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Put common sense into Australian health care ... put the mouth into medicare! |
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Table of contents SECTION 1: Introduction SECTION 2: Medical implications of oral health issues. SECTION 3: Oral health and socio-economic status. SECTION 4: Psychosocial implications of oral health conditions. SECTION 5: Conclusion INTRODUCTION For 1999-2000 total expenditure on health services in Australia was $53.7b, a rise of $2.6b from the previous year. This represents an average rate of health expenditure of $2,817 per person, an increase of $111 per person on the previous year (ABS 2002). Routine dental services are not provided through Medicare so the majority (88%) of dental services are provided in the private sector with the remainder (12%) provided by the public sector. Specific groups of people who are financially unable to access the private sector, or whose needs have not been met in the public sector miss out on dental care. Notably, these include young adults, low income earners, unemployed persons, people with disabilities, people who suffer chronic ill health, people from non-English speaking backgrounds, Aboriginal and Tones Strait Islanders, older persons and people living in rural and remote areas (Short 1999). In 1996 the Howard Government abolished the Commonwealth Dental Health Program (CDHP) and in its place introduced subsidies for those choosing to take out private insurance. The lack of public health cover for dental services has been defended by the argument that dental services are separate and distinct from the medical profession, however research has shown a strong link between illness, disability and socio-economic disadvantage. Oral health care is an often neglected component of total health care. Poor oral health can significantly impact on a person's quality of life, causing considerable psychological distress. The National Health Priority Areas Paper 1998, which was compiled as a collaboration of Commonwealth, State and Territory governments, with an aim to improve the health of Australians by targeting diseases or conditions that impose a high social or financial cost, has identified Australia's five priority areas as: cardiovascular health, cancer control, injury prevention and control, mental health and diabetes mellitis (AIHW, NIIPAs 1998). At a societal level, a large gap exists between the 'deprived' and the 'privileged' in Australia in oral health and the use of dental services. Poor oral health can have an economic impact which is manifest in work days lost, school days lost, hospitalisation and oral contributions to medical illnesses such as diabetes, cardiovascular diseases, stroke and pre-term low birthweight babies. Major dental diseases such as caries and periodontal disease, which lead to medical illness, are both preventable and treatable, thus the provision of dental health care is a cost-effective way to prevent and/or manage systemic health conditions. Signs and symptoms of life-threatening diseases appear in the mouth long before they show up in any part of the body (ADHA Surgeon General's Report, 26.07.02). Providing oral health care can prevent, or detect early, the onset of medical diseases such as oral cancer, pre-term births, and can alleviate oral conditions that arise as a consequence of medical treatment (as in arthritis, cancer, diabetes) thereby reducing the increasing rate of health expenditure. The 1992 National Health Strategy identified inequalities in oral health care and access to dental services as major issues in public health in Australia. Since then, oral health goals and targets have been set in place, however dental problems in general are increasing, particularly for government concession card holders. Access to dental care by card holders has deteriorated, with affordability being an issue (AIHW 2001). Research over the last thirty years has established that the major oral diseases (i.e. caries and periodontal disease) are in fact infectious diseases (Mandel 2002). Periodontal disease, which leads to potential problems in older adults, has been identified as having public health significance that needs consideration. Periodontal disease is the primary cause of tooth loss in adults. It results from untreated gingivitis, and causes inflammation and destruction of tissue surrounding and supporting teeth, bones and fibres which hold the gums to the teeth. Demonstrating a similar situation to the one experienced in Australia, approximately 75% of American adults have some form of periodontal disease and because it is usually painless and silent in its early stages, the majority of them do not know they have it (ADHA Surgeon General's Report May 25, 02). In Australia, public funded patients, particularly those over 65 years have poorer periodontal health compared with the general population (Brennan, Spencer, Slade (2001). This paper presents scientifically based evidence to show that:
: MEDICAL IMPLICATIONS OF ORAL HEALTH CONDITIONS Oral health problems have been found to be linked to medical conditions such as:
Circulatory diseases ABS health studies reveal that the prevalence of cardiovascular disease in the Australian population is increasing (from 17% in 1989-90 to 21% in 1995). Circulatory diseases account for 40% of all deaths in Australia. Research has shown a link between cardiac illness and oral health. There is a strong relationship between socio-economic disadvantage and death, illness and disability from coronary heart disease, stroke and many other illnesses. Cardiovascular disease and stroke is the largest cause of premature death and death overall in Australia. Stoke is one of the principal causes of long term disability. (AIHW National Priority Areas 1998). Mortality rates for coronary heart disease and stroke are high among people of working age living in the most socio-economically disadvantaged areas, with cardiovascular death rates being around double those among people living in the least socio-economically disadvantaged areas (AIHW National Health Priority Areas 1998). Coronary Heart Disease Longitudinal studies conducted in the U.S. provide powerful evidence that dental disease, most likely periodontal disease is a risk factor rather than a marker or indicator of Chronic Heart Disease (CHD).
