Return to Council on the Ageing (COTA) Home Page COTA's Submission to Inquiry into Public Dental Services

search | about COTA | index | links | membership | policy and information
publications | State and Territory COTAs | what's new | feedback

COUNCIL ON THE AGEING (AUSTRALIA)

SUBMISSION TO INQUIRY INTO PUBLIC DENTAL SERVICES

SENATE COMMUNITY AFFAIRS REFERENCES COMMITTEE

February 1998

TERMS OF REFERENCE

On 29 October 1997, the Senate referred to the Committee an inquiry relating to public dental services in Australia. The terms of reference to the Inquiry are:

Current arrangements for the provision of public dental services in Australia, with particular reference to:

  1. the current and future dental care needs of low income earners and other disadvantaged groups of Australians and the capacity of both private and public dental services to meet those needs;
  2. the effect of the abolition of the Commonwealth Dental Health Program;
  3. the nature of the Commonwealth's responsibility to make laws for the provision of dental services pursuant to section 51 (xxiiiA) of the Australian Constitution and the extent to which the Commonwealth is currently fulfilling that responsibility;
  4. the Commonwealth's role and responsibility in setting and monitoring national goals for oral health in Australia; and
  5. options for reform in the delivery of public dental services, including a exploration of the efficiency and effectiveness of a range of options for delivering dental services to low income earners.

INTRODUCTION

Why is dental health important for older people?

COTA considers that good dental health is one of the foundations for a positive experience of ageing and the avoidance of ill-health.

There are three aspects of the importance of good dental care we wish to highlight.

1. Good nutrition

Good dental health, meaning well-maintained natural teeth or well functioning dentures, is a basic pre-requisite of good nutrition which is a building block for good health. Well maintained natural teeth are always preferable to dentures. Modern dental treatment emphasises maintenance of natural teeth where at all possible.

Poorly maintained natural teeth or poorly functioning dentures constrain the dietary choices of older people. Poor diet is linked to a wide range of conditions in older people such as cardio-vascular disease and bone-thinning. In older people poor diet can contribute to memory loss and poor cognitive functioning. These conditions cause suffering for the individual, their families and carers. These conditions will be more expensive to treat in the long term than some adequate dental care in the short term.

2. Freedom from pain and discomfort

Lack of dental treatment causes physical pain and suffering. This can lead to depression and other mental health problems. It can mean the long term use of pain killers and anti-depressants that have negative effects on overall health and well-being.

COTA argues that poor dental health can contribute to the deterioration in the overall health of older people that can lead to premature admission to a nursing home or death.

3. Social functioning and independence

Good dental health has important implications for adequate social functioning and the independence of older people. Older people can feel constrained in socialising if poor teeth or dentures compromise appearance, speech or eating.

We believe that good dental care has a vital role in contributing to the quality of life of older people.

Unlike many other conditions, there are no alternative treatments for dentistry. People are unable to undertake any self-help strategies to deal with dental disease once the disease or problem has taken hold. Dental problems cannot improve of their own accord.

Early intervention for dental problems is important in preventing further deterioration and to encourage preventive dental health practices such as regular and appropriate cleaning.

Many of the older generation have dental health problems as a result of a number of factors:

These problems do not afflict as many younger people who are more likely to have benefited from water fluoridisation, fluoride tooth-paste, better education on oral health care and less aggressive dentistry. Younger people have also benefited from greater accessibility to a higher standard of dental care than was available to the generation growing up through the Depression, the war and the immediate post-war years. This is not to say that younger people especially those on low incomes and from disadvantaged groups, do not suffer from dental problems. However, we would argue that dental problems are concentrated amongst older people for the reasons listed above.

COTA's response to term of reference:

  1. the current and future dental care needs of low income earners and other disadvantaged groups of Australians and the capacity of both private and public dental services to meet those needs;

COTA considers that there will be ongoing need for public dental health services that ensure that low income people receive a minimal standard of dental health care. COTA does not envisage that there will be any diminution in need for many years into the future. Older people - people over 55 - will make up a very significant proportion of those requiring public dental health services.

