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11 Apr 2019

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR, PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Stop for a moment and meditate on teeth.

Think of the painful advent of baby teeth, making way in a few years for adult teeth and even wisdom teeth followed by carious teeth and (one hopes not) prosthetic and false teeth. It is a strange progression and our relationship with our teeth is, well, somewhat weird.

But does this odd developmental pathway explain why we do we not consider teeth to be a part of our bodies as much as hands and feet? We have Medicare and private insurance to pay for therapy for illness and injury of just about everything but our teeth.  

A recent report Filling the gap: A universal dental scheme for Australia from the Grattan Institute, a policy think tank, argues for a ten-year plan to bring dental care into the publicly funded tent. It was authored by Stephen Duckett, a health economist and former senior health bureaucrat, Matt Cowgill, a senior associate, and Hal Swerissen, an expert in health policy research and analysis. They were assisted by a dozen experts in the field of oral health.

The problem that Filing the Gap addresses is expressed as follows:

When Australians need to see a GP, Medicare picks up all or most of the bill. When they need to see a dentist, Australians are on their own. There’s no compelling medical, economic, or legal reason to treat the mouth so differently from the rest of the body. Australia should move towards a universal primary dental care scheme, funded by the Commonwealth Government.

Most spending on dental care comes straight out of patients’ pockets. As a result, people who can’t afford to pay don’t get dental care, unless they go on long (often multi-year) waiting lists for public care. About two million people who needed dental care in the past year either didn’t get it, or delayed getting it, because of the cost. Low-income people are most likely to miss out on care – about a quarter of Australian adults say they avoid some foods because of the condition of their teeth; for low-income people, it’s about a third.

When the Federal Government committed to assisting financially with health care in the immediate post-World War II years, the focus was on life-saving drugs and services. Over decades the subsidy for pharmaceuticals was extended well beyond the original narrow limits so that now it costs over $12 billion a year and rising at about 10 per cent per annum, and the contribution to medical services is vast. So, dental services may well have been put to one side and left there. Also the dental profession showed no enthusiasm for Medicare.

A further factor in the dental services saga is the effect of fluoride. Australia has experienced serious positive changes in the incidence of dental caries so much that Australian “children at age 12 have one of the best oral health records in the world with 65 per cent children completely free of any dental disease,” according to Heiko Spallek, Head of School and Dean, at the Sydney Dental School. “The deterioration of oral health happens in young and adolescent age groups.” Thus there has been a shift in the demography of oral health problems away from the very young, yet programs for dental care for this age group are still regularly proposed.

Another consequence of fluoride and changing community expectations is the opportunity it creates for increasing popularity of orthodontic dentistry for more cosmetically pleasing dental appearance.  The near-perfect, dazzling white smile of flight attendants is an example of what can be achieved and legitimate questions arise as to who should pay for these dental adjustments and treatments. 

Given the historical complexities surrounding dental care, the report argues that:

The first step is for the Commonwealth to take over funding of existing public dental schemes, fund them properly to the tune of an extra $1.1 billion per year, and enable private-sector providers to deliver publicly-funded care. Coverage should then be expanded – first to people on Centrelink payments, then all children. After that, the Commonwealth should take the final step to a universal scheme, ideally within a decade.

Such an approach would allow for workforce development, new approaches to the education and training of a new oral health profession and its time for adjustment. It may seem a slow process, but we have not got to where we are in a hurry. It will take time to unravel and move forward. All this assumes there is political and professional will to change.

 


Published: 11 Apr 2019