Cerebral Vascular Accidents A case control study by Syrjanen et al (1989) has shown that dental infection is statistically associated with cerebral vascular accidents (CVA), or 'stroke'. Similarly, Grau (1997) and colleagues found poor dental health to be independently associated with cerebral vascular ischaemia. Further, Beck (1996) and colleagues demonstrated that US veterans who had lost bone around their teeth (from dental disease) in their thirties were 2.8 times more likely to be diagnosed with a CVA than those with little or no bone loss around their teeth (Loesche 2000). The biological explanation for the link between dental disease and cardiovascular disease appears to be that the bacteria or their products that are produced in dental disease elicit host responses that contribute to increased levels of cytokines and inflammatory mediators that may affect the endothelial lining of vessel walls which subsequently promotes atheroma formation on the endothelial surface (Loesche 2000). Diabetes Diabetes is a major public health problem, being the 6th leading cause of death in Australia (ABS 2002) and contributing to significant illness and disability. Research by Albrecht et al (1989) has shown that diabetics have a higher prevalence of periodontal disease than non-diabetics (cited in Kawamura, Fukuda, Kawabata, Iwamoto 1998). Approximately 95% of Americans who suffer from diabetes also have periodontal disease and research shows that people with periodontal disease have more difficulty controlling their blood sugar level. Severe periodontal disease can increase the risk of developing diabetes (ADHA Surgeon General's Report May 2000). Further, among diabetics, the presence of periodontal disease is a risk factor for the development of cardiovascular disease.
Respiratory disease - Pneumonia Pneumonia is an infectious disease which is prevalent in a high rate in those over 65 years, and is the leading cause of death among nursing home residents. Research has shown a biological link between oral health and pneumonia. The oral cavity can serve as a pathway for infection for respiratory diseases. Bacteria in the oral cavity frequently invades the blood, and whilst healthy individuals have adequate immunological defence mechanisms to prevent further invasion by such bacteria, individuals whose health is compromised by old age or illnesses such as cancer, diabetes, or immunodeficiency cannot expel the bacteria. Subsequently the bacteria are aspirated into the lungs, causing pneumonia (Okudo et al 1998). Yoneyema et al (cited in Okudo at el 1998) reported that providing good oral care to nursing home residents reduced bacterial pneumonia and fervescence in the elderly. Arthritis Recent research demonstrates a link between poor oral health and arthritis. Arthritis is Australia's major cause of disability and pain. It affects an estimated 3.1 million people (as at June 2000) or approximately 16.5% of the population. Nearly 5% of Australians are taking medication for arthritis and 2% of the population are disabled or handicapped with arthritis. Arthritis affects nearly 11% of the workforce and is responsible for nearly 1.8 million days of reduced activity and 213 000 days off work or school each year in Australia. The overall financial cost of arthritis in Australia was approaching $9b in 2000. As the population ages, arthritis is becoming a growing burden on health expenditure. The cause of rheumatoid arthritis (RA) is unknown, however research has shown that oral bacterial antigens can cause chronic infectious disease in the articular cavity (of a joint) and induce an immune response that results in arthritis due to inflammation and osteoclast activation (Okudo et al 1998). Ongoing oral health care is important as long term use of medications for arthritis can cause gingivitis, and the disease can lead to destruction of underlying bone in the tempero-mandibular joint and increased incidence of periodontal disease, including loss of alveolar bone and teeth (Triester and Glick 1999). Cancer Cancer, the first of the five major health priorities in Australia, is the leading cause of death in Australia. Early detection of oral or pharyngeal cancer, especially before it has metastesised, reduces illness and death. In Australia's ageing population it is a concern that as people grow older they are at an increased risk of oral and pharyngeal cancers and other chronic disabling conditions that have oral manifestations. If detected early, oral cancer can be treated successfully 90% of the time (ADHA Surgeon