Chapter 2Unmet need for dental services
2.1This chapter outlines unmet need for dental services in Australia by exploring the following topics:
barriers that impact access to dental services;
service gaps for specific cohorts of people;
the economic costs and social impacts associated with poor oral health; and
comparison of the committee’s survey results against official research and data.
2.2In order to better facilitate the involvement of a diversity of members of the public with lived experience of dental health service access and issues, the committee agreed to conduct an online survey. The survey was held between 17April 2023 and 4 June 2023, and recorded a total of 17 544 responses.
2.3The survey was circulated by members of the committee, other members of parliament, community members, dental and other organisations.
2.4The committee notes that the sample size is large, participants self-selected and that results are presented in their primary format—independent statistical analysis on the data has not been conducted.
2.5A selection of results has been analysed and presented throughout the chapter and a full list of the questions and results is available in Appendix 1.
Barriers to accessing care
2.6Many Australians experience barriers when trying to access dental services, and this section will expand on the following barriers: cost, workforce availability, and long waiting times.
Cost
2.7The cost of dental care is a barrier to many Australians when accessing dental services. The Australian Institute of Health and Welfare (AIHW) reports that 39per cent of people aged 15 and over avoided or delayed visiting the dentist due to cost reasons. This barrier is more pronounced for people in lower socioeconomic positions.
2.8The committee’s survey results indicated a higher proportion of people delayed going to the dentist due to costs, compared to the AIHW. 61 per cent of individuals who completed the survey delayed going to the dentist because of the cost (Figure2.1).
Figure 2.1Have you, or someone you care for, delayed going to the dentist because of cost?
Source: Committee's Survey: Question 19 (Appendix 1)
2.9The Australian Bureau of Statistics reported (2021–22) that people delayed seeing dental professionals due to cost at a higher rate compared to general practitioners (GPs) and other medical specialists (Figure2.2).
Figure 2.2Delayed or did not make healthcare visit where cost was a factor by socioeconomic disadvantage
Source: The Guardian, Cost of medical and dental care a barrier to Australians – survey, 13 November 2015.
2.10The average household out of pocket expenditure for dental services is $240, which is the second highest household expenditure on health, following non-subsidised medications ($429). Approximately a quarter of Australia’s population would have trouble paying a $200 bill for dental services. Over 4000 people reported in the committee’s survey that they went without basic necessities to pay for necessary dental services.
2.11Adults aged 25–34 years were the most likely to delay or avoid dental care compared to any other age group. The AIHW reported in 2017-18, 50 per cent of people in this age group delayed or avoided dental care due to cost.
2.12Having private health insurance can help alleviate the costs, however private health insurances have a gap, on average, of 54 percent of dental expenses. This still leaves people paying significant out of pocket costs in addition to their premiums.
2.13The committee’s survey indicated that over half (57 per cent) of those who completed the survey do not have private health insurance, and would therefore be paying for dental services completely out-of-pocket or relying on public dental if eligible.
2.14If people cannot pay for dental services, they will either delay, miss out on dental care, or rely on the public system if they are eligible. For those eligible for the public system, there are long waiting lists.
2.15The committee’s survey indicated that cost was the largest barrier affecting peoples’ access to dental services (Figure 2.3), when compared to accessibility, cultural and/or language barriers, wait times, and fear of the dentist. 98 per cent of survey respondents indicated that the Government should make more dental healthcare free.
Figure 2.3What factors impact your access to dental services?
Source: Committee’s Survey: Question 21 (Appendix 1)
Workforce availability
2.16The Australian Health Practitioner Regulation Agency reports that there are over 26000 registered dental practitioners across Australia. Dentists employed in Australia predominantly work in the private sector, with only five per cent of dental practitioners practicing in the public dental system.
2.17Similarly, to other health professionals, there is a maldistribution of dental practitioners between regional and remote Australia compared with major cities. The AIHW reports in 2020 the rate of full-time equivalent dentists ranged from 26.3 in remote and very remote areas to 63.8 per 100000 population in major cities. Similarly, the rates of both dental hygienists and oral health therapists also decreases with remoteness. There are currently no workforce initiatives to support recruitment or retention of dental health practitioners in rural, regional and remote Australia.
