Publications Approval Number 6334
(c) Commonwealth of Australia 2009
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(c) Commonwealth of Australia 2009
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TABLE OF CONTENTS
Committee members 1
Executive summary 3
Issues for noting 4
Terms of Reference 5
Conduct of the Review 6
Dental Benefits Act 2008 7
Dental Benefits Rules 2008 8
Medicare Teen Dental Plan 8
Eligibility requirements 9
Arrangements for representative public dentists 12
Public feedback 12
Discussion of key issues 13
Issue 1 – do the Act And Rules provide an appropriate legislative
framework for the payment of dental benefits? 13
Issue 2 – do the Act and Rules support the appropriate administration
of the Medicare Teen Dental Plan? 15
Issue 3 – has the start-up of the Medicare Teen Dental Plan been successful? 16
Chart 1: Voucher Utilisation by Seifa – 1 July 2008 to 30 November 2009 17
Chart 2: Voucher Utilisation by Remoteness Area – 1 July 2008 to
30 November 2009 18
Chart 4: Bulk Billing by Remoteness Area – 1 July 2008 to 30 November 2009 19
Other issues 20
Appendix 1: Dental Benefits Act 2008
Appendix 2: Dental Benefits Rules 2008
Appendix 3: Medicare Teen Dental Plan Voucher 2009
Nature of Appointment
Professor Jim Bishop AO (Chair)
Commonwealth Chief Medical Officer
Required by legislation
Dr Christopher Wilson
Australian Dental Association
Australian Dental Association representative, required by legislation
Ms Darlene Cox
Representative of the Consumers Health Forum of Australia; and
Executive Director of the Health Care Consumers’ Association
Representative of Consumers Health Forum of Australia, required by legislation
Dr Andrew Barnes
Private dental practitioner; and
Dental adviser, Department of Veterans’ Affairs
Appointed by the Minister for Health and Ageing
Dr Martin Dooland
South Australian Dental Service
Appointed by the Minister for Health and Ageing
The Review of the Dental Benefits Act 2008 (the Act) has been undertaken as a requirement of Section 68 of the Act. Section 68 stipulates that the Minister for Health and Ageing must cause an independent review of the operation of the Act to be undertaken as soon as possible after the first anniversary of the commencement of the Act; and further independent reviews as soon as practicable after the Act’s third anniversary and at three yearly intervals thereafter.
To undertake this initial Review of the Act, the Minister for Health and Ageing, the Hon Nicola Roxon MP, appointed a Review Committee on 29 September 2009. The Committee comprised the following persons, as stipulated under Section 68 of the Act:
person occupying the position of Commonwealth Chief Medical Officer (CCMO);
a person nominated by the Australian Dental Association (ADA);
a person nominated by the Consumers Health Forum of Australia (CHF); and
two other persons nominated by the Minister, at least one of whom must have qualifications in medicine or dentistry.
The list of Committee members is on page 1.
The Committee found that the Act achieves its aim of providing a legislative framework for the payment of dental benefits, and supports the administration of the Medicare Teen Dental Plan which is, currently, the only program administered under the Act.
The Committee also found that the Act supports the aim of the Medicare Teen Dental Plan which is to help teenagers to improve their oral health habits through access to annual preventative dental services.
However, it is the Committee’s view that some changes to the Medicare Teen Dental Plan could be made in order to provide the Government, the dental profession and members of the public with a clearer understanding of the types of preventative services being accessed by eligible teenagers under the program and to streamline administrative processes.
ISSUES FOR NOTING
The Committee notes that:
the Government could consider replacing the single preventative dental check item (Dental Benefits Schedule item 88000) with individual items for each procedure provided to patients during their annual preventative dental check; and
as the Medicare Teen Dental Plan is in its early stages of operation, the Government could consider evaluating the program once it has matured, as part of the second statutory review of the Act.
TERMS OF REFERENCE
The Review Committee’s Terms of Reference were as follows:
The Review Committee will conduct the Review before the end of 2009, having regard to:
the attainment of the purposes of the Act; and
the administration of the Act, particularly in relation to the Medicare Teen Dental Plan.
The Committee was tasked to deliver:
a Draft Report one month from its first meeting on 27 October 2009; and
a Final Report two months from its first meeting.