The Australian Institute of Health and Welfare shows that the prevalence of dental problems increases with age but that across all age groups there has been steady improvement in dental health. Many more older people now have their own teeth than even just fifteen to twenty years ago.

67.7 % of people aged 65 and over were edentulous (without teeth) in 1979, but only 44.4% in 1992-93 (AIHW, 1994, p 96).

The fact that many people will be reaching older age groups with their own teeth will have significant implications in the future for the need for good dentistry to maintain those teeth in good working order. This is especially the case if the teeth have been filled as they are most likely to be for the pre-fluoridisation generation (AIHW, 1994, p97)

Current and future dental care needs amongst older people

Amongst older people over 50 years old there will be a range of dental care needs. COTA has identified several groups of older persons with specific care needs in terms of dental health.

Group characteristics Dental care issues Service needs
1. Late fifties to late sixties

People with their own teeth who nevertheless have had extensive fillings and restoration.

Living independently, some working.

This group will expand as a proportion of the older population. Over time many more in this age group will have better teeth than the present cohort.

Maintenance of existing teeth and fillings.

Prevention of decay.

Likelihood of significant needs for restorative work such as crowns.

 For those still working, services in line with that of rest of community.

For retired people on adequate but modest fixed incomes, cost-shared subsidised services may be appropriate

For people on low incomes including Age Pension, readily accessible, heavily subsidised/free public dental services are required with focus on preventative care.

2. The over 65s living independently

People who have few or no natural teeth. A group with high rates of wearing dentures or partial plates compared to younger age groups.

More likely to be in older age groups and retired.

Living independently without disability.

The people in this group without teeth, is declining as a proportion of the older population due to greater rates of retention of natural teeth into older age brackets

 Dentures and plates need to fit well. Should enable eating of wide variety of foods and be comfortable for the wearer.

Any remaining teeth to be maintained as per group 1.

 Access to affordable dental services in local area which ensure dentures and natural teeth function well and people are free from pain and discomfort.

For people on low incomes including Age Pension, readily accessible, heavily subsidised/free public dental services are required.
3. The frail aged (over75)

As a group, high rates of having few or no natural teeth. High rates of wearing dentures or partial plates.

Living in nursing home/hostel due to frailty or disability or living at home with the help of community services.

There are growing numbers of frail aged in the community. In the future more of the frail aged will have their own teeth.

 Dentures and plates need to fit well. Should enable eating of wide variety of foods and be comfortable for the wearer.

Any remaining teeth to be maintained as per group 1.

 Access to dental services which ensure dentures function well.

Services that minimise travel requirements for the frail ambulant.

Specialist services that cater for frail aged people, people with disabilities and dementia.

For people on low incomes including Age Pension, readily accessible, heavily subsidised/free public dental services are required.
4. People with dementia (concentrated amongst the over 80s)

People who have few or no natural teeth. High rates of wearing dentures or partial plates.

People with dementia living at home or in supported accommodation.

The number of people with dementia in the community is growing. In the future more people with dementia will have natural teeth.

 Dentures and plates need to fit well. Should enable eating of wide variety of foods and be comfortable for the wearer.

Any remaining teeth to be maintained as per group 1.

 Access to dental services which ensure dentures function well.

Visiting dental services that ensure people with dementia have needs assessed. People with dementia less able to communicate if they have a dental problem.

Specialist services that cater for people with dementia.

For people on low incomes including Age Pension, readily accessible, heavily subsidised/free public dental services are required.

The chart suggests that there will be changes over time in the mix of dental care needs of the older population.

Amongst the older age groups of the older population, at the present time there is a strong need for services that focus on well-functioning dentures. This service need will diminish over time as more people grow older with their own teeth.

