The great disconnect


ColgateHero_002_PPA powerful new report highlights the vital connection between good oral health and broader physical, mental and emotional wellbeing. Chris Sheedy delves into its details to discover its practical implications.

Dr Susan Cartwright has a theory that is very likely close to the truth about why there is such a disconnect between medicine and dentistry. The scientific affairs manager for Colgate Oral Care explains that in past generations, people simply expected to lose their teeth. Once the teeth were gone, the health of the mouth seemed of little importance. This informed the way that several generations felt about the practice and importance of dentistry, and possibly also influenced the politics around the topic. It is now clearer than ever that all of this needs to change.

Dr Cartwright is a member of the Oral Health Advisory Panel, a body of academics, dentists, dental therapists and hygienists, industry experts and health professionals established in 2013 to raise awareness of the importance of good oral health, and of its impact on general wellbeing. The panel’s report, titled Oral health and general health in Australia: The great disconnect, outlines why a complete re-education around the topic has become so necessary.

The report details that sugar consumption is on a steady rise globally. The World Health Organization [WHO] has issued recommendations on sugar consumption to reduce the risk of non-communicable diseases in adults and children, with a specific focus on tooth decay and obesity. Thanks to tooth decay, WHO says, dental care costs between five and 10 per cent of the health budget in industrialised countries. “Despite the fact this is largely preventable,” the paper says, “tooth decay is the most common chronic disease of childhood. Worldwide, 60 to 90 per cent of school children have cavities.”

Perhaps most worrying, considering the prevalence of the issue in our children, is the fact that tooth decay in early childhood is a significant predictor of long-term dental health problems.

Perception meets reality

“There is quite a lot of literature coming out about how oral diseases relate to systemic diseases,” Dr Cartwright says. “The associations between heart disease, diabetes and so on have highlighted these sorts of issues. Then there is the fact that some lifestyle diseases are connected to sugar, and of course tooth decay is connected to sugar. There are common risk factors for some systemic diseases that also apply to oral disease. But traditionally, oral health has been left out of the equation when people are talking about these lifestyle issues.”

The actual connections between oral health and broader medical health are just part of the issue. Public opinion and political viewpoints towards oral health, which hold powerful sway over physical outcomes and political regulations, are affected by historical attitudes around the topic.

So, despite the fact that tooth decay is largely preventable, Dr Cartwright says, 58 per cent of people believe cavities are inevitable. And according to the WHO, almost 100 per cent of adults have experienced tooth decay, which is perhaps unsurprising as further research has revealed that 49 per cent of Australians forget to brush their teeth—and furthermore to floss—before going to bed.

“There needs to be a little bit more expectation on behalf of the public to be able to keep their teeth and to be able to keep them without requiring fillings.”—Dr Susan Cartwright, Oral Health Advisory Panel

“It appears that many people do not believe they can prevent tooth decay, but in fact it is almost entirely preventable,” Dr Cartwright says. “Usually, gum disease is not painful, so people feel they can ignore it. And maybe they are not too concerned about losing their back teeth—certainly in the past that was not a great concern. But now there needs to be a little bit more expectation on behalf of the public to be able to keep their teeth and to be able to keep them without requiring fillings.”

In an environment in which there is a disconnect between oral health and other medical outcomes, political and regulatory decisions can further exacerbate the problem. Once those regulatory decisions are made, dentists can find they are being rewarded for carrying out procedures rather than educating patients about lifestyle issues and preventive measures.

“Today’s dentist is rewarded for filling teeth,” Dr Cartwright says. “Preventive practices are much more difficult to assess and support from the government and insurance company perspective. With chronic diseases, it is recognised that in the end it is much more economical for governments to support prevention than to have to pay for the consequences of disease. So it does make sense to do that; it is just a hard thing to put in place.”

Oral health and adult wellbeing

As is well known, a large percentage of children suffer tooth decay, which in itself is a predictor of long-term dental health problems. What makes this more of a concern is that long-term dental health problems can have major and detrimental effects on people’s lives.

Over half of those who experience depression also suffer oral health problems that affect their daily lives, the report says. Of course, this could mean depression causes oral health problems, rather than things being the other way around. And in some cases, this could be correct. But the report points out some important facts, all backed up by academic research, around this matter.

Poor oral health in children is related to reduced school attendance and inattention in class, it says. It is also linked to problems with speech, eating, poor self-esteem and feelings of worthlessness. As those youngsters grow into adults, oral health problems can translate to self-consciousness, avoidance of social contact, avoidance of smiling and laughing, reduced quality of life and depression and anxiety.

“These problems can affect important experiences, such as the confidence with which children and adults socialise with peers and approach new challenges, and these help to shape our developing identity,” the paper’s authors wrote.

“For adults, self-consciousness and the avoidance of smiling can affect your performance in job interviews and your ability to get a job,” Dr Cartwright says. “That is a reality for some people, and as a result, the sad reality is that it affects every part of their life.”

Practical implications

One in six Australian adults avoid eating certain foods because of problems with their teeth, the Oral Health Advisory Panel report says. A quarter of Australians over the age of 15 report feeling uncomfortable about their dental appearance. And despite improving dental technology and greater awareness and vigilance around health and appearance, the severity and prevalence of tooth decay has been increasing, in Australian children and adults, since the mid-1990s.

What does all of this mean? How can such trends, fuelled by generations of beliefs and attitudes, be turned around? How do you re-educate an entire society that appears newly concerned with the whiteness and straightness of their teeth but unconcerned with their underlying oral health?

“I saw a funny video the other day containing cartoon characters,” Dr Cartwright says. “The character went to the dentist and said they wanted straight, white teeth and the dentist said, ‘But you have terrible oral disease and you need to get that fixed before you have your teeth whitened.’ The person responded with, ‘No, I just want white teeth. Give me white teeth!’ And the dentist was saying, ‘But your breath really stinks! I can tell that you have disease in your mouth.’ It was very funny, but actually that is quite often the mindset. Even the people who care about the appearance of their teeth often don’t feel the same way about what is going on at the back of their mouth. It’s all about the front teeth.” People should care much more about the welfare of their teeth. 

So, how is it fixed? This battle can’t just be fought on one front, Dr Cartwright says. She recommends a three-pronged approach in order to bring about a change in attitude and a re-connection between medicine and dentistry. “First of all, there needs to be a change in dental education to ensure practitioners are practising the best prevention they can. They need to be putting extra effort into promoting preventive practices to their patients and being rewarded for doing this,” she says.

“Then, I think, members of the public need to understand that they can have perfect teeth and that, in fact, it is not that hard. I’m not necessarily talking about straight teeth—that is harder and more expensive—but from a disease perspective, they can have a really good outcome with their teeth. They don’t have to have fillings and they don’t have to suffer decay. That sort of education needs to be had as well.

“Finally, it needs to be a topic discussed in a new light in the political and regulatory forum. Shouldn’t there be some sort of system that recognises dentistry within medicine? Should discussions be had that are led by agendas around insurance payments and government support and that sort of thing? These are the three fronts on which I think this needs to be fought. If one does not succeed then the rest will fall over. It is not an easy task but the more we do to raise awareness, the closer we come to changing those all-important mindsets.”

A recently commissioned report, the 2014 Lonergan Study, said many Australians wished they had taken better care of their teeth and agree that ‘nothing looks worse than bad teeth’. If they had been offered the right advice and had understood the simple processes involved in looking after their oral health, they would probably not have such regrets. The next generation, Dr Cartwright says, doesn’t need to feel the same way.

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