The Minister for Health and Ageing was required to table the Final Report in Parliament (both Houses) within 15 sitting days of its receipt from the Committee.
CONDUCT OF THE REVIEW
The Committee undertook the Review with Secretariat support from the Dental Services Section of the Department of Health and Ageing (the Department).
The Committee met twice – on 27 October and 8 December 2009.
The Committee’s Final Report was provided to the Minister for Health and Ageing on 23 December 2009.
Dental Benefits Act 2008
The Dental Benefits Act 2008 (the Act) commenced on 26 June 2008. It establishes a legislative framework for the payment of dental benefits and specifically provides for the administration of the Medicare Teen Dental Plan, introduced by the Government on 1 July 2008 as an election commitment.
establishes an entitlement to dental benefits;
provides for the payment of dental benefits;
provides a framework for the issuing of vouchers (for example, in respect of teenagers who are eligible for the Medicare Teen Dental Plan);
establishes provisions for the protection (and, where authorised, the disclosure) of protected information;
creates general offence provisions relating to assignment of benefit agreements and the giving of false or misleading information;
allows the Minister for Health and Ageing to make Dental Benefits Rules under the Act (through a legislative instrument); and
provides for funds relating to the payment of dental benefits to be appropriated through a new special appropriation.
The Act is broadly modelled on relevant provisions of the Health Insurance Act 1973 (HIA) relating to the payment of Medicare benefits, which is a long established legislative framework for the payment of benefits for medical services. Unlike the HIA, the Act provides a framework for providing benefits under a means test.
To date, there has been limited application of the Act’s legislative framework as the Medicare Teen Dental Plan is the only program administered under it.
Dental Benefits Rules 2008
The Dental Benefits Rules 2008 (the Rules) commenced on 1 July 2008. The Rules set out detailed requirements in relation to a number of provisions under the Act, mostly related to the Medicare Teen Dental Plan.
The Rules provide for the establishment of a new Dental Benefits Schedule (DBS), which sets out the single item number, service descriptor and dental benefit payable for the Medicare Teen Dental Plan’s annual preventative dental check service (item 88000). The DBS could be expanded to include items for other dental services in the future.
The Rules also set out the administrative and eligibility requirements for the annual preventative dental check item, including:
the classes of persons that can be ‘dental providers’, or can render a service on behalf of a dental provider, for the purposes of the Act;
the circumstances where more than one voucher may be issued for a person in a calendar year;
the particulars to be recorded on an account, receipt or assignment of benefit form; and
the circumstances where vouchers are not required to be issued.
Copies of the Act and Rules are at Appendices 1 and 2 respectively.
Medicare Teen Dental Plan
The Medicare Teen Dental Plan was introduced by the Australian Government on 1 July 2008 as an election commitment. The program provides financial assistance to families to help assess the health of their teenagers’ teeth, and to introduce preventative strategies to encourage lifetime good oral health habits. The program was enhanced on 1 January 2009 to include additional groups of teenagers. Approximately 1.3 million teenagers are eligible for the program each year, out of a population of approximately 2 million 12 to 17 year olds.
Under the program, eligible teenagers receive a voucher each calendar year to assist with the cost of a preventative dental check provided in that year (see Appendix 3). The preventative dental check consists of an oral examination as a minimum requirement and, where necessary, x-rays, a scale and clean, fluoride treatment, oral hygiene instruction, dietary advice and/or fissure sealing.
Preventative dental checks are provided by dentists who are registered with Medicare Australia. The preventative dental check can also be provided by a dental therapist or dental hygienist on behalf of the dentist. Vouchers can be used at private dental surgeries and public dental clinics participating in the program.
In 2008, the voucher provided a Medicare benefit of up to $150 towards the cost of an annual preventative dental check. This was indexed to $153.45 for 2009. Dentists may set their own fees for services, however, the Government has encouraged dentists to bulk bill preventative dental checks for eligible teenagers. As at 30 November 2009, 57% of preventative dental checks were bulk billed. However, as the lag time between service provision and benefit claiming can be several months, it is not possible to predict the future annual bulk billing rate for the program at this early stage.
The Medicare Teen Dental Plan is available to teenagers who are eligible to receive Medicare benefits, and who, at some time in the calendar year:
are aged between 12 and 17 years; and
satisfy the means test for the program.
