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

Mar 29, 2018

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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