.2) 13.3 (12.0,14.6)
Rural/remote 2053 27.3 (24.0,30.9) 5.4 (4.9,5.9) 0.7 (0.4,1.0) 4.3 (3.7,4.8) 9.6 (8.8,10.3) 13 (11.6,14.4)
Year level of schooling
Year 10 or less 1190 25.5 (23.5,27.8) 7.7 (7.1,8.2) 0.6 * (0.2,1.0) 4.7 (4.0,5.4) 10.2 (9.4,11.1) 14 (12.5,15.6)
Year 11 or more 3793 74.5 (72.2, 76.5) 3.3 (3.0, 3.5) 0.6 (0.4, 0.7) 3.4 (3.0, 3.8) 7.7 (6.8, 8.6) 11.8 (10.7, 12.9)
Highest qualification
Int. J. Environ. Res. Public Health 2021, 182, 1539
attained 11 of 15
Degree or above 2026 29.3 (26.9,31.8) 2.3 (2.0,2.5) 0.6 (0.3,0.8) 2.4 (2.0,2.7) 6 (5.4,6.6) 11 (9.1,13.0)
Other/None 2931 70.7 (68.2,73.1) 5.3 (4.9,5.6) 0.6 (0.4,0.8) 4.3 (3.9,4.8) 9.4 (8.7,10.1) 13.4 (12.2,14.5)
Eligibility for public
dental care
Eligible 1634 groups, particularly
30.7 (28.3,33.1) among those1 aged
7.6 (7.0,8.2) 35–44 years
(0.5,1.4) and above,10.1
5.2 (4.5,6.0) showing
(9.3,11.0)substantial reduc-
13.6 (12.5,14.7)
Ineligible 3373 69.3 (66.9,71.7) 3 (2.7,3.3) 0.5 (0.4,0.6) 3.3 (2.9,3.6) 7.6 (6.7,8.4) 10.8 (9.1,12.5)
Dental insurance tions in complete tooth loss among them since 1987–88. For instance, there were only 1.7%
Insured 2548 of45.3 (42.5,48.1) aged
individuals 3.9 (3.5,4.2)
45–54 years0.4 (0.3,0.6)
with complete3.0tooth
(2.6,3.4) 7.6 (7.0,8.3)
loss in 2017–18, compared 10.8 (9.8,11.8)
to 16.8%
Uninsured 2385 54.7 (51.9,57.5) 5 (4.6,5.4) 0.7 (0.5,1.0) 4.3 (3.8,4.8) 9.8 (9.0,10.7) 15 (13.4,16.5)
Usually visit dentist in 1987–88. The proportion of edentulous persons among 55–64-year-olds declined from
For a check-up 3135 27.8%
61.5 (58.8,64.1)
in 1987 to 3.5
5.8 (3.2,3.8)
in 2017–18. 0.5 (0.3,0.7) nearly
Likewise, 3.1 one
(2.7,3.5) 7.3 (6.8,7.9)
in six adults aged 75+ were11.3 (10.3,12.3)
edentu-
For a dental problem 1796 38.5 (35.9,41.2) 6 (5.5,6.5) 0.8 (0.6,1.1) 4.5 (4.0,5.0) 10.6 (9.5,11.7) 16 (14.2,17.8)
lous in 1987–88 compared to just one in three in 2017–18.
* Indicates a relative standard error of at least 25%, and hence should be interpreted with caution.

25

20
Mean number of Teeth

15

10

0
1987-88 2004-06 2017-18
F 7.8 7.4 5.9
M 5.7 4.6 4.4
D 1.5 0.6 0.8

D M F

Figure 1. Trends in dental decay experience among dentate Australians aged 15 years and over, 1987–88, 2004–06 and
Figure 1. Trends in dental decay experience among dentate Australians aged 15 years and over, 1987–88, 2004–06 and
2017–18.
2017–18.
 M 5.7 4.6 4.4
D 1.5 0.6 0.8

D M F
Int. J. Environ. Res. Public Health 2021, 18, 11539 8 of 14
Figure 1. Trends in dental decay experience among dentate Australians aged 15 years and over, 1987–88, 2004–06 and
2017–18.

Int. J. Environ. Res. Public Health 2021, 182, 1539 12 of 15

inclination of the proportion of Australian adults affected with periodontal disease across
all age groups between 2004–06 and 2017–18. For example, the proportions of Australians
aged 15–34 years and 75+ years with periodontitis increased from 7.4% to 12.2% and from
Figure 2. Trends in complete tooth loss among Australians aged 15 years and over, 1987–88, 2004–06
60.8% to 69.3, respectively, between 2004–06 and 2017–18.
Figure 2. Trends inand
complete tooth loss among Australians aged 15 years and over, 1987–88, 2004–06 and 2017–18.
2017–18.