At the time of implementing the scheme, the means test limited access to teenagers 12 to 17 years of age in families receiving Family Tax Benefit Part A (FTB-A), and teenagers in the same age group receiving Youth Allowance or Abstudy. However, it was determined that the means test excluded some groups of teenagers that should benefit from the Medicare Teen Dental Plan. For example, 16 and 17 year olds receiving financial assistance under the Veterans’ Children Education Scheme (VCES), the Military Rehabilitation and Compensation Act Education and Training Scheme (MRCAETS), or the Disability Support Pension are not eligible to receive Youth Allowance or Abstudy and their families are not eligible to receive FTB-A with respect to that teenager.
In consultation with the Department of Human Services, Department of Veterans’ Affairs (DVA), Department of Education, Employment and Workplace Relations, Department of Families, Housing, Community Services and Indigenous Affairs, Centrelink and Medicare Australia, eligibility for the Medicare Teen Dental Plan was extended from 1 January 2009 to teenagers 12-17 years of age where:
the teenager is receiving either Carer Payment, Disability Support Pension, Parenting Payment, Special Benefit; or
the teenager’s family/carer/guardian is receiving either Parenting Payment, or the Double Orphan Pension in respect of the teenager; or
the teenager’s partner is receiving Parenting Payment; or
the teenager is receiving financial assistance under VCES or MRCAETS and cannot be included as a dependent child for the purposes of Family Tax Benefit because they are 16 years or older.
This enhancement has extended eligibility to a further 15,000 teenagers each year.
Funding for the Medicare Teen Dental Plan was announced as $490.7 million over five years to 2011–12. The following table details administered funding to 2012–13:
Medicare Teen Dental Plan – Administered funding
Departmental (operational) costs for Medicare Australia and Centrelink to administer the program are $37.4 million over 5 years from 2007–08.
Actual administered expenditure under the Medicare Teen Dental Plan in 2008–09 was $66.7 million. Expenditure for 2009–10, to 30 November 2009, was $54.7 million.
The projected utilisation rate of vouchers for the 2008–09 financial year was 55%. Voucher utilisation for the 2008 calendar year (from 1 July when the program was introduced) was 26.4% (345,074 services claimed of 1.30 million vouchers sent)1. Utilisation of 2009 calendar year vouchers is 21.8% as at 30 November 2009 (296,672 services claimed of 1.36 million vouchers sent)2. The 2009 utilisation rate is expected to rise as claims are still being made. A more accurate picture of utilisation will not be available until some time in 2010.
The Medicare Teen Dental Plan is administered by Medicare Australia using client eligibility data provided by Centrelink and DVA. In mid-January each year, Centrelink and DVA provide Medicare Australia with data on teenagers who will be eligible for the program that year. From March onwards, Centrelink and DVA provide Medicare Australia with monthly data on newly eligible teenagers.
Medicare Australia matches Centrelink/DVA data with data held by Medicare Australia (to confirm the teenager’s eligibility to receive Medicare benefits) and issues a voucher. Where data cannot be matched, Medicare Australia is unable to issue a voucher. To date, around 97% of eligibility records have been able to be matched with Medicare Australia records.
Medicare Australia undertakes a bulk mail out of vouchers at the beginning of each calendar year – in 2008, this occurred in July/August. Medicare Australia also sends vouchers to newly eligible teenagers or their families at the beginning of each month between March and November. Vouchers are not automatically distributed to teenagers who become eligible in November and December. Instead, vouchers are provided on request of the teenager, family or carer. A voucher is not required for a dentist to confirm eligibility. Medicare Australia can be contacted directly by the provider or patient for eligibility confirmation.
Prior to its introduction, information about the Medicare Teen Dental Plan was sent to all dentists (this included a letter from the Minister and the Medicare Teen Dental Plan booklet), as well as to dental and medical professional groups. Information and resources are also available on the Department of Health and Ageing’s website at www.health.gov.au/dental and Medicare Australia’s website at www.medicareaustralia.gov.au. Medicare Australia has also provided dentists with brochures promoting the program, for display in their surgeries. Medicare Australia also displays posters and brochures on the program in Medicare Offices. Each year, eligible teenagers and families receive a letter from Medicare Australia, together with their voucher(s). The letter outlines the program and explains how to use the voucher.