2.18La Trobe University notes in their submission, that despite the establishment of rural dental schools, the rural oral health workforce is still a considerable concern. The following issues impact rural schools to train practitioners that would potentially continue to practice in rural and remote locations:
a shortage of dental educators to sustain rural placements;
the increasing cost to maintain clinical placements; and
the reliance on community health services, as university dental schools are unable to run their own clinics.
2.19To assist with providing dental care to regional and remote Australia, the Royal Flying Doctor Service (RFDS) established a dental service designed to support communities in country Australia. The RFDS provide services using fly-in, fly-out or drive-in, drive-out services. In 2021-22, the RFDS delivered 58 976 dental services over 507 locations.
2.20There are significantly fewer dental practitioners in rural and remote Australia; however, there are more dental practitioners who practice publicly compared to major cities.
2.21The Productivity Commission reported that the rate of full-time public dentists was higher in remote and very remote areas (6.7 per 100 000 people) of Australia compared to other areas (4.9 to 5.4 per 100 000 people) of Australia (Figure 2.4).The highest rate of dentists employed in the public sector per 100 000 people was in the Northern Territory, and the lowest rate was in Victoria.
Figure 2.4Full time equivalent public dentists by jurisdiction and remoteness
Source: Productivity Commission, Report on Government Services 2023, Part E, Section 10, 2 February 2023.
Rate = dentists per 100 000 people.
2.22There are 13 approved dental specialities in Australia, and in 2020 it was reported that only 9.8 per cent of dentists were specialists. The most common speciality is orthodontics, which accounts for 35 per cent of all specialist dentists. The least common specialities are special needs dentistry, oral pathology, and dento-maxillofacial radiology.
2.23The Dental Board of Australia reports that there are currently no special needs dentists in the Australian Capital Territory, Northern Territory, and Tasmania.
Waiting times
2.24The committee’s survey indicated that long wait times to access dental services was the second largest barrier for those who competed the survey (Figure 2.3).
2.25Only five per cent of dental professionals practise in the public dental system, leading to high levels of demand for public dental services. Due to the demand, the focus is placed on treating the most urgent cases first and placing the remaining patients on a waiting list. These waiting lists (depending on which state or territory) can have adult patients waiting up to three years to receive care. Competition with the private sector makes it challenging for the public sector to meet demand and to attract sufficient dentists.
2.26These waiting times preclude patients from accessing timely dental services, resulting in adults being unable to receive regular care based on their oral health needs.
2.27Once general care is completed (a full course of dental treatment), eligible adults typically have to be placed back onto the waiting list to receive follow-up appointments for ongoing oral health care.
2.28Without timely access to dental services, patients end up seeking care from alternative health care professionals –GPs, pharmacists, and hospitals.
Service gaps for specific populations
2.29There are populations who are at a greater risk of poor oral health, due to barriers to accessing oral health care in either the private or public sector. The National Oral Health Plan identifies four priority population groups that experience poor oral health at higher rates than other sectors of the population: people who are socially disadvantaged or on low incomes; Aboriginal and Torres Strait Islander Australians; people living in regional or remote areas; and people with additional and/or specialised health care needs.
2.30The committee’s survey indicated that approximately 61 per cent of respondents had average, poor or very poor access to dental services (Figure 2.5).
Figure 2.5How would you rate your current level of access to dental services?
Source: Committee's Survey: Question 20 (Appendix 1)
2.31This section expands on these populations of Australia that have reduced access or barriers to accessing dental services.
People who are socially and economically disadvantaged
2.32This group has traditionally been identified as those on a low income and/or receiving some form of government income assistance. This priority group now extends to include people experiencing other forms of disadvantage, including refugees, homeless people, some people from culturally and linguistically diverse backgrounds, and people in institutions or prisons.