In younger age groups of the older population, there is a need for services that help them maintain teeth that are likely to be heavily filled. As this group moves into older age groups, they will be less able to afford private dental services and will need a higher level of publicly subsidised services in order to maintain their natural teeth.

Eventually however, there will be less need for extensive dental services as the present younger generation - the fluoride generation - grow older with their own teeth and without major fillings. People from low income and disadvantaged backgrounds, however, will continue to be at risk of poor dental health due to poor diet and lack of regular dental care.

Top of Page

The capacity of both private and public dental services to meet those needs

It is clear that in their current state neither private nor public dental services meet the needs of low income and disadvantaged older Australians, including those who are frail, ill or have a disability or dementia.

Private dental services

The simple fact is that the costs of private dental care are out of the reach of low income older people. Reliance on an Age Pension or other low income precludes the capacity to pay for private dental treatment.

A number of factors are relevant in terms of the barriers to access to private dental services:

Public dental services

The second barrier to adequate dental health care for disadvantaged older Australians is created by a hopelessly under-resourced public dental system characterised by long waiting times and little capacity for it to handle anything other than emergencies.

Unless there is an increase in public funding for dental services, COTA sees no capacity for the public system to improve its services to meet the need.

COTA discusses the options for improved public dental services in response to term of reference (e) below.

COTA'S response to term of reference:

  1. the effect of the abolition of the Commonwealth Dental Health Program

COTA has received information that a number of submissions being prepared for this Inquiry will demonstrate the extent of the problems caused by the demise of the Commonwealth Dental Health Program. COTA does not attempt to provide the same documentation.

In summary we understand the effects as:

1. A decline in resources for public clinics and access to private dentists.

2. The closure of public clinics in some areas.

3. An increase in waiting times for general and preventive dental care, which amount to years in some States.

4. The closure of waiting lists and clients no longer getting any indication of when, if at all, they are likely to get treatment in some States.

5. Treatment being confined to emergency work only.

6. A return to an emphasis in dental care on extractions rather than fillings. (This reminds us of the use of radical amputation of a limb in times gone by rather than the more painstaking and lengthy treatment to save a limb).

7. An increase in problems for people in special circumstances getting dental care: eg people in nursing homes or rural and remote areas

COTA runs information and advisory services in a number of States and Territories.

COTA's Seniors Information Service (SIS) in NSW received 123 calls between 1 July 1997 and 30 November 1997 on dental care issues which illustrate and support the broader statistics on the effects of the abolition of the CDHP.

The majority of these calls have been from older people wanting information as to where they might obtain dental care sooner than through the public system. They report a 3 year wait for treatment for dentures and an 18 months wait for dentistry for natural teeth.

A sample of the calls that were taken included the following:

Client, 82, went to Royal Newcastle Hospital Dental Clinic and was told her case didn't constitute an emergency even though her dental plate was so loose she couldn't wear it, her lower teeth had ground down to gum level. She could not eat meat or chew. She was in danger of malnutrition. She is incapable of travelling all the way to Sydney for an appointment with the dental hospital. SIS advised her to obtain a letter from her doctor to challenge the clinic's decision.

A 65 year old pensioner, called to find out if she could claim a refund from Medicare for dental work. She lives in an isolated rural town a long way from the nearest hospital, and had visited the closest dentist who did some dental work for which she paid several hundred dollars. Overnight, Hilda experienced considerable pain and felt very ill. She made an appointment to see the dentist again. This time, he advised her to have every tooth extracted. She didn't want this but could not afford any other alternative. Hilda had all her teeth extracted and a denture plate made. She paid a total of $2,000 and was left penniless. The SIS officer told Hilda she is not entitled to any Medicare refund and her dentist offered no discount, even after she explained her financial predicament.

A disabled 61 year old pensioner, with most of her natural teeth, was in need of extensive dental treatment. After waiting many hours at Sydney Dental Hospital to be assessed she was placed on a two year waiting list. She has since moved into a nursing home and has been treated by the visiting dentist.

