Ending the medical / dental divide (redux).

Mar 12, 2018

In a piece published in the Medical Journal of Australia in December 2014, I called for an end to the artificial medical/dental divide. At the same time, writing in The Conversation, I outlined six first steps towards the better integration of dental and medical care to improve health outcomes and contain overall health care spending. My thoughts then are applicable today, especially in light of additional data and information that has emerged over the past three years.

An Aussie smile is an instant indicator of socioeconomic status, employability and self-esteem. It’s also a predictor of physical health. Yet statistics from the Australian Institute of Health and Welfare show that  1 in 4 Australian children aged 5-10 years have untreated tooth decay in their primary teeth and 1 in 25 Australians aged 15 and over have no natural teeth.  Millions of Australians suffer from toothache, gum disease and dry mouth. We must recognise that bad teeth and poor oral hygiene are not simply cosmetic problems but the cause of sickness, disability and even death.

To quote what I wrote in 2014:

“Oral diseases can ravage the rest of the body and physical illnesses and trauma affect oral health. Moreover, the risk factors for oral disease and dental decay — high sugar diets, poor hygiene, smoking and excessive alcohol consumption — are also risk factors for heart disease and cancers. Yet medicine and dentistry remain distinct practices that have never been treated the same way by the health care system, health insurance funds, public health professionals, policymakers and the public.  … it is time to make dental and medical professionals partners in delivering health care services and to include the mouth as part of the body.”

Here are the six first steps that I proposed:

  1. Government funding should focus on the best-value investments, which span three broad areas: fluoridation, preventive services for children, and preventive and treatment services for the poor and those with special needs.
  2. Dental and medical professionals must become partners in delivering health care services. This should entail some shared training, a recognition that dental services are an integral part of primary care, inclusion of dental information on Personally Controlled Electronic Health Records and professional courtesies around patient referrals.
  3. A “Dental Health Service Corps” made up of dentists and dental staff, doctors, nurses, community/Aboriginal Health Workers and public health professionals could ameliorate the maldistribution of the dental workforce and take oral health services and education where they are needed.
  4. Health promotion activities around tackling obesity, smoking and substance abuse, breastfeeding and better management of chronic conditions and the use of multiple medications need to include oral health information. Help with oral hygiene is also a critical aspect of care for the frail aged, people with mental illness, people with disabilities and those on certain medication regimes.
  5. Governments should consider establishing emergency dental services within hospital emergency departments, at least on weekends.
  6. If private health insurance funds are serious about greater involvement in primary care to keep patients out of acute care, they must consider providing better access to dental care with reduced out-of-pocket costs.

Implementing these proposals will require concerted action from all stakeholders. They are as much about changes in cultures and focus on increased resources – although these are also needed. The consequences of doing nothing are severe, and are borne by governments, healthcare systems, employers, and individuals.

There is also another dental divide, based on income and geography. Dental care is expensive. Much of the cost is borne by the patient, even when they have private health insurance. Those Australians who can afford regular and routine dental care report low levels of extractions and relatively low levels of fillings. But for too many Australians, a visit to the dentist is an unaffordable luxury and the waiting times for public services are incredibly long. In such circumstances, many people are forced to seek pain relief from general practitioners and emergency departments, adding to the pressure on these services.

The situation is made worse because although Australia has an oversupply of dentists on a population basis, most work in the private sector in metropolitan areas. As a consequence, people living in rural areas report the highest levels of complete tooth loss, the lowest level of dental insurance coverage, and the highest levels of dissatisfaction with their dental health.

The consequences are also costly:  an analysis published in 2015 using Western Australia data of potentially avoidable hospitalisations for oral health-related conditions over 10 years indicated rates increasing over time, high rates in children under 14 years, most hospitalisations for dental caries, and hospitalisations among Indigenous people increasing at a rate almost twice that of non-Indigenous people. Across the nation, there were 67,060 preventable hospitalisations for oral health conditions in 2015-16 ( that’s 10% of all preventable hospitalisations, at an estimated cost of some $230 million). In Tasmania, dental conditions are the number one reason for acute preventable hospital admissions.

Results released this month from the latest Royal Children’s Hospital National Child Health Poll reveal rates of tooth decay are on the rise in Australia, particularly among young children. In large part this is because many parents lack the basic knowledge to prevent tooth decay in their children: 33% of children aren’t brushing their teeth twice a day and almost half of parents (46%) don’t know that tap water is better for teeth than bottled water. The poll found that 1 in 4 children under five years are put to bed most days of the week with a bottle containing milk-based or sweetened drinks, a practice strongly linked to tooth decay.

Clearly, tomorrow would not be too soon to establish a scheme that would provide affordable access to essential dental services (preventive and treatment) and associated public awareness and education programs and campaigns. This might be means tested, although many have called for a Medicare-style dental scheme. Such an approach is no longer the sole purview of idealists. Indeed, it has been argued that the current inconsistencies in public dental funding lead to false economic savings.

Increasingly Australians – faced with rising out-of-pocket costs for healthcare and dental care and with little assistance from private health insurance – agree. Polling released by Essential Report in February reveals that 48% of Australians favour abolishing the taxpayer subsidy for PHI and using the savings to establish a Medicare Dental Scheme (32% oppose such a change and 20% do not have a view).

As John Menadue has pointed out, this poll clearly shows that Australians believe health and equity would be much improved if the PHI subsidy (variously estimated at between $7 and $12 billion annually) was abolished and those funds allocated to universal dental care within Medicare.

That’s a very expensive proposition and begs some difficult questions such as how much Medicare should pay for cosmetic procedures, for dentures that are never used, and for restorative work over prevention. It’s a perfect topic for a citizens’ jury – but only if governments are brave enough to act on the results.

Also on the table for discussion and analysis is a proposal from the Australian Dental Association that proposes Health Savings Accounts as a radical alternative to PHI. The ADA argues that “there’s a compelling need to return to the drawing board and to reassess the way in which dental and allied healthcare is funded”. The Consumers Health Forum assessment of this proposal is correct – it shows that “there is significant scope for improving the current poor insurance deal on dental care”.

And if universal dental care and HSAs are steps too far, then my list of kick-starter initiatives still stands – at a fraction of the cost, but with certain early returns on the investments.

Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney. She was the inaugural Menzies Foundation Fellow at the Menzies Centre for Health Policy and a Research Associate at the US Studies Centre at the University of Sydney. Prior to that, she was a health policy adviser to the federal Labor Party. She worked for seven years as health policy adviser on the Energy and Commerce Committee in the US House of Representatives, and has been a Visiting Fellow at the Center for American Progress and a Senior Adviser to the US surgeon-general.

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