Why is dentistry not part of health care?
Most people cannot understand why the mouth is not included in medical management, especially since there is mounting evidence that oral and dental infection can cause medical complications that cost many times more to treat medically than prevent dentally.
How did this happen?
Dentistry separated from medicine over 500 years ago when the previously allied barber surgeons evolved into two streams, medicine and dentistry, and subsequently established independent schools to train doctors and dentists. Not only is dentistry independent of medicine it is also privatised, self regulated, outside health care, and Medicare legislation (1973)excludes it, which, as you will see, was a big mistake.
Dental infections can cause medical complications
The connection between infection from the mouth and medical problems is not new. In the 1930’s, the ‘focal sepsis’ theory was in vogue. It proposed harmful bacteria could be swallowed, inhaled, or travel via the blood stream, to distant sites, and cause infection there. To prevent this there was an epidemic removal of tonsils, teeth, and appendixes. The theory gradually lost favour and was discarded, but has since re-emerged with medical research giving it credence. Because of this, there is a clear distinction between what is non elective ‘medically necessary dental care’, and belongs in primary care, and what is elective ‘dentally necessary dental care’, which belongs in dentistry.
Why should we make this distinction?
AIHW (2010) reported 1 in 2 Australians have private dental cover, which is a reliable indicator of use of dental services. Most of the 8 million without dental cover have a chronic disease, a disability, or require care. So they are the highest medical and dental risk groups. Herein is the problem. GP’ frequently treat these patients, but dentists don’t.
Dental infections in these patients go undiagnosed and untreated and cause medical complications, which are treated medically, but not dentally. These INDIRECT costs are many times more than cost of preventing them, and add billions to health care costs. If these INDIRECT were added to the DIRECT costs the disease that costs the most and affect the most people is dental disease, NOT heart disease. You’ll see why.
The DIRECT costs for those using dental services are known. In 2008-09, they were $7 billion (AIHW 2010), almost as much as heart disease, $7.7 billion. Individuals pay for 90% of that. These high costs reflect the increasing demand for expensive crowns, bridges, veneers, and implants, which are cosmetic, not health related.
How much are the Indirect costs? Can they be avoided?
No one knows, but there is some useful US data. The US has 120 million uninsured who do not receive any dental care. Increasingly they are accessing emergency rooms (ER’s) with acute dental problems. Although ER’s do not have any dental services, they can provide temporary relief with pain killers and antibiotics, but most of the uninsured cannot pay. 60% of US bankruptcies are for unpaid medical bills. Florida has a population approaching 20 million. It recently reported 139,000 visited ER’s with acute dental problems that cost $141 million, $1000 each. They estimated a dental service by a dentist in a dental office would probably cost only $100. Instead of spending $141 million it would cost only $13.9 million. There is the saving, there is the solution.
Another study by the US Institute of Health, Office of the Actuary (1988), investigated medical complications after surgery caused by untreated dental infections. It cost $100 million (10%) to treat the complications, but if there had been a dental assessment before surgery it would have cost only $16 million to prevent those complications. There is the saving, again the solution.
The US subsequently introduced a limited Medicare dental scheme in 1998, but US dentists have never embraced it because the fees were inadequate and it did not include any restorative dentistry.
These two examples clearly show the costs, the savings, and the solution. The inclusion of an oral and dental assessment in medical practice and prioritising ‘medically necessary dental care’, and referring to a dentist. This immediately costs less, provides better health, saves money, and keeps patients out of expensive emergency departments and hospitals.
A Japanese study into fatal broncho pneumonia in nursing homes found professional antibacterial l oral care reduced the number of fatalities. Importantly, they also found the risk of fatal broncho pneumonia was just as high with those who had NO teeth or dentures as it was for those who teeth and dentures. The risk was NOT the condition of the teeth, but the uncontrolled bacteria inside on the mouth that collected at the back of the mouth and entered the lungs.
The US estimates each hospitalisation for pneumonia cost $25,000. Preventing it might cost only $1 a day.
What is this costing in Australia?
There is no data. One can only make estimates. AIHW estimates range from $10 million- $300 million.
My estimates are very different as I have spent 25 years experience in aged care, mental health, disability, general practice, and indigenous health. AIHW statistics do not present the real picture.
GP consults $10-100 million
Emergency departments (ED’s) $50- 100 million
Hospitals admissions $400 – 1billion
Aged care $1.4 billion
These cost range from $2 – 2.6 billion. Based on demonstrated savings in the US, there might be potential savings of $1-2 billion.
AIHW (2010) reported 80% of health expenditure is spent on treating chronic conditions, and 50% of hospital admissions are for treating chronic disease complications that are preventable. It therefore would not be unreasonable to assume many of those medical complications that are treated medically are caused by underlying untreated dental infections that remain untreated.
Aged care costs are huge because mouth problems (not teeth related) such dry mouth, ulcers, thrush, mucisitis (inflamed soft tissues) affect eating, sleeping, swallowing. speaking, which then lead to weight loss, digestive disorders, dehydration, constipation, behaviour changes, confusion, etc. The consequences are treated but the cause is not. That’s why it costs so much. This aspect of health care has been sadly neglected.
If the GP is responsible for health care outcomes, they must be made aware of existing oral and dental infections that will affect their medical management.
An oral and dental assessment therefore should be mandatory in health care, carried out by a dental resource specifically trained for health care (Bachelor of Oral Health), have a dental background, and included in the allied health team.
Medicare legislation should be amended to include an oral and dental assessment, prevention, and education, facilitating referrals for ‘medically necessary dental care’, which is carried out by participating dentists/therapists (?) all covered by Medicare. This would include inexpensive intermediate dental restorations, extractions, and scaling and cleaning. These costs, as has been shown, are many times less than what is currently spent and wasted, it would put high risk patients in safe mode preventing future disease and complications.
As shown in Japan, more effective oral care practices should be adopted and covered by Medicare. Since the objective is to reduce the bacterial load and prevent disease, the use of antibacterials is mandatory. Toothpastes have no antibacterial effect and often make sensitive mouths worse. Health care related oral care needs should be managed and monitored in health care as part of their ongoing medical management, not in dentistry. The products should be covered as medical items as those who need these can least afford them. The costs of prevention are many times less than treatment.
Beyond general practice, a lot also needs to be done. There are NO oral health services in HACC, young disabled, mental health, spinal units, head injured, or homeless. Palliative care is an area that needs urgent attention as does intensive care, cancer patients, and those in neuro science wards in hospitals.
This is not just about health care and costs. What are lacking are compassion and empathy and a focus on personal needs that translate into quality of life, self esteem, dignity, and comfort.
If this was to happen, Australia could have the best health system in the world and one which would be the global benchmark.
Dr Patrick Shanahan BDSc(WA)DipPH(Syd) Oral Health Consultant
Clinical dentistry 1961-82: Public policy 1983-2015. Aged Care Legislation (1988, 1995) MCDDS (2004) AMA(WA)COGP Ministerial Submission for Inclusion of Oral Health in Health Care.