How the pandemic forgot about more than a few dental check-ups
COVID-19 amplified many inequalities within our society and one which will be felt for some time is its impact on the oral health of Australians.
Many will say there are bigger casualties, but when we take into perspective the fact that pre-COVID 70,000 Australians were admitted to hospital each year for potentially preventable dental health problems we know the impact is likely to be severe.
Lockdowns and closures of dental services for safety reasons, continued reduced operating capacity in some public dental facilities and increasing financial instability will take their toll on Australia’s dental health and in turn our health system, and it will affect the vulnerable in our society more than any other.
While medical complications related to delayed care are very real, they aren’t the only concern. People with toothache, visibly misaligned or missing teeth are often blamed for their own deteriorating of oral health, with implicit and explicit stigma based on assumptions of having wilfully engaged in damaging behaviours or neglected to visit a dental professional. People are well aware of this stigmatisation, with research demonstrating that having a visible dental disease is connected to assumptions of lower socio-economic status (Moeller et al., 2015). Or are these just people who could not go to the dentist, or continue to be on waiting lists due to COVID?
The reach of COVID extended to our teeth—in many unexpected ways. Australia’s underinvestment in oral healthcare, a well-known fact among public health experts, became widely apparent to the public during the pandemic.
While around 85% of dental care is provided by dental practitioners working in private practice, funded through private health insurance arrangements or directly by patients themselves, state and territory governments provide means-tested access to 39 percent of Australia’s most vulnerable populations to public dental services. Even before COVID, they were left on multi-year long waiting lists (Australian Institute of Health Welfare, 2018) until their minor problems become major ones. To ease the burden, some public patients in NSW are issued vouchers to fund care in private practice to reduce waiting times. For the working poor, those who don’t meet the means-test of eligibility for public treatment but who cannot afford private care costs, dentistry is even harder to access. Many public oral healthcare facilities are still operating with reduced capacity in order to ensure patient safety. As these services act as the only safety net for those who cannot access care in the private sector, this is another way that COVID has contributed to widening oral health inequity.
It’s worth noting that 19 percent of patients with Private Health Insurance reported pre-pandemic that paying for dental care was a large financial burden (Australian Institute of Health Welfare, 2019). One can only anticipate this would increase with greater job insecurity resulting from the pandemic.
Unlike medical and other health profession students, dental and oral health students are deemed competent after graduation under their own independent registration. This means our dental accrediting body, the Australian Dental Council (ADC), insists on graduating only fully competent dental practitioners to protect the public, ensuring safe and effective treatment for all patients. Thus, interruptions of clinical placements that occurred predominantly in the public dental service resulted in the need to shift some education to the simulation clinic learning environment, extend hours of clinical operations afterwards, and extend the academic year.
While we were fortunate at the University of Sydney, with low levels of community transmission and indeed through the heroic efforts of our staff, we were able to accommodate such changes however our colleagues at many European dental schools and indeed here in Melbourne were not as lucky.
Biomedical researchers across the board would agree that 2020 was a rough year for them. The impact ranged from shutting down of wet labs during the lockdown to stopping time-sensitive experiments to heightened risks when screening or recalling patients for routine clinical data collection and to the general inability to enrol new patients into clinical trials.
On the other hand, working from home allowed some researchers to spend more time on catching up writing scholarly articles and preparing grant submissions. Online conferences featured world-famous speaker who would normally not have travelled to some of these conferences if it had involved multi-day travel; but now that they could deliver their keynote in pyjama pants (plus business tops) from home, they engaged in these conferences providing learning opportunities for early career scholars and students. The topic of COVID itself provided ample opportunity for scholarly enquiries far beyond the expected fields of virology and immunology.
The topic of value-based care, or the reduction of ineffective and the elimination of not-evidence-based treatments, is a hot topic in healthcare as it is seen as one of the levers to reduce waste and improve patient outcomes. However, as Harvard Business Review recently pointed out, “we won’t get value-based health care until we agree on what ‘value’ means”.