90 A comparison of the proportions of Australian adults with moderate or severe peri-

80
odontitis by age is depicted in Figure 3. The overall prevalence of periodontal disease
increased from 22.9% in 2004–06 to 30.1% in 2017–18. This was reflected in a consistent
70

60
Periodontitis (%)

50

40

30

20

10

0
All ages 15-34 35-54 55-74 75+
2004-06 22.9 7.4 24.5 43.6 60.8
2017-18 30.1 12.2 32.7 51.1 69.3

2004-06 2017-18

Figure 3. Comparison of the prevalence of moderate or severe periodontitis among dentate Australians aged 15 years and
Figure 3. Comparison of the prevalence of moderate or severe periodontitis among dentate Australians aged 15 years and
over between 2004–06 and 2017–18.
over between 2004–06 and 2017–18.
3.1. Dental Caries
4. Discussion
Table 1 shows the proportion of Australian dentate adults aged 15 years and over
withThe findingscoronal
untreated of the present studyorindicate
caries (one that overall
more decayed levelson
surfaces of dental
crownscaries andteeth).
of their tooth
loss
Nearly one third of Australian adults (32.1%) had at least one tooth surface affectedFor
among Australian adults have considerably declined over the past three decades. by
example,
untreatedthe severity
dental of dental
caries. caries experience
The proportion of adultsand complete
with dentaltooth
cariesloss among
across the Austral-
four age
ian adults
groups has decreased
varied, by nearly 27%
with the prevalence and
being 72%, respectively,
highest from 1987–88
in 35–54-year-olds (35.4%) toand2017–18.
lowest
In general,
among thosethisaged
decline in dental
75 years caries
and over experience
(24.5%). has been
The highest reflected in
prevalence of all three compo-
untreated dental
nents
caries among participants of all ages was reported in those who visited a dentistmean
of the DMFT index, showing overall reductions of 46%, 22% and 24% in the for a
number of decayed,
dental problem missing
(43.5%), whileand filled teethwho
participants overvisited
30 years
the since
dentist 1987–88. In contrast,
for a check-up had the
the
periodontal status of
lowest prevalence Australian
(24.3%). Higheradults has substantially
proportions deteriorated
of untreated dental cariesbetween
were 2004–06
seen for
and 2017–18,
males, with anfor
those eligible overall
publicincrease
dental in theand
care prevalence of moderate
those without or severe periodonti-
dental insurance. Across age
tis by nearly
groups, higher31%. This deterioration
proportions were seenisforevident acrosspeople
Indigenous all ageaged
groups, in years
55–74 particular with
and those
the
agedalmost
35–5465% increase
years in the
with Year 10proportion
or less levelofofAustralian
schoolingadults agedcounterparts.
than their 15–34 years who have
moderate or severe periodontitis.
Several factors may explain improvements in dental caries experience, as well as
tooth retention, that have been observed among Australian adults over the past three dec-
ades. Nearly 90% of Australians have access to fluoridated drinking water, while almost
97% of Australian children and adults brushed their teeth daily using a fluoridated tooth-
Int. J. Environ. Res. Public Health 2021, 18, 11539 9 of 14

The mean number of decayed tooth surfaces per person in Australian dentate adults
aged 15 years and over is presented in Table 2. Overall, Australian dentate adults aged
15 years and over had, on average, 1.4 decayed tooth surfaces. The mean number of
decayed tooth surfaces among all ages was lowest in participants who usually visited a
dentist for a check-up (0.7), and usually visiting the dentist for a problem was strongly
associated with higher mean number of decayed tooth surfaces across all age groups.
Those who reported visiting for dental problems had, on average, 2.3 decayed surfaces. In
addition, participants who had Year 11 or more schooling, a degree or higher educational
qualification, those who were not eligible for public dental care and those with dental
insurance had a lower mean number of decayed tooth surfaces than their counterparts.
Table 3 shows the mean number of decayed, missing or filled tooth surfaces (DMFS)
per person in the Australian population. On average, Australian dentate adults aged
15 years and over had, on average, 29.7 decayed, missing or filled tooth surfaces, and
it increased gradually across four age groups, with people aged ≥75 years having the
highest mean DMFS (75.3). Among individuals of all ages, those who were eligible for
public dental care had the highest mean DMFS (44.8), and Indigenous people had the
lowest mean DMFS (18.7). Moreover, males, individuals with higher levels of schooling
and degree or higher qualifications, and those who usually visited a dentist for a check-up
had significantly lower mean DMFS as opposed to their counterparts.

