While often taken for granted, good oral health is fundamental to good mental and physical health.
Poor oral health precipitates and perpetuates low self-esteem and adversely affects a person’s ability to eat a nutritious diet, find employment and engage socially without embarrassment.
Oral diseases cause pain and suffering and have an adverse impact on overall health. And yet, despite the well-meaning policy initiatives of some governments over the last half century, dental care remains out of the reach of many Australians and dental health inequality is increasing.
We need to put the mouth back into the body
Poor oral health is one of the most obvious and public indicators of poverty.
Australia’s public dental system is a tattered safety net failing Australians on lower incomes, forcing them to face long years waiting for general care, as highlighted in the recently released Senate Inquiry into access to dental care.
Dental care remains excluded from Medicare, apart from limited dental services for some children and eligible adults. The mouth has been left out of the body.
We urgently need a national conversation about how this situation can be remedied.
For our new book, we studied the dental health of Victoria and Australia since 1970 to show how we have arrived at the current state of affairs. We trace oral health and disease alongside the complex interaction of social, political and economic factors.
We use the World Health Organisation (WHO) building blocks of a health system as a framework, then by drawing on the latest WHO global strategy on oral health, we chart a future where better oral health is achievable for all.
While our focus is on Victoria and Australia, the issues are common internationally.
From self-governance to community involvement
Governance is one area that has greatly improved over the years.
In 1970 the all-male dentist Dental Board of Victoria was responsible for regulating the profession. This has now been replaced, after several iterations, by the Dental Board of Australia with a membership that is more representative of the community.
The 2023 Board has an equal number of women and men, five dentists, two oral health therapists, a prosthetist and four community members.
From ‘drill, fill, bill’ to ‘prevention over cure’
For dental practices in 1970 the adage ‘drill, fill, bill’ was probably at its height – there were too many patients with too much decay and too few dentists. It was still common in some communities to be gifted a full set of dentures as a 21st birthday or wedding present.
Now there is a more preventive approach to keeping teeth and less than a fifth of older adults have full dentures.
Far-reaching changes to infection control practices have also been introduced in response to conditions like AIDS and Creutzfeldt-Jacob Disease. The non-gloved, non-masked dentist of 1970 will never be seen again.
In 1970 most dentistry was done in the private sector. There was a small school dental service and the Royal Dental Hospital of Melbourne was trying to cope with those too far from, or too poor to afford a private dentist.
Electoral pressure in the 1970s forced the Victorian government to legislate two new classes of clinicians – dental therapists to treat children and advanced dental technicians (now prosthetists) to make dentures.
Dental hygienists were first registered in 1989, so there are now four dental professionals compared with just dentists in 1970.
A further Act in 1973 permitted the fluoridation of public water supplies. This was critical in reducing the level of dental decay, especially in children.
International support for primary healthcare as expressed in the 1978 Declaration of Alma-Ata helped support advocacy for dental clinics within locally managed community health centres. Now, dental care is provided in over 50 Victorian community health centres and hospitals.
DENTAL CARE too expensive and too hard to access
While all of these changes combined to somewhat reduce waiting times and helped state school children, they did not adequately solve the twin problems of lack of access to, and affordability of, dental care.
While there is an Australian government-funded program for children from low-income families and a Victorian school dental service, the Smile Squad, disadvantaged adults have only a tattered safety net.
Waiting times can be several years for general dental care.
Governments provide less than one-fifth of the $AU11 billion annual spending on dental services compared to two-thirds for other healthcare costs. More people are delaying or avoiding dental treatment because it is too costly.
There has been a rollercoaster of government programs with many stopped by incoming governments, lengthening waiting times. There has also been the all-too-common blame game over funding and services between the Australian and state governments.
Oral health has improved but not for all
Although tooth decay has decreased from over 90 per cent of adults and children affected 50 years ago, it is still one of the most common health problems with over 80 per cent of adults affected and over a third of younger children.
An unequal burden of preventable oral disease remains and inequality has increased. Poor adults now have six more decayed teeth than the general population.
What’s the solution?
Improving oral health and reducing longstanding inequities requires action at all levels of government and in all sectors of civil society.
The overall vision of the WHO global strategy on oral health – adopted by the World Health Assembly (including Australia) in May 2022 – is universal health coverage in oral health for all individuals and communities by 2030.
Based on our look back to 1970, we recommend areas for action on oral health under each of the six strategic objectives of the WHO global strategy. We think the key actions that are required are: a greater focus on prevention; improved oral health information systems; and a phased introduction of basic dental care into Medicare.
This is an ambitious reform agenda that will ultimately ‘put the mouth back into the body’ and requires urgent discussion and policy attention to determine priorities, timelines, funding and implementation responsibilities.
Looking Back Looking Forward – Oral health in Victoria 1970 to 2022 and beyond, by John Rogers and Jamie Robertson, is available as a free PDF and physical copies can be purchased from all major book retailers.