ARRANGEMENTS FOR REPRESENTATIVE PUBLIC DENTISTS
Preventative dental checks provided in public dental clinics are bulk billed. As the Medicare system requires providers to be individually registered with Medicare Australia, states and territories have nominated one or more ‘representative public dentists’ (RPDs) under whose name and special Medicare provider number the preventative checks are billed. 100% of the benefits assigned to RPDs are paid by Medicare Australia directly into state/territory or public health service controlled bank accounts.
The Commissioner for Taxation has ruled that income derived by RPDs from Medicare benefits assigned under the Medicare Teen Dental Plan is taxable income (Class ruling CR 2009/16). However, the amount paid by Medicare Australia to a state or territory bank account in respect of those benefits is an allowable deduction to the RPD under section 8-1 of the Income Tax Assessment Act 1997 (ie 100% deductible).
Members of the public have provided feedback on the program through ministerial correspondence and direct contact with the department. This feedback includes concerns about:
the level of benefit for the preventative dental check and ‘value for money’;
teenagers being charged the full $153.45 for a short oral exam (which is the minimum requirement for claiming item 88000), compared with a sibling or friend who received a more comprehensive service (including, for example, a scale and clean, fluoride treatment and x-rays) for the same price;
access to, and Medicare coverage of, follow-up treatment needed after a preventative dental check identifies an oral health issue; and
limited access to participating dentists outside metropolitan areas.
DISCUSSION OF KEY ISSUES
In examining whether the purposes of the Act have been attained, and whether its administration in relation to the Medicare Teen Dental Plan has been appropriate, the Committee explored the following key issues:
Whether the Act and Rules provide an appropriate legislative framework for the payment of dental benefits.
Whether the Act and Rules support the appropriate administration of the Medicare Teen Dental Plan.
Whether the start-up of the Medicare Teen Dental Plan has been successful.
Issue 1 – do the Act and Rules provide an appropriate legislative framework for the payment of dental benefits?
The Committee finds that the Act and Rules achieve their aim of providing an appropriate legislative framework for the payment of dental benefits.
However, the Committee also perceived some benefit in making some structural and administrative changes to the Medicare Teen Dental Plan.
The use of a single item number (DBS item 88000) for the range of procedures covered by the preventative dental check causes systems problems for dentists. All dentists use the Australian Schedule of Dental Services and Glossary (currently, 9th Edition) published by the Australian Dental Association (ADA) for the charting and billing of private patients. This is the generally accepted coding system of dental treatment and is endorsed by the National Coding Centre.
The ADA Schedule assigns a three-digit code to items or clinical procedures. As a general rule, each item describes a treatment outcome (eg, an oral examination, x-ray, clean and scale, fluoride treatment, oral hygiene instruction, dietary advice and fissure sealing are all ascribed an individual item number).
It is acknowledged that the Medicare system cannot accommodate the ADA three digit codes as set out in the ADA schedule of items. However, the Medicare chronic disease dental scheme (CDDS) already applies a two-digit prefix to corresponding ADA items for services provided by dentists, dental specialists and dental prosthetists under the scheme. For example, dentists use Medicare CDDS items 85011 (oral examination), 85022 (x-ray), 85111 (clean and scale), 85121 (fluoride treatment), 85131 (dietary advice), 85141 (oral hygiene instruction) and 85161 (fissure sealing). These items correspond to ADA items 011, 022, 111, 121, 131, 141 and 161 respectively.
The use of the single DBS item (88000) to describe the range of treatment outcomes covered by the preventative dental check also does not allow policy makers and researchers to collect meaningful data about the impact of the Medicare Teen Dental Plan (ie it does not allow the Government to know which services patients are getting). This lack of transparency also affects patients who can be left unsure about which services they have received during their check-up.
In the Committee’s view, the introduction of new item numbers for each procedure included under the preventative dental check, using ADA schedule codes as per the CDDS items, may solve these issues.
The Committee notes the potential difficulties experienced by eligible teenagers moving between the private and public dental sectors where they require follow-up treatment. This may include problems with transferring patient records between sectors, and potentially incompatible treatment plans across jurisdictions. Patients are also often unaware of what treatment they require.
Although the issue of ongoing treatment is not part of the Medicare Teen Dental Plan, the Committee notes that the Government and the ADA both have a role in ensuring that dentists are aware of this problem and in encouraging dentists to provide teenagers who need follow-up treatment with a written copy of their proposed treatment plan.
