JOHN DWYER. Poor oral health in Australia; a costly chronic problem getting worse and which current strategies have no chance of resolving.

Australia’s health “system”, such as it is has two “Achilles’ Heels”. The left one is our lack of emphasis on the prevention of disease while the right one concerns our incompetence in integrating health services in a patient-focused way. Both were on vivid display recently with the release of a new report by the  “Australia’s Oral Health Tracker”.

Oral health is an essential requirement for good health. For decades health professionals have been arguing that it is illogical and costly to regard the protection of oral health any differently than the protection of our hearts and lungs. Poor oral hygiene leads not only to discomfort and disfigurement, it increases the risk of developing oral cancer and malnutrition. The just-released report documents a distressing (indeed shameful) reality that one in six Australians are missing more than ten teeth making it harder for them to get adequate nutrition. Because frequent exposure of our teeth to sugar is a factor in generating tooth day, the problem is often associated with obesity, diabetes and cardiovascular disease. What taxpayer-funded dental services are available are inadequate, difficult to access and grossly underfunded. We spend about 2% of the health budget on dental care and about the same amount on “prevention” in general.

In 2005 the World Health Organisation called for oral health care to be integrated with all health care.  Australia’s Oral Health Tracker report emphasises that the “compartmentalisation involved in viewing the mouth separately from the rest of the body must cease because oral health affects general health by causing considerable pain and suffering and by changing what people eat, their speech and quality of life and well being” The wake up call that is this new report clearly supports the imperative that is the assumption of dental care into Medicare.

In New Zealand, where children have received the benefit of universal publicly-funded dental services since 1921, 59.7% of children aged 2 to 4 have visited a dentist in the last 12 months compared with 28.4% in Australia. The proportion of New Zealand children aged 2 to 4 with untreated tooth decay is only 14.9 %.In Australia, the figure is close to 37%. New Zealand provides an example of the association between affordable early dental service utilisation and low rates of untreated tooth decay.

Here are some more sobering points from the report. Gum disease affects one in five adults.More than one-third of five and six-year-olds have decay in their primary (baby) teeth, no doubt contributed to by the fact that 75% of children in this age bracket exceed the recommended daily intake for sugar. Almost half of Australian adults and one-third of children do not brush their teeth twice daily and when they do they brush for too short a time for the cleaning be maximally effective.Ten percent of all hospital admissions that should be avoidable involve children aged 5-9 years who need dental treatment that requires an anaesthetic. About 50 % of adults and 25% of children have not had a dental checkup in over a year. Each year about two million adults delay checkups with a dentist because of the costs involved.

There are a number of State and Federally funded programs supporting dental health. It is obvious that they are not satisfactory. Public hospital dentistry though touted is practically non-existent. There are a staggering 555,000 Australians on the waiting list for hospital treatment of serious dental problems.Waiting times vary from 130 days in Tasmania to 933 days in Western Australia! Disadvantaged children can be provided with a Federal payment of $700 over two years to pay dentist who participate in the care scheme. The Coalition reduced the figure from $1000 last year.

In 2011 Nicola Roxon convened a top-level working party to advise her government of how we could address the costly inequity. The National Advisory Council on Dental Health (the Council) was established as a time-limited group to provide strategic, independent advice on dental health issues.  In the report that followed was the following conclusion “The Council understands that a comprehensive response for those facing access barriers is potentially very costly. Achieving better access across the population would require a level of funding way beyond what is currently available”.

The Council put forward two broad models for a universal children’s scheme based on then-current dental service delivery systems. The first would utilise an individual capped benefit entitlement and provide a basic suite of preventive and treatment services. The second would expand services and improve consistency across state and territory public dental services.

For adults, they recommended a means-tested individual capped benefit entitlement aimed at increasing access to basic dental services for all concession card holders.