Man in his seventies from a rural area had tooth broken off during weekend. He was quoted $1,000 to have acrylic crown inserted by private dental practitioner. As a pensioner he could not afford this amount of money and was referred to local dental clinic where he was told he would be on a two year waiting list as it was not considered to be an emergency. He was told he would not only need to be in pain but would also have to be bleeding.

Pensioner in his late eighties went to local hospital after not having eaten properly for 3 days because he had broken his upper denture plate. He had no lower teeth or dentures. He was told that the hospital had no dental service and that he would have to be treated at Sydney dental hospital after a 6-8 month wait. SIS contacted his local hospital and and was told that it did in fact have a visiting dental service and referred him to the service. He was seen by the clinic two weeks later and waited a further two weeks to have his dentures repaired.

COTA (Victoria) asked its members to write in with their recent experiences of trying to get assistance through their public dental services in Victoria. This is a sample of what they had to say.

"In recent years, as there has been little original tooth left, teeth have been breaking off. This has required several crowns and a bridge so far. The last crown cost $700. When another tooth broke off last year I did not have that much money, so I still have not seen the dentist for about four years.... While paying half my pension in rent, I feel I am in a very precarious position."

"For 8 years I attended a dental clinic....with very satisfactory attention. I was transferred to another dental clinic (when the first one was closed down) two years ago. I am still waiting for an appointment. They cannot give me any indication of an appointment. I am on the age pension and cannot afford private dental fees."

"I was at the top of the list for new dentures at --- clinic when they cut it out. I have had my top dentures for 20 years... also I have a condition and have to have my teeth cleaned every 6 months. Now my teeth are loose and my gums bleed. It seems I will have to have them out when I can. I cannot eat meat and alot of things as I can't chew them."

"Both my friend and his wife have been having dental difficulties since the closing of their clinic in late 1996 and although they have been in touch with the -----Clinic on numerous occasions, they were never given a definite answer except that they are on the waiting list."

"I have not needed dental treatment since 1944 when, at the age of 18, I was fitted with a full set of dentures that cost my father 18 guineas. Needless to say nowadays these are causing some problems. I consulted a dental surgeon who did some minor adjustments and relieved me of $25. The adjustments did not work for long. The recommendation is that I get a complete new set. I am however, loathe to enquire as to the cost."

These stories illustrate the appalling social inequality in Australia today because of inadequate public funding of dental services.

It is barbaric that people have such stories to tell in Australia in the 1990s.

COTA's response to term of reference:

  1. the nature of the Commonwealth's responsibility to make laws for the provision of dental services pursuant to section 51 (xxiiiA) of the Australian Constitution and the extent to which the Commonwealth is currently fulfilling that responsibility;

The Commonwealth has specific powers (as a result of the referendum in 1946) in the area of dental health under section 51 (23a) of the Constitution. This section states that:

51. The Parliament shall, subject to this Constitution, have power to make laws for the peace, order and good government of the Commonwealth with respect to 23 (a) the provision of maternity allowances, widows' pensions, child endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical and dental services (but not so as to authorize any form of civil conscription), benefits to students and family allowances.

It is not clear why the Commonwealth in the past has not instituted dental health programs under this 1946 constitutional provision, while it is involved in all the other areas listed.

Undoubtedly, cost has been the major consideration.

We noted that the MInister for Health and Family Services, Dr Michael Wooldridge, compared dental care to allied health services such as physiotherapy, occupational therapy and clinical psychology in a radio interview (LIfe Matters, ABC radio, 30 September 1996). He made the point that allied health services were areas, as justifiable as dental health for Government funding, if they could be afforded.