3.2. Gingivitis
Table 4 shows the prevalence of gingivitis in the Australian dentate adult population.
Overall, 28.8% of Australian dentate adults aged 15 years and over had gingivitis. Although
the prevalence of gingivitis was decreasing with age across the four age groups, the
differences were not statistically significant. Among all age groups, males had the highest
prevalence of gingivitis (34.7%) and females the lowest (23.1%). In addition, those who
usually visited a dentist for a dental problem (33.2%) had a greater prevalence of gingivitis
than their counterparts.

3.3. Periodontitis
Table 5 presents the percentage of Australian dentate adults aged ≥15 years with
moderate/severe periodontitis. Accordingly, the overall prevalence of moderate or severe
periodontitis among the Australian dentate population was 30.1%. In contrast to gingivitis,
the prevalence of moderate or severe periodontitis significantly increased with age: almost
70% of dentate adults aged ≥75 years experienced periodontitis. The prevalence of peri-
odontitis among participants of all ages was lowest in Indigenous Australians (11.0) and
highest in those participants who had Year 10 or less of schooling (45%). Males, individuals
without a degree or higher qualification, those who were eligible for public dental care,
those not dentally insured and those who usually visited a dentist for a dental problem
experienced significantly greater periodontitis levels than their counterparts.

3.4. Tooth Loss

In general, 4% Australian adults aged ≥15 years had lost all their teeth (Table 6). While
complete tooth loss was non-existent among the 15–34-year age group, the proportion
of adults with complete tooth loss steadily increased from 1.1% among 35–54 year olds
to 20.5% for those aged ≥75. Among all age groups, the dentally uninsured had the
highest prevalence of complete tooth loss (10.5%), while those who with a degree or
above qualification reported the lowest prevalence (0.7%). There was a subtle difference
between Indigenous and non-Indigenous adults in regard to complete tooth loss, however,
a significantly higher proportion of Indigenous adults aged 55–74 years reported complete
tooth loss (29.3%) as opposed to their non-Indigenous equivalents (7.7%). Among all age
groups, those with Year 10 or less level of schooling, those without a degree or higher
qualification, people who were eligible for public dental care, the dentally uninsured and
Int. J. Environ. Res. Public Health 2021, 18, 11539 10 of 14

those who usually visited a dentist for a dental problem had significantly higher levels of
complete tooth loss than their counterparts did.
Table 7 shows the severity of tooth loss due to pathology in Australian adults aged
15 years and over. In general, Australian adults had lost, on average, 4.4 teeth due to
pathology. The mean number of teeth lost due to pathology increased consistently with
age, from 0.6 at 15–34 years to 13.2 at 75 years and above. Among all age groups, the
mean number of teeth lost due to pathology was lowest among those who had a degree or
above qualification (2.3) and highest among those who were eligible for public dental care
(7.7). In addition, people residing in rural/remote areas, those with Year 10 or less level of
schooling, those dentally uninsured and those who usually visited a dentist for a dental
problem had a significantly higher mean number of teeth lost due to pathology.

