Dentist Mark Hutton is rarely far from his patients. In the rural South Australian city of Mount Gambier, halfway between Adelaide and Melbourne, it’s not uncommon for the person whose teeth he is working on in the morning to be serving him coffee that afternoon.
But he tries to keep his work and personal life separate, which means resisting a good-hearted reminder when he notices someone hasn’t been by the clinic in a while.
“Although, I have to admit the reverse happens,” he says. “We meet people and sometimes they’ll say, ‘By gee, it’s been a while since I’ve been to see you, I better make an appointment’.”
At the best of times, few look forward to a visit to the dentist, which for most people is recommended at least once a year. And when COVID-19 came to our shores in early 2020, it provided another reason to bump a check-up down the to-do list.
A survey released last month confirmed as much, revealing two-thirds of Australian adults hadn’t been to see their dentist in the past two years and a quarter had not been in more than five years. Of the 25,000 people surveyed by the Australian Dental Association at the end of 2021, one-third said they had postponed dental treatment since the beginning of the pandemic.
“That’s a very high number of people who are not accessing dental services,” says Dr Hutton, who is also the national president of the Australian Dental Association (ADA).
And it’s not just COVID-19 that’s behind it, he says, with most respondents who have delayed treatment in the past 12 months reporting cost as the major factor.
It’s this combination of factors that has dentists worried. Just as people may be looking to get back into their dental health routines after COVID-19 lockdowns, increased financial pressure caused by inflation may mean, for many, it’s just too expensive right now.
Dr Hutton says he personally hasn’t experienced a noticeable drop in patients, but he attribute that to South Australia’s limited COVID-19 lockdowns.
For Melbourne dentist Elice Chen, it’s been a far different story. The city endured almost nine months of lockdowns across 2020 and 2021. During those periods, the services dentists could offer were stripped back to emergency treatments only; no check-ups, cleans or cosmetic work.
That is largely due to the nature of the work, which requires dentists to be quite physically on the front line. There’s no social distancing when the task at hand requires you to be mere centimetres from a patient’s open mouth for extended periods of time.
While it now appears dental clinics were not a major source of transmission, in the early days Dr Chen says there was a lot of confusion.
“People were concerned about exposure to COVID, so some people were self-isolating even when it wasn’t mandated,” she says.
In dental, where issues are often out of sight and only become painful once it’s too late, prevention is everything. And without access to regular check-ups, the problem can quickly snowball.
Dr Chen describes a web of factors that have come together to create a perfect storm for people to fall out of their dental care routine.
If someone misses one appointment, they may be crossed off the contact list for reminders from the clinic.
Without that contact with dentists, personal oral health habits like flossing can also fall by the wayside.
And then there’s the reality that if you’re not leaving your house, maybe keeping your teeth in good shape becomes less of a priority.
The result, she says, has been more severe cases of gum disease and decay.
“We’re now seeing patients who haven’t been to the dentist in two years or more, partially because of the lockdowns and partly because maybe they’ve been putting it off for a little bit before the lockdowns,” she says.
“So suddenly it’s been four or five years since the last visit — and a lot can happen to change your mouth in that time.”
A perfect storm of tooth decay
Retired truck driver Johannes Boon chuckles when he hears that the majority of Australians haven’t been to the dentist in two years.
“It’s been a lot longer than two years since I’d been to the dentist,” he says.
The 67-year-old recently visited the dentist for the first time in about eight years, but his absence wasn’t due to COVID-19 or affordability.
“I used to be an interstate truck driver, and that was one of the reasons. I was never in one place long enough,” he says.
Now retired and with some more time on his hands, he bit the bullet and made an appointment with Dr Hutton about three months ago.
He’s now catching up on years of untreated issues, including having a couple of teeth removed and some cavities filled.
Soon he’ll be travelling to Adelaide from his home in Naracoorte to see a gum specialist about underlying decay — something he expects “isn’t going to be real pleasant”.
“I’m going to spend about six hours sitting in a chair there,” he says. “I’d prefer not to go, but it’s one of those things, I’ve still got all my own teeth and I’d like to keep it that way.”
Gum disease, like what Johannes is getting treated, is one of the conditions dentists are most worried about — describing it as a slow burn that can easily slip by undetected without regular examinations.
“Gum disease is one of those conditions that doesn’t really present with pain until it’s in the quite severe stages,” Dr Chen says.
“And when it progresses, and the teeth become loose, sometimes there’s no option but to remove the tooth — which can drastically impact on your quality of life.”
While there is no official national data, anecdotally dentists have also reported a recent increase in cracked teeth, which they put down to stress and anxiety-related grinding.
“When people are going through a period of stress, they can clench or grind their teeth, sometimes during the day but also at night when they’re not aware of it,” Dr Chen says.
“That puts excessive pressure on the teeth, so over time that can weaken the tooth and parts of the tooth can break off.
“That’s one of the side effects of the stress caused by the COVID pandemic.”
Grinding, and the subsequent cracks and chips that can emerge, can have “quite devastating” effects on our health, according to Dr Hutton, as can other oral diseases.
But, he says, “one would hope that if patients get back to their dentist, they’ll be able to get any periodontal conditions under control.”
How oral health affects the body
In the face of a deadly pandemic, people may be quick to assume the longer health cost of an occasional toothache or a less-than-perfect smile pales in comparison.
But the reality is poor oral health has been linked to a range of wider health conditions, including heart disease, diabetes and even adverse pregnancy outcomes.
Gum disease — or periodontitis, where bacteria collects between the teeth and gums — has specifically been linked to heart disease.
People with periodontal disease are two to three more times at risk of experiencing a heart attack, stroke, or another cardiovascular issue, according to an article published by the Harvard Medical School.