2.33Adults with low incomes are less likely to purchase private health insurance, leaving them reliant on public dental services (if eligible), or required to pay for private dental services completely out-of-pocket.
2.34Public dental care is only available for limited sections of the population. It differs by state and territory, but generally adults must have a healthcare card or pensioner concession card to be eligible.
2.35As indicated in the committee’s survey, 37 per cent of respondents were unaware that public dental care was available in Australia (Figure 2.6). Those who rely on public dental services have little choice on who provides their care, when they can access this care, and where it will be provided.
Figure 2.6Did you know that some people are eligible for public, or government funded dental services in Australia?
Source: Committee's Survey: Question 25 (Appendix 1)
2.36Mitigating factors also contribute to poor oral health services in this population. Individuals in prisons/correctional facilities have higher rates of tobacco smoking and high-risk alcohol consumption compared to the general public. These behaviours have been linked to increased risk of oral disease. This means prisoners often need higher levels of dental care and more intensive treatments.
2.37Despite the need for dental care in prisons, there are significant barriers to accessing this care. The Office of the Inspector of Custodial Services in Western Australia noted the following issues in its submission:
shortage of dentists;
long waitlists;
onsite dental suites are not available at every facility; and
dental care is focused on extractions and has little preventative services.
2.38Prisoners do have the option to seek and pay for private dental services, however they are required to cover the staffing and vehicle costs to escort them to and from the appointment. This adds on average $700 to their appointment costs, which few prisoners can afford.
Aboriginal and Torres Strait Islander Australians
2.39Aboriginal and Torres Strait Islander Australians suffer from higher rates of oral disease, have more untreated dental problems, and have more tooth extractions than the general population. They are also less likely to receive essential dental care when required.
2.40Key barriers to accessibility of dental care for Aboriginal and Torres Strait Islander Australians include the disproportionate burden that the socioeconomic determinants of health have on health outcomes,lack of access to public preventative dental services, and inadequate oral health education.
2.41Private dental practices are often unaffordable for many Aboriginal and Torres Strait Islander people, and public dental services are not meeting their oral health needs. Public dental services are often hard to access without transport, incur a cost, have no facilities for parents or carers with babies and young children, and there is a lack of culturally appropriate services.
2.42Accessibility of dental services is a big factor contributing to the poor oral health of Aboriginal and Torres Strait Islander populations compared to the rest of the population. The National Oral Health Plan 2015–2024 reports that 43 per cent of Aboriginal and Torres Strait Islander people live in regional Australia, and 21per cent live in very remote areas. Regional and remote areas have limited local availability for dental services and limited transport options to travel to receive care.
2.43The Office of the Inspector of Custodial Services in Western Australia noted the importance of culturally safe access to dental services for Aboriginal and Torres Strait Island people in prisons. With a high representation of Aboriginal and Torres Strait Islander Australians in adult and youth custody, combined with an already increased risk for oral diseases, they are disadvantaged without culturally safe dental services.
2.44The dental and oral health needs of Aboriginal and Torres Strait Islander people are unmet due to inadequate dental services in a culturally safe environment.
Box 2.1 Barriers experienced when accessing dental services – Testimonies from members of the public The committee received evidence directly from disadvantaged members of the public regarding barriers they face accessing dental services in Australia. Referenced quotes are from submissions to the inquiry and can be found on the committee’s website. Gum disease at 30 I began my apprenticeship in 2016, and like many adult apprentices, I struggled to make ends meet. The meagre income I received barely covered my living expenses, leaving me with no room for additional costs such as dental care. During this time, I neglected my dental health, as I simply could not afford regular check-ups or treatments… Those years of forced neglect have now culminated in a diagnosis of Advanced Late-Stage Gum Disease, I am only 30 years old… The cost of treating my gum disease is staggering. Restoration of the gum is expected to cost upwards of $2,500 for just one area that has gum recession. Facing this reality, I have come to the heartbreaking realization that I cannot afford this treatment. My front tooth will eventually fall out, and as the disease progresses, I will lose the rest of my teeth with it. – Name withheld, Submission 47. Severe tooth decay at 6 years oldAlison was screened by a Kimberly Dental Team (KDT) dentist which she saw in class at her local school. Alison has substantial decay in various teeth in both her upper and lower archers. She has been in a lot of pain and has been on the waitlist to receive treatment via General Anaesthetic by public dental health services for over a year. Multiple extractions would be required to relieve Alison of pain and minimise risk of further infection. Due to her age, Alison would need to receive GA to tolerate this level of treatment. Therefore, the KDT could not carry out any treatment to support Alison. – Supplied by the Kimberley Dental Team, Submission 46. |
People living in regional and remote Australia
2.45People living in regional and remote areas in Australia have poorer oral health compared to those living in major cities, and people’s oral health status generally decreases as remoteness increases.
