Why don’t we take oral health seriously?
Poor oral health is one of the strongest indicators of disadvantage in Australia. It’s time governments acknowledged this and funded dental care in the same way they fund the rest of health.
This week I was interviewed on ABC Radio National on the topic ‘Is dental now only for the rich?’ The overarching theme from presenters, guests and talkback callers was that dental care is no longer accessible for a large part of the population. Indeed just over half of Australian adults visit the dentist each year, a proportion that hasn’t substantially changed in decades. For one in ten people their last dental visit was more than 5 years ago, and around 20% only visit when they experience a dental problem – data that should concern health policy makers.
The radio program was a reaction to a Productivity Commission report highlighting the long wait for public dental care across the country. It showed that 50% of non-indigenous Victorians waited longer than 800 days to visit a public dentist, almost double from the prior year, with 10% waiting longer than 4 years.
Waiting times for public dental care
We have been tracking waiting times for public dental care in Victoria for a decade, and the picture is pretty grim. In June 2022 the average waiting time for care was 27 months, but there were clinics such as Merri Health in Brunswick (46 months) and Maryborough District Health Service (46 months) where the waiting times are approaching 4 years.
There is no doubt that the pandemic has played a role – Victoria experienced 265 days of lockdowns across 2020 and 2021 where access to dental care was severely restricted by the government to only emergency treatment. This is apparent in the large jump in waiting times since 2020. But immediately prior to the pandemic, the average waiting time was 19 months – still significantly longer than what would be considered clinically acceptable – and the longer term trend was increasing. And whilst there has been a one-off injection of waiting list blitz funding, that doesn’t address the structural problems inherent in public dentistry.
Hidden waiting times
Of course, 27 months to wait for essential dental care is a significant problem. But what many people don’t realise is that patients must wait 12 months after receiving care, before they are allowed to go back on the waiting list again. So the true waiting time between appointments is actually closer to 40 months (or 58 months if you are trying to access care in Brunswick or Maryborough). Just to put that in context – we generally recommend that people see a dentist every 12 months (and more frequently if they have a high risk of dental disease).
Dental disease in Australia
Around 30% of Australian adults have periodontal (gum) disease, and this has been increasing over the past decade. Periodontal disease is more prevalent with ageing, affecting half of those aged 55-74 years, and it is a major contributor to tooth loss, impacting on quality of life and nutrition. By the age of 55-74 years, the average Australian is missing 9 teeth. But the impacts extend beyond the mouth, with periodontal disease linked to a range of other health problems including heart disease and diabetes.
Dental caries (tooth decay) is probably the most prevalent health condition affecting Australians, and it commences almost from the time that we have teeth. By the age of 5-6 years, one in three children already have experienced tooth decay in their deciduous (baby) teeth, and this increases to 40% of children experiencing tooth decay in their permanent (adult) teeth by the age of 12-14 years. In fact, tooth decay is the leading cause of preventable hospitalisation in Australia. Tooth decay continues to be a problem throughout life, with one third of Australian adults have untreated tooth decay.
Importance of regular dental visits
Both periodontal disease and dental caries are preventable, and an important part of a regular dental visit is focused on early identification of risk factors for disease and working with patients to help prevent disease. When half of the population is not accessing regular care, or they are forced to wait more than two years to access public dental care, we are missing a significant opportunity to reduce the burden of disease. Dental caries can progress from a stage where it might be reversible to needing a filling, root canal treatment or even extraction of the tooth. Untreated periodontal disease will progress to eventual tooth loss. Irregular dental visiting patterns invariably mean the opportunity for early intervention is missed, and as a consequence is linked to poorer oral health outcomes.
It’s not just about tooth decay and gum disease – head/neck and oral cancers (of the lip, tongue and oral cavity) affect more than 5000 Australians every year, making them the 7th most common form of cancer. Sadly in many cases they are detected late, leading to poorer outcomes. Regular dental check-ups are essential for oral cancer screening and many cases are detected by dentists – most recently in the case of John Farnham.
Why do we have a problem?
There is a huge inequity in the way the governments at both the state and federal level fund (or actually don’t fund) dental care, and as a consequence oral health continues to be neglected in the health policy agenda. In 2020/21, the Australian government spent $94 billion dollars on health care but only 1% of that ($1.35 billion) went to dental services – with $775 million of that in private health insurance premium rebates. Only 2% of $61 billion state government health expenditure was allocated to dental services, despite dental expenditure representing around 5% of total health expenditure.
Governments contribute 80% of hospital expenditure, 79% of medical services and 88% of benefit paid pharmaceuticals, but they only fund a paltry 21% of dental expenditure. Is it a surprise then when we see public dental waiting lists greater than 2 years in many states, and poor oral health affecting so many people.
In Victoria 1.5 million adults are eligible to access public dental care in more than 60 community health centres across the state. However, the Victorian government only allocates funding to provide basic treatment to around 220,000 adult patients each year – around 15% of those eligible. This number has remained relatively unchanged over the past decade. Whilst they have invested funding into a dental van program to provide care to all Victorian primary and secondary school children (where incidentally around 80% of children were already receiving dental care and where Medicare funding was available for children from a lower socioeconomic background to improve their access to care), there has been stagnation for adult patients.
Poor oral health is one of the strongest indicators of disadvantage in Australia, with a greater burden of disease experienced by people across a range of socioeconomic indicators. The last time I checked, the mouth was part of the body. It’s time our governments acknowledged this and started to fund dental care in the same way they fund other areas of our health.
This week in dental research
‘The pattern of association between early childhood caries and body mass index in pre-school children within Aotearoa | New Zealand: a national cross-sectional study’ recently published in Community Dentistry and Oral Epidemiology caught my eye. I have previously written on the need for a levy on sugary drinks, and that is part of a broader campaign linking sugar consumption to a range of health problems including obesity. This study further adds to the evidence of an association between overweight/obesity and dental caries, linked to commercial and social determinants, and highlights the need for measures that address the marketing of unhealthy foods and drinks to children and their parents.
Next week: I’ll take a deep dive into the history of public funding for dental care in Australia.