While limited national oral health data exists, the Australian Institute of Health and Welfare estimates 32 per cent of Australian adults over 15 have untreated tooth decay.
But according to the ADA’s survey, 66 per cent of respondents were unaware that poor oral health could impact medical conditions.
It’s an especially large issue among older Australians, particularly those in residential care, where poor oral health can also lead to malnutrition, aspiration and pneumonia.
A quarter of Australians over 75 have teeth affected by decay, while 20 per cent have complete tooth loss.
“Poor oral health is one of those chronic diseases that will show up later in life,” says Sarah Raphael, a registered dentist in Sydney.
“It’s a slow burn, that’s the problem, it takes a long time for it to impact on you … it might not cause too many acute problems right at the outset, but the fact that you’ve had had poor oral health all of these years, it comes to a point where it might lead to diabetes, or cardiovascular disease, or other issues.”
Oral health was one of the issues raised in the Aged Care Royal Commission, which recommended the creation of a new Dental Benefits Scheme for seniors.
The scheme, they said, should minimise out-of-pocket payments for older Australians who live in residential care, receive the age pension or qualify for the Commonwealth Seniors Health Card.
Dr Raphael says the challenge for dentists now is ensuring dental is recognised as part of broader health treatment.
“The mouth is being treated very separately from the rest of the body,” she says.
“And why should it be? It doesn’t make sense that we treat the mouth, which is part of the head and the neck, any differently to the rest of the body in terms of funding, treatment and recognition of its impacts.”
Now we know, how accessible is treatment?
For many Australians, booking a dentist appointment is not as simple as picking up the phone.
The vast majority of dental treatment is not covered by Medicare, and bills at private clinics can quickly balloon into thousands of dollars.
Even for people with private health insurance, the rebates are often a small sliver of the overall cost of the treatment.
And in the midst of rising inflation and widespread financial stress, this means it’s often one of the first things to be crossed off the expense list.
“The group of people that were least able to afford visits to the dentist before are now in a situation where they’ve got to make their dollars go further,” Dr Raphael says.
“And one of the first things to go in those situations is dental visits for preventative treatment.”
There’s also availability to consider. According to Dr Hutton, anecdotally, dentists have never been busier.
“Right now dental clinics are really under pressure to provide treatment,” she says.
“And compounded on that is practices are having a lot of trouble getting dental assistants and staff because the entire job market is very tight.”
At his clinic, he says they’re booked months ahead, though he adds that the reality is different in metropolitan areas where he believes most people would be able to get appointments with private practitioners “within a reasonable amount of time”.
However, when it comes to the public dental system, administered by the states and territories, it’s a very different situation.
Dr Raphael is the general manager of Filling the Gap, a Sydney-based charity that seeks to provide pro-bono dental treatment to people who are unable to access care through the usual channels.
The organisation works by linking volunteer dentists with charities that assist refugees and asylum seekers, people experiencing homelessness, those going through drug and alcohol rehabilitation, and people who have experienced domestic violence.
Their clients are often people that could be covered by public dental care, which is typically available to children and adults on government concession cards, but Dr Raphael says it’s clear the system isn’t working.
To see this, she says, you only need to look at the waitlists; as of December last year, almost 100,000 people were waiting for treatment in NSW alone.
While the actual time frames for treatment vary depending on a person’s location and the severity of the issue, Dr Raphael says for people needing dentures it can often blow out to three years.
“We wouldn’t expect someone who’s had their leg amputated not to be given a pair of crutches for two or three years, and told: ‘You’ve just got to make your way around’.
“But people don’t seem to equate that with the fact that if someone has no teeth or very poor teeth, they’re not able to eat, they’re not able to hold down a job or get a job interview, and they’re not able to feel confident enough to be part of society,” she says.
Because urgent and emergency treatment is prioritised, those needing preventative care fall down the list, “and all the time that they’re waiting their oral health is deteriorating more — they may have been waiting to have one or two teeth extracted, but by the time they come off the waiting list it might be four or five”.
“It isn’t a system that’s working well enough for the people it should serve, and most of that boils down to funding.”
Calls for change
In the lead-up to this year’s election, the Greens made headlines for promising universal access to free dental care — a $77.6 billion pledge over 10 years. But while Labor has committed to a “long-term” goal of expanding Medicare to cover dental health, they haven’t specified a time frame.
In a 2019 report, titled Filling the Gap, the Grattan Institute called on the government to introduce a “Medicare-style universal insurance scheme” which would cover primary dental care.
The report estimated such a scheme would cost the government an extra $5.6 billion a year.
“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,” it reads.
The ADA is also calling for a seniors dental benefits scheme to be introduced, in addition to the program that already exists for children and teenagers under 18 whose families receive government benefits.
“The oral health of Australians doesn’t seem to be drastically improving, and that’s something we have to be very concerned about,” Dr Hutton says.
However, Dr Hutton adds, “there’s still time for us to get our act together”.
Even before COVID-19 and the current cost of living pressure, Dr Raphael believes Australia was walking into an oral health crisis — especially in low-socioeconomic communities where access to fresh food is more limited.
“We were already in a danger zone,” she says. “If you’ve got some issues, you’re on the public waiting list, and your diet is poor, you can imagine how quickly all that can deteriorate by the time you’re waiting a year or more for treatment.”
Between appointments, Dr Chen stresses the importance of good home care — like thorough flossing, brushing and watching out for sugar — which can slow the progression of dental and gum disease.
But ultimately, she says, even the most stringent at-home care can’t compensate for professional treatment once an issue arises.
“The longer you leave the problem, the bigger and more expensive it’s likely to become,” Dr Chen says.
“If you bury your head in the sand, you know there’s a problem and you think you can’t deal with it, it will get worse — so I’m really hoping people take that initial first step to check in with a dentist to see what needs to be done and work out a financially feasible plan.”