2.46Factors influencing poor oral health in regional and remote Australia are related to higher rates of tobacco and alcohol use, reduced access to fluoridated drinking water, lack of service availability, high cost of healthier food options, and increased cost of oral hygiene products.
2.47The National Oral Health Plan 2015–2024 states that all communities with populations over 1000 should have access to fluoridated water supplies. However, a recent study in the Australian Journal of Rural Health found that 33 per cent of rural towns in Victoria with more than 1000 people did not have access to fluoridated water. Over 50 per cent of children under 12 years living in these non-fluoridated communities had increased rates of decayed, missing or filled teeth.
2.48The RFDS reports that approximately 119 000 people in rural and remote Australia do not have access to general dental services within a 60-minute drive time. A 60-minute drive in rural and remote Australia can be a significant undertaking, with difficult terrain, weather, condition of roads, and a person’s ability to access transport impacting the accessibility.
2.49In rural and regional areas of Australia, there are significant gaps in dental services for complex or specialised services. Tertiary referral services (like orthodontics), dental hospitals and specialised clinics are primarily located in major cities, making it difficult for people living in regional and remote Australia to access them. In many cases there are no options for accessing these specialised services due to the high cost of travel to a major city, along with treatment and accommodation required.
2.50For children, early oral health education is an essential preventative measure against poor oral health. In rural and remote Australia, there is limited school screening, toothbrush programs, and restricted oral health educational programs.
People with additional and/or complex health care needs
2.51This group includes people living with mental illness, disabled people, people with complex medical needs, and older people. People with additional health care requirements often receive fragmented care, resulting in poor oral health.
2.52The factors that lead to suboptimal care for this priority group are as follows:
a shortage of dental health professionals with special-needs dentistry expertise;
difficulties in physically accessing suitable dental services; and
the cost of dental services.
2.53COTA Australia conducted a survey in 2023, which showed that dental services were the most difficult health or medical service for older people to access. This is coupled with the risk that many oral diseases tend to increase with age (Figure2.7).
Figure 2.7Prevalence of oral health conditions among older Australians
Source: COTA Australia, Submission 11, p. 5
2.54Residents of aged care facilities have been identified as a particularly vulnerable subpopulation of older Australians who have high-risk oral health needs and limited access to dental care.
2.55As most dentists in Australia operate in private dental practices, it is difficult for older Australians to access them for regular care. There are few organised programs that target people in aged care, and those that do, do not have the capacity to care for the high number of aged care residents.
2.56Oral health was one of the issues raised in the Aged Care Royal Commission, and it was recommended (recommendation 60) to create a new dental benefits scheme for seniors.
Disabled people
2.57Barriers affecting access to dental services for disabled people can include long wait times, cost of services, accessibility of dental suites, and communication barriers.
2.58Some disabled people cannot verbally communicate their pain and may rely on non-verbal communication to express their discomfort. This can lead to communications barriers between the individual and the dental professional, leading to suboptimal care.
2.59The AIHW reported in 2018, that 32 per cent of disabled people between the ages of 15 and 64 did not see a dental professional due to cost. In the committee’s survey, 74.5 per cent of respondents who identified as a disabled person said that the cost of dental services impacts their access to those services.