Dentistry is not excluded from this dialogue that requires all stakeholders, patients, carers, providers, insurance companies, public health experts and the government to listen to each other to find out what value means for each group. While most dental practitioners will have no trouble explaining how teeth should look and how they should be aligned, patients might value other aspects of their dental care, like a short wait time, reasonable costs, white teeth and pain-free treatment. These values will undoubtedly have changed because of COVID—now probably including the lowering of infection risks for patients and providers and the desire for teleconsultation—something dentistry is struggling with given the hands-on nature of most treatment. We are still at the beginning of understanding values in oral healthcare.
On January 21, 2021, the 148th session of the World Health Organization (WHO) Executive Board adopted a comprehensive resolution on Oral Health calling on member states to integrate oral health within their national policies and, as part of general health, to reorient the traditional curative approach and move toward a preventive and health promotion approach to oral health, develop surveillance and monitoring systems, map and track fluoride in drinking water, and reduce risk factors for oral diseases and strengthen oral health care as part of universal health coverage.
When will Australia follow suit? In 2018, the Grattan Institute released its report: ‘Filling the Gap: A universal dental care scheme for Australia’, setting out a roadmap towards a scheme that would provide universal access for Australians to dental care (Duckett, Cowgill & Swerissen, 2019). The report estimates such a scheme would cost an additional $5.6 billion/year when it is fully established. I had the honour to contribute to this report. The most recent data demonstrates stark inequalities remain in oral health outcomes across Australia; in 2019–20, those living in the poorest areas were more likely to report that they needed to see a dental practitioner, but did not (24%), compared to those living in the wealthiest areas (11%) (Australian Bureau of Statistics, 2020).
COVID has shone a light on the inequality that exists within dentistry and now is the time to look at how we can do better.
Can we learn in dentistry? Can we learn from our patients? Can we shape an equitable and a just system that allows everyone to experience good oral health as defined by FDI World Dental Federation's Vision 2020:
Oral health is multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex.
Change is hard, but we need to unfreeze dentistry using evidence-based principles, dialogue with patients, government interventions where needed and digital technology as sources of heat.
Professor Heiko Spallek serves as Head of School and Dean at the University of Sydney School of Dentistry where he works closely with the Faculty of Medicine and Health's leadership to promote a cross-health profession and a shared understanding, including negotiations with New South Wales Health and Local Health Districts, to establish joint appointments to share teaching, research and clinical service. Additionally, he was appointed Academic Lead Digital Health and Health Service Informatics.
Moeller, J, Singhal, S, Al-Dajani, M, Gomaa, N & Quiñonez, C 2015, 'Assessing the relationship between dental appearance and the potential for discrimination in Ontario, Canada', Social Science and Medicine Population Health, vol. 1, pp. 26-31.
Australian Institute of Health Welfare 2018, 'A discussion of public dental waiting times information in Australia: 2013–14 to 2016–17', AIHW, Canberra.
Australian Institute of Health Welfare 2019, 'Oral health and dental care in Australia', AIHW, Canberra.
Royal Commission into Aged Care Quality and Safety 2021, 'Final Report - Volume 1: Summary and Recommendations'
Grytten, J 2017, 'Payment systems and incentives in dentistry', Community Dentistry and Oral Epidemiology, vol. 45, no. 1, pp. 1-11
Duckett, S, Cowgill, M & Swerissen, H 2019, Filling the gap: a universal dental care scheme for Australia Grattan Institute, Carlton, Victoria.
Wallace JP, Mohammadi J, Wallace LG, Taylor JA 2016, Senior Smiles: preliminary results for a new model of oral health care utilizing the dental hygienist in residential aged care facilities. First published: 25 November 2015 https://doi.org/10.1111/idh.12187
Holden, ACL, Adam, L & Thomson, WM 2020, 'Overtreatment as an ethical dilemma in Australian private dentistry: A qualitative exploration'