The reason for mentioning this report relates to the report’s estimated (2011) costs involved in providing the required support. The first two years of these expanded access programs would require 10 billion dollars! Currently, the Federal government spends two billion dollars a year on oral health but Australians “out of pocket” expenditure on dental care amounts to ten billion dollars a year! When you look at the fiscal challenge involved its hard not to feel frustrated when the seven billion dollars in direct taxpayer support for Private Health Insurance would be so much better spent if made available for a National Dental Scheme within Medicare.

As is true when talking about all our major health challenges the long-term solution involves preventing tooth decay and its consequences. In the Medical Home model often discussed in these pages, a Medicare-funded Dental Hygienist should be a standard member of the multidisciplinary team. When you are enrolled in a program designed to help you stay well oral health should obviously be included. A dental Hygienist can educate ( less sugar please, proper cleaning techniques etc), clean teeth and apply a Fluoride paste and inspect and recognise more serious problems that need referral to a Dentist. The inclusion of such skills is common in other countries.

The bigger and more Immediate challenge is to provide treatment for the many who need urgent care. Unlike doctors, dentists have no set fee structure, they can and do charge what they like. They make more money than General Practitioners and enjoy their independence. Many, but nothing like enough, participate in what government schemes are available. Most dentists I believe are already very busy. This shocking report on our dental health must provoke a re-think by government, professional and consumer advocates. The Dental profession needs to be more involved in considering the current inequity in access to dental services while good government looks harder at expenditure priorities.The problem is of long standing but the evidence is telling us that far from solving the problem, oral health in our wealthy country is continuing to worsen, as usual having a disproportionate effect on the most financially insecure Australians. It is likely that the cost associated with oral disease exceed the costs that would be involved in preventing it. It’s hard to see the “fair go mate ” country giving all a fair go without spending a lot more money now. This would represent an investment returning good dividends and the social justice we would like to again be an Australian characteristic.

Professor John Dwyer is an Emeritus Professor of Medicine at UNSW and has been involved in the promotion of structural  reforms to Australia’s health system for many years. He was the Founder of  the Australian Health Care Reform Alliance.

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3 Responses to JOHN DWYER. Poor oral health in Australia; a costly chronic problem getting worse and which current strategies have no chance of resolving.

  1. Heather Cameron says:

    Having suffered at the hands of dentists and allowing one rather high profile dentist talk me into doing a root canal treatment. Alas, this gravely disturbed my teeth for years. Once the root canal tooth fell out, things settled down, and I was able to get very proactive re preventative treatments.

    Once a dentist of Indian extraction suggested I wash my mouth out every day with a very strong salt solution. He did not specify what sort of salt. Wish I’d listened to him and avoided the Root Canal treatment. These days I quickly use a strong Himalayan Rock salt and water solution, when there looks like even a minor flare-up. This works well.

    Searching the web for preventative treatment was hard, but I eventually found a guy who just used soap to clean his teeth, and since doing this he says his teeth had been fine. I now use 2 small cakes organic coconut oil soap, one with Activated charcoal and one with Bentonite Clay, plus a pure cake of Himalayan Rock salt, with my toothbrush coated with these three each night before sleeping. Best not to fully wash the mouth out leaving a little to sit on the gums and teeth. This method of cleaning my teeth is working much better than all the toothpastes and mouth washes I have ever tried. I have also used diluted food grade Hydrogen Peroxide 6% as a mouth wash as this gets rid of the gram positive/anaerobic bacteria or keeps them down. This will also whiten the teeth. Expecting my shipment of Emu Oil spray to arrive soon and this is supposed to be very good at healing gum disease even the deep pockets. So am guessing it will actually go in and dissolve the buildup of tartar.

    It is not hard to guess why the dentists aren’t into preventative treatment; greed being a good guess and not being able to resist humans in a vulnerable position, which kind of looks rather psychopathic. Even the alternative dentists are bad enough with lack of sharing knowledge.