2.60Disabled people often require extra support to access dental services. For people who require general anaesthesia (GA) to be able to access basic dental services, there is funding available under the National Health Reform Agreement for public hospital in-patient dental services. However, most states and territories have strict eligibility criteria and long wait times.
2.61The Dental Board of Australia reports that there are currently only 26 practising special needs dentistry specialists across Australia. This is equivalent to one per cent of dental specialists in Australia. Although disabled people can be treated by a general dentist, it can be difficult to find one happy to treat them without referring them to a specialist. An article published by the ABC states that one third of general dentists would be unwilling to treat people with disabilities, mostly due to a lack of confidence and training in how to treat disabled people.
2.62The AIHW reported that 70 per cent of disabled people wait more than a year on the public dental waiting list before receiving dental care. The Department of Health in Western Australia reported that the current waitlist for Special Needs Dental Clinics is 2 years 8 months for recall, and 3 years for GA.
2.63To access GA through the private system for dental services, patients could be out-of-pocket between $3500 and $5000.
Box 2.2Barriers experienced when accessing dental services – Testimonies from members of the public A 6-to-10-hour car journeyThe oral health story of the Yolgnu people who live in our communities is distressing. Many adults suffer ongoing pain and discomfort. They are unable to make appointments to see a dentist unless they go to town (Darwin), most times this is either a flight or a 6-to-10-hour car journey. The Yolgnu people are totally reliant on a service attending the community they live in. – Supplied by the Northern Territory Department of Health, Submission 27. Mouth cancer Elderly lady. Mentally competent. Supportive family. Pensioner. Wheelchair bound. Travelling well. Denture wearing.Advised she had a mouth ulcer. Ulcers are frequent. Last about 10-14 days with removal of denture and local analgesic application. This one didn't.When I saw her 2 months later the ulcer was not an ulcer but an aggressive mouth cancer and needed IMMEDIATE treatment. She was now bed bound, lost a lot of weight, on morphine, and sleep deprived.A biopsy was needed, but no one would do it. I couldn't because I was a dentist (policy), it needed a specialist. DHS didn't have one. Private didn't do domiciliary. Eventually I contacted a colleague at the dental school in Oral Medicine. He did the biopsy gratis. It confirmed my diagnosis. She was referred to RPH and assessed for surgery.Being a public patient, she had to wait. If she was private, it could have been done next day.To facilitate treatment, I approached the Health Insurance Commission. Not possible (legislation 1973), the health funds not possible. They required 3 months waiting period(policy).She died in pain shortly afterwards.Her family was very upset. This is not a rare event. – Supplied by Dr Patrick Shanahan, Submission 1. |
Impacts of poor oral health on individuals and families
2.64Poor oral health has substantial impact on individuals, the health system and society. Poor oral health can affect both an individual’s physical and mental health, and have social impacts such as poor appearance, low self-esteem, and decreased quality of life. The impact of poor oral health on the health system causes direct and broader economic costs.
Social impacts associated with poor oral health
2.65People who have access to appropriate and quality dental care are more likely to visit the dentist. Improving the pattern of dental visits would have a positive impact on the population’s oral health through earlier access to prevention, earlier diagnoses, and increased education on oral hygiene measures.
2.66Good oral health contributes positively to physical, mental and social wellbeing and enables people to speak, eat and socialise unhindered by pain, discomfort, oral disease and embarrassment. On the other hand, poor oral health can negatively affect speech, sleep, mental health, self-esteem, relationships, and a person’s general wellbeing. Improved oral health has the following positive effects:
improved general health;
decreased absences from work and school;
improved self-esteem and improved mental health;
improved nutrition;
decreased dental hospitalisations and a reduced need for acute care; and
improved oral health care knowledge.
2.67In the committee’s survey, 74 per cent of respondents reported they had dental problems or concerns that impacted their health or quality of life (Figure 2.8).
Figure 2.8Have you ever experienced dental problems or concerns that have impacted your health or quality of life?