3.5. Time Trends in Oral Health

Over the past three decades, three national surveys of adult oral health have
been carried out in Australia, namely, the National Oral Health Survey of Australia
1987–88 [18], the National Survey of Adult Oral Health 2004–06 [19], and the National
Study of Adult Oral Health 2017–18 [12]. Accordingly, trends in oral health are sourced
from these three national surveys, based on three time points. Given comparable
data for periodontal disease were not available in the National Oral Health Survey of
Australia 1987–88, an analysis of time trends in periodontal disease was not possible.
Therefore, only a comparison of the prevalence of moderate or severe periodontitis
between 2004–06 and 2017–18 surveys is presented.
Figure 1 presents the trends in the severity of dental caries experience in Australian
adults aged ≥15, as denoted by mean DMFT. There has been a consistent declining trend
in the mean DMFT over 30 years, from 14.9 in 1987–88 to 12.6 and 11.2 in 2004–06 and
2017–18, respectively. It was revealed that substantial reductions in all three components of
the mean DMFT over 30 years have contributed to this declining trend. For example, the
mean number of decayed teeth (D) and missing teeth due to pathology (M) declined from
1.5 (1987–88) to 0.8 (2017–18) and 5.7 (1987–88) to 4.4 (2017–18), respectively, whereas the
average number of filled teeth (F) reduced from 7.8 in 1987–88 to 5.9 in 2017–18.
Figure 2 shows time trends in the proportion of Australian adults with complete tooth
loss by age. It is apparent that there has been a steady decline in the overall proportion of
Australian adults with complete tooth loss during three time points, from 14.4% in 1987–88
to 6.4% in 2004–06, and to 4% in 2017–18. This decline is reflected across all age groups,
particularly among those aged 35–44 years and above, showing substantial reductions
in complete tooth loss among them since 1987–88. For instance, there were only 1.7% of
individuals aged 45–54 years with complete tooth loss in 2017–18, compared to 16.8% in
1987–88. The proportion of edentulous persons among 55–64-year-olds declined from 27.8%
in 1987 to 5.8 in 2017–18. Likewise, nearly one in six adults aged 75+ were edentulous in
1987–88 compared to just one in three in 2017–18.
A comparison of the proportions of Australian adults with moderate or severe pe-
riodontitis by age is depicted in Figure 3. The overall prevalence of periodontal disease
increased from 22.9% in 2004–06 to 30.1% in 2017–18. This was reflected in a consistent
inclination of the proportion of Australian adults affected with periodontal disease across
all age groups between 2004–06 and 2017–18. For example, the proportions of Australians
aged 15–34 years and 75+ years with periodontitis increased from 7.4% to 12.2% and from
60.8% to 69.3, respectively, between 2004–06 and 2017–18.

4. Discussion
The findings of the present study indicate that overall levels of dental caries and tooth
loss among Australian adults have considerably declined over the past three decades. For
example, the severity of dental caries experience and complete tooth loss among Australian
adults has decreased by nearly 27% and 72%, respectively, from 1987–88 to 2017–18. In
general, this decline in dental caries experience has been reflected in all three components
Int. J. Environ. Res. Public Health 2021, 18, 11539 11 of 14

of the DMFT index, showing overall reductions of 46%, 22% and 24% in the mean number
of decayed, missing and filled teeth over 30 years since 1987–88. In contrast, the periodontal
status of Australian adults has substantially deteriorated between 2004–06 and 2017–18,
with an overall increase in the prevalence of moderate or severe periodontitis by nearly
31%. This deterioration is evident across all age groups, in particular with the almost 65%
increase in the proportion of Australian adults aged 15–34 years who have moderate or
severe periodontitis.
Several factors may explain improvements in dental caries experience, as well as tooth
retention, that have been observed among Australian adults over the past three decades.
Nearly 90% of Australians have access to fluoridated drinking water, while almost 97% of
Australian children and adults brushed their teeth daily using a fluoridated toothpaste [20].
There has been consistent evidence to suggest that community water fluoridation alongside
widespread use of fluoridated toothpaste in Australia has played the most important
role in preventing dental caries [21,22]. Prevention of dental caries in turn has led to
increased retention of teeth, given that dental caries is regarded as the main cause of
tooth loss. Furthermore, there has been a notable shift in dental treatment strategies, from
high-extraction versus low-restoration to low-extraction versus high-restoration, which
may have also contributed to improved tooth retention over the past three decades. These
findings have consistently shown that Australian adults who usually visited only for a
dental problem had higher levels of dental caries and tooth loss than those who visited
for a dental check-up. For example, the severity of dental caries (as denoted by the mean
DMFT) and the prevalence of complete tooth loss, respectively, were 1.31 and 6.8 times
higher among Australian adults who usually visited only for a dental problem than for
their counterparts who visited for a dental check-up. This finding concurs with what has
been reported previously, indicating an association between improved oral health and
favourable dental visiting patterns, including visiting for a dental check-up [23,24].
The NSAOH 2017–18 report has used several independent variables, such as year
level of schooling, highest qualification attained, eligibility of public dental care and dental
insurance, as socioeconomic indicators of the study population. Accordingly, the present
findings have revealed that poor oral health has consistently been associated with lower
levels of socioeconomic status. For instance, the prevalence of untreated dental decay was
1.22 times and 1.58 times higher among persons who had Year 10 or less of schooling and
those who were dentally uninsured than their counterparts with Year 11 or more years of
schooling and those with dental insurance. Likewise, the prevalence of complete tooth loss
was 5.26 times and 3.82 times higher among individuals with Year 10 or less schooling and
those who were without dental insurance, as opposed to their counterparts. These findings
are consistent with those of previous studies, where more socially advantaged individuals
presented with much improved oral health levels than those who were worse-off, and,
consequently, supported the existence of socioeconomic inequalities in oral health [25,26].
Deterioration in periodontal health in Australian adults, which has been observed
between 2004–06 and 2017–18, could be mainly ascribed to increased tooth retention. While
the overall proportion of edentulous persons declined from 6.4% to 4%, the mean number
of missing teeth due to pathology dropped from 4.6 to 4.4 during this period. Consequently,
both the increase in the proportion of dentate adults as well as the number of retained teeth
pose a greater vulnerability for periodontal disease. Our findings were consistent with
those of previous studies where a strong association between age and periodontitis was
observed; the older the individuals, the higher the prevalence of periodontal disease [10].
Associations between socioeconomic variables and periodontal disease, on the other hand,
were similar to those seen with regard to dental caries and tooth loss. Accordingly, the
prevalence of moderate or severe periodontitis was consistently higher among Australian
adults in the lower socioeconomic strata. This is consistent with previous studies [10] and
provides further evidence for the presence of socioeconomic disparities in oral health.
Employing a nationally representative sample of Australian adults and using a stan-
dardized examination protocol, as well as rigorous epidemiological survey methods, were
Int. J. Environ. Res. Public Health 2021, 18, 11539 12 of 14