COTA is of the view that dental health is fundamentally different from the allied health services that he mentions. We believe that dental health can be seen as a primary health care need for the following reasons:

The historical importance of dental services as a primary health need is indicated by its inclusion in the Commonwealth Constitution at section 51 (23a) as a concurrent Commonwealth power, along with medical services. Medical and dental practitioners were accorded the same status in the Constitution in terms of the prohibition on their civil conscription. This implies that medical and dental services were accorded equal status as elements of primary health care.

The reading of the Constitution leaves little doubt that at the time of the 1946 amendment, a role for the Commonwealth was envisaged in the provision of dental services. This was not a role envisaged for allied health services, desirable as such services would be for many people. Indeed, the capacity for allied health services to become more integrated into medical treatment practices is currently being explored in the Commonwealth Government's Coordinated Care Trials.

COTA's response to term of reference:

  1. the Commonwealth's role and responsibility in setting and monitoring national goals for oral health in Australia.

COTA is of the view that the Commonwealth does have an important role in setting and monitoring national goals for oral health in Australia so that all Australians have access to the same level and quality of services.

In terms of national goals COTA wishes to see the development of a National Policy on Dental Health. The policy should set out a range of objectives in the following areas:

prevention: regular check-ups to prevent problems arising

appropriate and timely treatment: swift, remedial action when problems do arise that aim to save teeth rather than extract them

services to meet the needs of special groups:

- people on low incomes
- the frail aged
- people with dementia
- people in rural and remote areas
- people in residential aged care

It is essential that a national policy should be underpinned by Commonwealth resources for dental health.

Without the commitment of resources, the Commonwealth is abrogating its moral responsibility to ensure that there is consistent standards for national goals for dental health.

Australia needs the Commonwealth to provide a good public dental health program for people on low incomes or to fund the States as specific purpose payments to do so.

Private dental care is very expensive. The simplest treatment can cost $50 to $100. People on low incomes, including pensions and benefits, simply do not have sufficient income to cover the costs of private dental care.

There are major social equity issues in the dental health area which the Commonwealth has a responsibility to address. It is a gross injustice, that people on low incomes have to endure pain and discomfort, social stigmatisation and tooth loss because they cannot afford the cost of basic dental care.

Social equity is primarily a Commonwealth responsibility. Commonwealth economic policies and income distribution policies contribute to social inequality in Australia. It is these policies which create the opportunities for people to look after themselves and to afford the services that they need.

As we have mentioned before, dental health is important in preventing other major health problems requiring expensive treatments that would have to be funded by the Commonwealth through Medicare.

States do not have the revenue sources to increase funding for dental health services. It is unreasonable to push back full responsibility to the States in this area.

The loss of the Commonwealth Dental Health Program means that people literally have to wait years to get to see a dentist. This will mean that their dental health will get worse and they will need more expensive treatment. However, as they won't be able to afford it and the system will not be able to provide it, quite likely they will end up losing teeth.

The cost of the Commonwealth Dental Health Program at a little over $100 million per year was not a vast sum in terms of Commonwealth finances. However, it represented a vast investment in helping people on low incomes get access to dental services when they needed them.

COTA's response to term of reference:

  1. options for reform in the delivery of public dental services, including an exploration of the efficiency and effectiveness of a range of options for delivering dental services to low income earners.

The possibilities for improving accessibility to dental health services for low income and disadvantaged older Australians are as follows:

1. Rebates, subsidies or concessions.

Visits to doctors, optometrists and hearing services are subsidised by the Commonwealth. Older people with concession cards are entitled to rebates for services in these areas. It is strange that while hearing and seeing are considered important, eating is not.

The reasons for this anomaly need to be closely examined in the light of the provision of other concessions. Of course theoretically, there is a public dental health program in each State and Territory but this is not adequately resourced by either State or Commonwealth Government to do its job.

It would be possible however to have a Medicare type system for dental care which depended solely on private dentists to provide services for which selected users would receive a subsidy, rebate or concession.

For medical services, this system depends on containment of fees of the medical profession.

Costings of a Medicare type system for dental services are worth doing.