  2. Chris Peck says:

    John Dwyer makes valid and salient points demonstrating the need to put the mouth into health. Whilst dental services are largely funded through a user-pay system, a large proportion of the population (in NSW those under 18, over 65 or on government support) is eligible for public dental services. A major issue, if we are to agree that universal health care is a basic human right, is the inconsistent approach to public dental funding. Whilst they are state-provided the funding is derived from both state and Commonwealth governments. Over the past 45 years, we’ve had different Commonwealth programs that differ with respect to eligibility and funding. We’ve seen the Australian School Dental Program, Commonwealth Dental Health Programs, Allied Health and Dental Health Care Initiative, Chronic Disease Dental Scheme, Medicare Teen Dental Plan, Child Dental Benefits Schedule, and other initiatives. This erratic and unpredictable approach makes it very difficult to do any service delivery planning and requires enormous resources from dental providers to change tack with each new government’s initiative. What is needed is an enduring funding model which is reviewed and improved regularly. In a utopian world, we would have a large preventive focus, and a system of evidence-based interventional care as needed and offered to the entire population. Whilst that should be an ultimate aim, a pragmatist would suggest an initial focus on the most disadvantaged members of society. Improving dental health has enormous physical, mental and social effects and some interesting outcomes including school and work participation could be assessed. Although it’s a no brainer on what direction these would head.

  3. Tony Ryan says:

    I have no proof, but I would bet that the prime lobby responsible for governmental abrogation of public health dental intervention responsibility, would be dentists.

    For several years, I had to work and save to pay for a simple metal plate for my upper jaw. Cost $4000. This is the life of an age pensioner in corrupt market-led Australia. To get additional help, other than for a tooth extraction, was a two-year delay. Sadly, no dentist was available.

    Asking one’s dentist why this is so, is an invitation for a over-hasty completion of that appointment; coupled with a punishing bill.

    I see little difference between Australia’s dental health and the establishment which targets the rest of the body: a thousand ways to make money out of human misery.

    Even Professor Dwyer’s well-intentioned analysis glosses over inconvenient realities. For example, it is simply not true that “other countries” apply fluoride paste, as part of the skills application. Following a lengthy period of research completed in 1954, all western European nations abandoned fluoridation proposals because of the established link with several fatal cancers. Specifically, Osteosarcoma, squamous cell carcinoma, osteosclerosis, hepatocholangio carcinoma, thyroid follicular cell tumours, and genetic damage to children in even half-doses; and it enhances the effects of other cancers.

    Yes, naturally-occurring fluroide hardens tooth enamel but the kind dumped in water supplies, an industrial waste-product, does not have the same effect. And I used the word “dumped” deliberately. There is no science applied in this contamination of water supplies. A decade ago the amount added to a Brisbane water supply was found to be thousands percent above the safe limit. There was no prosecution and no warning to consumers. And where is the science behind “safe”?

    Actually, the very idea behind having experts address such issues is illogical. Tooth decay in Australia is primarily caused by governments who protect the sugar, soft drink, food processing and confection industries; rather than protect the people. This is corruption, pure and simple.

    The second contributor is poverty. People cannot afford to go to the dentist. And the reason for the poverty is joblessness, which is a direct outcome of the collapse of manufacturing and domestic food industries since protectionism was abandoned and free trade installed. And I bet Professor Dwyer believes the government and social science lie that unemployment is only 6%. Try 50%.

    My own surveys, which test real people door-to-door, every three years from 2001, detail the real economy of Australia which, far from being an era of unprecedented prosperity as John Howard claimed, is a genocidal period of slow-motion death due to malnutrition, food toxicity, medical malpractice, and carefully nurtured ignorance.

    Another cause of death has been suicide, generated by male anguish at perceived failure to live up to artificial media-generated standards, which were never the fault of the victims in the first place.

    All of these problematic areas are linked by corporate control of government and of all sources of critical information, including the media. From 1936 to 1946 this was known as fascism but today it is called market-led democracy. I can tell you now, no medical doctor or academic dentist on this planet is equipped to make this kind of diagnosis.

    In point of very salient fact, there is no discipline or science which addresses this, the most lethal crisis in Australian history.

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