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The COVID-19 pandemic has provided further evidence of the significant disparities in oral health for disadvantaged Australians. But on whose shoulders should responsibility for the provision of care ultimately rest? By Tracey Porter
Federal and state governments need to alter the way they respond to COVID-19 outbreaks or risk the current backlog of delayed dental care spiralling even further out of control, leading public health academics have warned.
CEO of Australian Dental Association Victorian Branch (ADAVB) Associate Professor Matthew Hopcraft claims the lockdowns that Australians have experienced, particularly in Victoria but more latterly in NSW, have had a significant impact on the provision of dental care for all patients.
He says it’s imperative that there is a change in the government response to further outbreaks to ensure the country’s most vulnerable are not left grappling with longer-term issues such as tooth decay.
“Dentists now are reporting more emergencies and poorer health outcomes for their patients. There is also real concern about the impact of delayed diagnosis of oral cancers.
“It’s a difficult balancing act for the public health teams involved in the decision-making process, but as we learn more about the risks of transmission and have more of the population vaccinated, it’s important that future lockdowns do not unnecessarily restrict access to necessary health care.”
A/Prof Hopcraft’s comments are supported by The University of Sydney School of Dentistry dean, Professor Heiko Spallek, who says Australia’s underinvestment in oral healthcare became widely apparent to the public during the pandemic.
Professor Spallek says while it was already a well-known fact among public health experts, COVID-19 amplified many inequalities within Australian society and its impact on the oral health of Australians will be felt for some time.
“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.”
Professor Spallek says currently around 85 per cent of dental care is provided by dental practitioners working in private practice, where it is funded through private health insurance arrangements or by patients directly.
State and territory governments provide means-tested access to 39 per cent of Australia’s most vulnerable populations to public dental services.
However, Professor Spallek says even before the pandemic, data from the Australian Institute of Health and Welfare showed many were left languishing on multi-year long waiting lists 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.
He adds: “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-19 has contributed to widening oral health inequity.”
A/Prof Hopcraft believes the most pressing concern is the impact the pandemic continues to have on the provision of dental care to vulnerable children, who already experience higher levels of dental disease and disadvantage in accessing dental care.
He says it is widely recognised that tooth decay is one of the most prevalent health conditions affecting Australian children, affecting one in three children aged five to six years. As many as four in 10 children aged 12-14 years have tooth decay in their adult teeth.
Through his secondary role as a chief researcher for practice-based dental research foundation eviDent, A/Prof Hopcraft was involved in a recent study which used data from the Child Dental Benefits Schedule (CDBS) to retrospectively investigate the impact of COVID-19 on the provision of paediatric dental care.
The CDBS provides up to $1000 of dental care to children from lower socioeconomic backgrounds, with a strong emphasis on preventive care.
Despite not fully capturing the impact of the second lockdown in Victoria, the results of the study showed that from March to September there were 881,454 fewer dental services provided in 2020 than 2019. There was a greater decline in preventive and diagnostic services, and a smaller decline in endodontic and oral surgery services.
Restrictions imposed on dentists to provide only emergency dental care effectively shut down dental practices in late March through April, and again when Victoria experienced a second wave from July to September.
A second wave of COVID-19 in Victoria saw 198,609 fewer dental services provided in that state from July to September 2020 than 2019.
As a result of this, April 2020 also saw an 86.9 per cent decrease in treatment provided through the CDBS to vulnerable children across Australia, and this was replicated in Victoria later in the year.
With access to care reduced during the pandemic, routine dental problems were more likely to escalate to dental emergencies, and this was reflected in the fact that although there was a large decrease in preventive care provided, the number of extractions and root canal treatments did not decline by the same amount.
A/Prof Hopcraft says these ongoing lockdowns, with patient appointments continually deferred, has led to dental practices across both the private and public sectors struggling to manage the backlog of patients who have had their treatment postponed over the past 15 months.
This means that patients who have had their appointments cancelled during the recent May/June 2021 lockdown are having to wait another one to two months for the next available appointment.
“Given the chronic and progressive nature of dental disease, the deferral of necessary preventive dental care is likely to contribute to poorer oral health and long-term problems for many Australians,” he says.
“Delayed or deferred access to dental care meant that many routine dental problems deteriorated, and dentists now are reporting more emergencies and poorer health outcomes for their patients.”
In addition to their concerns regarding the government’s COVID-19 response as it relates to oral health, both doctors have also called for greater recognition from governments about the importance of oral health and access to dental care.
They cite the poor uptake of the CDBS—where only around one third of eligible children access the scheme as a clear example.
While welcoming the recent federal budget which saw an expansion of the scheme to children under the age of two years, A/Prof Hopcraft says with dental problems being the leading cause of preventable hospitalisations in Australian children, there is also a need for further reform to enable treatment performed under general anaesthetic to be claimed under the CDBS.