2. Improvements to basic income support.

Australia's income security policies have favoured a system of a basic payment supplemented by concessions for a range of key services such as utilities, pharmaceuticals and hearing services. However, in the absence of any concessions in the dental health area, the adequacy of income support payments must be questioned where people cannot afford to buy fairly basic services such as gettting a new denture made or a sore tooth treated promptly without extraction.

COTA has had particular concerns for some years about the fate of older people who are reliant on an Age Pension with no other source of income over a very long period. For instance a woman who begins to receive an Age Pension when she is 63 could well have nothing else to live on for another 20 years if she lives until 83.

Our concerns have been that such people have very little income left over from the Age Pension to meet large periodic expenditures such as white goods or dental care.

One option that would help overcome barriers to access to dental care would be the provision of adequate income support or income supplement for such costs. However, like Rent Assistance for pensioners in private rental accommodation, it is unlikely that such income support will be very successful in overcoming major affordability barriers to dental care.

3. Increased funding for public dental health services.

The only program of access to dental services in Australia for low income and disadvantaged people has been through the State and Territory public dental health services. These services have long been insufficient to meet the need. They received a great boost through the Commonwealth Dental Health Program which had a brief life of two years before its demise at the end of 1996.

The State and Territory public dental health services urgently need to be upgraded and receive adequate Commonwealth funding to provide a decent service for low income and disadvantaged Australians.

4. Reduction in the costs of dental care.

This is not seen as feasible in the short term. The dental profession argues that there are very high costs in operating a dental surgery which preclude any reductions in the costs of treatment.

The extent to which the costs of dental care can be moderated to create greater affordability for all Australians however is an issue that should be examined. Little is known about the setting of dental fees and why those fees are now out of reach of so many Australians.

Greater transparency in the costs of dentist's services, in terms of labour and other inputs is long overdue. This is also a necessary task for establishing some benchmarks for dentist's fees under a system receiving a greater level of public support.

The Government can also act to foster the development of courses which train people in ancillary dental health services particularly dental hygeniests who can play an important role in providing preventative services and do not involve the costs of a dentist's services.

COTA's recommendations for reform of dental health services

COTA considers that the task for the Commonwealth Government at this point in time is to ensure that the States can run efficient, effective and accessible dental health services that provide a reasonable standard of health care to low income and disadvantaged Australians.

  1. The Commonwealth Government should provide funds through a specific purpose payment to the States for them to run dental services through existing public dental clinics. Funding for dental health could be provided through the Health Care Agreements. The funding would:

focus on preventive dental services (check-ups, fillings and restoration rather than extractions);

ensure that dentures are well-fitting and comfortable;

enable the public dental service to contract private dentists or services;

ensure that people in rural and remote areas have access to public dental services;

ensure that people in institutions including residential aged care have access to dental services when they need them;

provide services for special needs groups.

  1. The Commonwealth Government should establish a National Dental Health Policy which sets out adequate standards of dental health care for all Australians covering:

prevention: regular check-ups to prevent problems arising

appropriate and timely treatment: swift, remedial action when problems do arise that aim to save teeth rather than extract them

services to meet the needs of special groups including:
- people on low incomes
- the frail aged
- people with dementia
- people in rural and remote areas
- people in residential aged care

  1. The Commonwealth Government should establish an inquiry into the costs of dental care aimed at creating greater transparency into the costs of inputs for dentist's services.
  1. Training for ancillary dental services including those provided by dental hygienists should be expanded by the Commonwealth.
  1. Costings of Medicare-type arrangments for dental health should be undertaken.

Reference

Australian Institute of Health and Welfare (1994) Australia's Health, Canberra, AGPS

Top of Page

Copyright © 1998 Council on the Ageing. All rights reserved.
Date: 4 April 1998
Revised: 30 October 2001

Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent, Melbourne Vic 3004
Tel (03) 9820 2655 Fax (03) 9820 9886
email cota@cota.org.au