The Committee notes that while Dental students provide a significant number of dental services in the public dental sector, the provision of preventative dental checks by dental students is not covererd by the Act.
Issue for noting:
The Government could consider replacing the single preventative dental check item (DBS item 88000) with individual items for each procedure provided to patients during their annual preventative dental check.
Issue 2 – do the Act and Rules support the appropriate administration of the Medicare Teen Dental Plan?
The Committee finds that the Act and Rules support the appropriate administration of the Medicare Teen Dental Plan.
However, the Committee views the key question about the administration of the program as the degree to which it supports behaviour change in teenagers (ie having regular dental check-ups) and the extent to which this has contributed to improving oral health outcomes.
Between 1994 and 2005, the proportion of teenagers aged 12 to 17 years who visited a dentist within the previous 12 months ranged from 74.2% in 1994 to 78.9% in 20053. It may be, therefore, that the majority of 12–17 year olds who have received preventative dental checks under the Medicare Teen Dental Plan would have had a check-up irrespective of the program. However, some dentists report that there is a proportion of teenagers who are having preventative dental checks because they have received a voucher under the program.
The Medicare Teen Dental Plan pays a flat fee (of $153.45 in the 2009 calendar year) for an annual preventative dental check which must consist of an oral examination as a minimum requirement and, where required, may include a clean and scale, x-rays, fluoride treatment, oral hygiene instruction, dietary advice and/or fissure sealants. There is a concern that the flat fee structure of the program may not provide a sufficient incentive for dental practitioners to provide some of the preventative services additional to the oral examination. However, without individual items for each procedure covered by the preventative dental check, it is not possible to know if this is happening.
In the Committee’s view, it is too early in the program cycle to tell whether the Medicare Teen Dental Plan has been the motivating factor in teenagers having preventative dental checks. Section 68 of the Act requires that the operation of the Act be reviewed again as soon as practicable after the third anniversary of its introduction (ie after 1 July 2011). Reviewing the Medicare Teen Dental Plan as part of the second review of the Act would allow it sufficient time to mature, giving it at least two full calendar years of operation prior to evaluation.
Issue for noting:
As the Medicare Teen Dental Plan is in its early stages of operation, the Government could consider evaluating the program once it has matured, as part of the second statutory review of the Act.
Issue 3 – has the start-up of the Medicare Teen Dental Plan been successful?
The Committee finds that the introduction of the Medicare Teen Dental Plan has been successful.
Eligible teenagers are receiving their vouchers and utilisation of the program has increased in the 2009 calendar year to 30 November 2009.
To better understand utilisation of the program and the social and geographical circumstances of eligible teenagers, the Committee considered data relating to teenagers who received vouchers and teenagers who used those vouchers. The Committee also looked at the breakdown of receipt and utilisation of vouchers in metropolitan, rural and remote areas and the proportion of bulk billed services in metropolitan, rural and remote areas.
The SEIFA index of relative socio-economic advantage and disadvantage was used for the SEIFA analyses of voucher utilisation and bulk billing rates. This is a general socio-economic index. A low score on the index indicates relatively greater disadvantage and a lack of advantage in general. An area could have a low score if there are (among other things) many households with low incomes, or many people in unskilled occupations; and few households with high incomes, or few people in skilled occupations. A high score indicates a relative lack of disadvantage and greater advantage in general. An area may have a high score if there are (among other things) many households with high incomes, or many people in skilled occupations; and few households with low incomes, or few people in unskilled occupations.
The Australian Standard Geographical Classification Remoteness Area was used for the remoteness area analyses of voucher utilisation and bulk billing rates. There are six ‘Remoteness Areas’ in this classification:
Major Cities of Australia: Collection Districts (CDs) with an average Accessibility/Remoteness Index of Australia (ARIA) index value of 0 to 0.2
Inner Regional Australia: CDs with an average ARIA index value greater than 0.2 and less than or equal to 2.4
Outer Regional Australia: CDs with an average ARIA index value greater than 2.4 and less than or equal to 5.92
Remote Australia: CDs with an average ARIA index value greater than 5.92 and less than or equal to 10.53
Very Remote Australia: CDs with an average ARIA index value greater than 10.53
Migratory: composed of off-shore, shipping and migratory CDs
All analyses are based on ‘date of service’ data available as at 30 November 2009.