some of the main strengths of the study. Other strengths included having both the inter-
viewers and oral examiners adequately trained to ensure the quality control of the study
(high intra-class correlation coefficient values were obtained indicating a high level of inter-
examiner reliability and agreement), and the instruments used were based on previous
studies, enabling comparisons to be made across the series of national surveys. Whilst the
cross-sectional nature of the study did not warrant ascertaining cause–effect relationships,
the present study could not represent Indigenous Australians in sufficient numbers. This,
in turn, has resulted in creating small cell counts and relative standard errors of at least
25% in regard to Indigenous group/subgroup analyses, so interpretation of these results
should be made with caution. Moreover, the use of partial recording protocols in the study
could have contributed to flaws in estimating the prevalence of periodontitis. Despite
such limitations, the findings showed that the overall oral health status, including the
experience of dental caries, periodontal disease and tooth loss, was poorer in Indigenous
Australians than in their non-Indigenous counterparts with regard to virtually all indepen-
dent variables assessed. These findings are consistent with the previous studies, which
were conducted among Indigenous groups in both Australia and elsewhere, indicating
that Indigenous populations are among the most socioeconomically disadvantaged com-
munities in the world [27–29]. It may be challenging for survey instruments and sampling
methods employed in conventional population-level oral health surveys to capture the true
picture of Indigenous populations and, accordingly, the need for implementing unique
study methodologies for such populations has been highlighted [29].

5. Conclusions
The present findings suggest that the overall oral health, barring periodontal status,
of Australian adults has improved over the last 30 years. Comparisons of national data
between 2004–06 and 2017–18 reveal that the periodontal health of Australian adults, in
general, has deteriorated during this period. The findings also indicate that individuals
from lower socioeconomic backgrounds present with poorer oral health on the whole,
pointing to socioeconomic inequalities in oral health. Such findings may be useful for
policy makers in planning and implementing future oral healthcare programmes at a
population level.

Author Contributions: Conceptualization, N.A., L.L., S.C. and L.M.J.; formal analysis, S.C. and N.A.;
writing—original draft preparation, N.A.; writing—review and editing, N.A., L.L., S.C. and L.M.J.
All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by the Australian Government Department of Health and the
National Health and Medical Research Council (Partnership Grant #1115649).
Institutional Review Board Statement: This study was reviewed and approved by The University
of Adelaide’s Human Research Ethics Committee (HREC; H-2016-046).
Informed Consent Statement: Interviewed subjects provided verbal consent prior to answering
questions. Parental/guardian consent was obtained for participants aged 15–17 years. All examined
subjects provided signed, informed consent prior to the examination (parents/guardians of those
aged 15–17 years provided signed, informed consent prior to the examination).
Data Availability Statement: The datasets used during the current study are available from the
corresponding author via completion of a data request.
Acknowledgments: The Australian Dental Association, Colgate Oral Care and BUPA provided
sponsorship. State/Territory health departments and dental services were partners in the study. The
research team acknowledge the Australian Government Department of Human Services, state and
territory dental health services and the participants involved in the study.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2021, 18, 11539 13 of 14

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