Source: Committee's Survey: Question 16 (Appendix 1)
2.68Poor oral health can cause bad breath, missing, decoloured and/or crooked teeth, which can negatively impact a person’s self-esteem and/or mental health. The AIHW reports that one-in-three people felt uncomfortable with their dental appearance over the last 12 months. Over 7500 people in the committee’s survey stated that their oral health negatively impacted their confidence and self-esteem. Secondly, over 3500 reported that their oral health negatively impacted their social life, relationships and community participation.
2.69The association between low socioeconomic status and poor oral health is well established. Oral diseases disproportionally affect poor and socially disadvantaged populations, which causes further social disadvantages. Poor oral health can result in time off from work and school, which affects disadvantaged groups disproportionately.
Economic costs associated with poor oral health
2.70The economic cost to Australia of poor oral health is not identified in Australia’s National Oral Health Plan, and there are limited Australian studies that provide costing estimates. Existing studies are generally neither current nor comprehensive in scope.
2.71The Australian Research Centre for Population Oral Health reported in 2012 that the estimated cost of reduced workforce participation due to dental conditions was approximately $556 million per year. This is a result of individuals taking time off from work or school due to dental problems.
2.72These long wait times have serious impacts on people’s oral health and can put people at a higher risk of developing or worsening oral health diseases. Without timely access to public dental care, patients end up seeking care from GPs and from hospitals (Figure 2.9). The AIHW reported that: ‘In 2020–21, about 83,000 hospitalisations for dental conditions could potentially have been prevented with earlier treatment.’
2.73Seeking alternative care options often results in larger cost for the patient and the government for largely preventable conditions.
Figure 2.9A stylised pathway of dental health care and the costs
Source: Productivity Commission, Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services, 27 October 2017, p. 360.
2.74The AIHW reported that in 2019–20, expenditure in hospitals on oral disorders was $639 million and $438 million on other oral disorders. Noting that $208 million of expenditure on other oral disorders was spent on private hospital services. It was also reported by the AIHW that $65.7 million was spent during 2019–20 on GP services for oral disorder conditions.
2.75Another impact of delayed dental care and worsening oral health is the need for further treatment. For example, once a tooth experiences decay, it enters a restorative cycle. This results in a filling that will need to be replaced periodically, which may require a crown or root canal, all resulting in an increased cost to save the tooth. Even a tooth which is extracted can have a lasting economic burden if the patient chooses to restore the gap left from removal. On a population level, this would have significant economic impact.
Committee view
2.76Australia is a wealthy country by global standards and people in Australia enjoy a relatively high standard of living. While there are certain inequalities in the system, healthcare is widely available and relatively affordable for most Australians—dental care is not.
2.77The prohibitive cost of dental care means simple, treatable dental problems turn into medical emergencies, leading to preventable hospitalisations and the costs associated with that. The committee believes that moving to a preventative based approach will improve Australia’s oral health status and have substantial social and economic impacts.
2.78The committee is concerned that dental decay and gum disease are increasing in Australia, and that dental services remain unaffordable and inaccessible to around half of the population. The committee heard consistently that people who are socially disadvantaged or who have low incomes, Aboriginal and Torres Strait Islander Australians, people living in regional and remote Australia, and people with additional and/or specialised health care needs. The committee believes that prioritising accessibility for these subpopulations is critical in addressing the unmet need for dental services in Australia.
2.79Public dental services, provided by state governments with some funding support from the Commonwealth, are woefully inadequate to meet the needs of eligible populations. They are understaffed and under resourced, serving only a quarter of those who are eligible and in need. By expanding the public dental system, training more dental professionals, and supporting a more diverse distribution of services, significant benefits could be achieved in Australia’s oral health.
2.80Australia's oral and dental health system is broken. 25 years’ worth of inquiries and reports have illuminated the problems, and recommended solutions.However, reforming the way in which oral and dental health services are funded and coordinated is a huge task, and one that governments across the political spectrum have been reluctant to take on.
2.81This inquiry will test suggested models for reform while looking to outline a realistic and achievable pathway towards universal access to oral and dental healthcare in Australia.