Important Note: where postcodes were not included in either the SEIFA or Remoteness Area concordance file (or both), the relevant data was included in the ‘Unalloc’ (unallocated) grouping in Charts 1, 2, 3 and 4 below. Less than 1% of vouchers across the analyses were ‘unallocated’.
Charts 1 and 2 show that uptake of vouchers during the period was highest in areas of relatively greater advantage (peaking at 29.4% in SEIFA index 10 locations), and in major cities and inner regional areas (24.8% and 25.1% respectively). This likely reflects greater availability of service providers in wealthier metropolitan and inner regional areas.
Chart 1: Voucher utilisation by SEIFA – 1 July 2008 to 30 November 2009
Chart 2: Voucher utilisation by remoteness area – 1 July 2008 to 30 November 2009
Charts 3 and 4 show that bulk billing rates for the period were highest in areas of relatively greater disadvantage (ranging from a high of 74.1% in SEIFA index 1 locations to a low of 43.5% in SEIFA index 10 locations). The bulk billing rate in SEIFA index 6 (63.2%) went against the trend. However, this may be an anomaly which will disappear over time.
Bulk billing rates were also highest in remote areas (64.6%), while rates in major cities, inner and outer regional areas were similar (57.8%, 55.0% and 55.3% respectively).
Chart 3: Bulk billing by SEIFA – 1 July 2008 to 30 November 2009
Chart 4: Bulk billing by area – 1 July 2008 to 30 November 2009
The results of the above analyses may reflect eligible families’ ability to pay out-of-pocket costs for dental services, and the current distribution of the dental workforce. However, it is too early in the program’s life cycle to know whether this is the case and if these early trends will continue.
The Committee notes that printed and web-based communication materials for the Medicare Teen Dental Plan have been appropriate for its introduction. However, consideration could be given to advertising the program more broadly to potentially increase uptake of the vouchers.
For example, the Government could use school newsletters in high schools, brochures in doctors’ waiting rooms and its relationship with relevant consumer organisations (eg Consumers Health Forum) to make families more aware of the program. Linking into the healthdirect Australia national telephone service and Centrelink’s communication to clients may also be useful in promoting the program.
Dental practitioners could also receive timely reminders about the availability of the program. This could be achieved with the support of the ADA.
In all of these measures, it will be important to ensure that communication materials are easy to read, particularly those aimed directly to eligible teenagers. It will also be important that the materials help manage the expectations of families with eligible teenagers.
The Medicare Teen Dental Plan voucher could also be improved with stronger branding. Currently, the voucher does not look like a ‘voucher’ and this may be contributing to the lower than expected utilisation of the program.
In addition, it may be prudent to delay slightly the bulk mail-out of vouchers at the beginning of each calendar year. Sending letters and vouchers to families at a time when children are on extended school holidays may not capture and retain their attention. Early to mid February may be a more suitable timeframe for the bulk mail-out of vouchers.
The Committee was tasked with examining whether the Act has attained its purposes and evaluating the administration of the Act in relation to the Medicare Teen Dental Plan.
In conducting this Review, the Committee has found that the Act, and its associated Rules, provide an appropriate legislative framework for the payment of dental benefits and support the administration of the Medicare Teen Dental Plan.
The Committee has also found that the introduction of the Medicare Teen Dental Plan has been successful.
The Committee has noted that introducing individual item numbers for the range of procedures covered by the preventative dental check may improve integration of the program with dentists’ billing systems and provide better information for patients and for evaluating the impact of the Medicare Teen Dental Plan.
The Committee also noted that the Government could consider including an evaluation of the operation of the Medicare Teen Dental Plan as part of the second statutory review of the operation of the Act, to be undertaken as soon as practicable after the third anniversary of its introduction (ie after 1 July 2011). The evaluation would confirm whether the early successes of the program have been sustained and show whether eligible teenagers are improving their oral health habits by coming back for regular preventative dental checks each year.
1Based on ‘date of service’ data available as at 30 November 2009.
2Based on ‘date of service’ data available as at 30 November 2009.
3Trends in access to dental care among Australian children (2009), Ellershaw AC and Spencer AJ, Australian Institute of Health and Welfare (AIHW) Dental Statistics and Research Series No. 51.