General's Report). Older people who have lost all their natural teeth (edentulism) are at the greatest risk of getting oral cancer, but are least likely to seek dental care. The survival rate for early stage cancer is 81% but is only 22% for persons diagnosed with advanced stage cancer (Healthy People 2010). With early detection, treatment is less complicated, the functional and cosmetic results are better and survival is improved, however late detection often involves lymph node metastases (Scully and Porter 2000). The fact that adults seek care most frequently from physicians rather than dentists, further illustrates the importance of providing access to dental health services for early oral cancer detection. Pre-term and low birth-weight babies Babies born prematurely are at a significant risk of developing serious and lasting health problems. Birth-weight is considered to be an important determinant of the chances of an infant to survive, grow and mature. Studies have found that expectant mothers with periodontal disease are seven times more likely to deliver premature (born before 37 weeks gestation), low birth-weight babies (less than 2500 grams) than women who do not have the disease (ADHA Surgeon General's Report, May 2000). Data from the National Centre for Health Statistics lists the major risk factors for pre-term births as: rural and poor minority women, smoking, alcohol use, maternal weight of less than 50 kg and various maternal medical problems. Further to these, a prospective study by Jeffcoat et al (2001) on 1313 pregnant women in Alabama shows a significant association between the presence of periodontitis at 21-24 weeks gestation and subsequent pre-term birth (Jeffcoat, Geurs, Reddy, Cliver, Goldenberg, Hauth 2001). The study provides evidence that pre-existing periodontal disease in the second trimester of pregnancy increases the odds of pre-term birth from 4.5 to 7.0 fold. Supporting the link between periodontal disease and pre-term birth, Offenbacher and colleagues' (1996) study of 124 pregnant or post-partum women found that mothers of pre-term or low birth-weight babies had significantly worse periodontal disease than the control group who delivered babies at full term. The biological explanation for the link between maternal periodontal disease and pre-term birth has not yet been scientifically presented, however it is plausible that endotoxins resulting from periodontal disease stimulate the production of cytokines and prostoglandins that are known to stimulate labour (Jeffcoat et al, 2001). In support of this explanation, Okudo and Ebihara (1998) state that the endotoxin P.intermedia, produced in oral bacteria, is a causative agent for premature delivery and birth and go further to emphasise the importance of appropriate oral health care during pregnancy (Okudo and Ebihara 1998). ORAL HEALTH AND SOCIO-ECONOMIC STATUS The socio-economically disadvantaged have poorer oral health and barriers exist that prevent their access dental health care. The disparity between oral health and the use of dental services was shown in a 1994-96 survey of 17 691 people selected randomly from all over Australia, which investigated dental health and dental visit characteristics of participants from the highest and lowest socio-economically located groups, determined by the ABS Socio-Economic Index for Areas (SEIFA) Index of Relative Socio-Economic Disadvantage (AIHW Dental Statistics and Research Unit March 2001). The highest group ('privileged') had an annual household income of above $40 000 and had dental insurance, whilst the lowest group ('deprived') had an annual household income below $20 000 and did not have dental insurance. The study revealed that compared to the 'privileged' group, the uninsured low-income residents of low socio-economic areas experienced:
An AIHW survey of the use of dental services by children aged 6 to 12 years and adolescents aged 13 to 16 years revealed similar socio-economic findings. During 1994-1996, school dental services (provided free in all Territories and States) were utilised more by the less advantaged. However barriers to dental care in the form of language, lack of insurance and low income still exist across the population (AIHW Dental Statistics and Research Unit January 2000). These results confirm that a large gap exists between the socio-economically advantaged and the socio-economically disadvantaged in Australia. Measures to reduce the inequality in provision of health care should include oral health promotion, improving public access to dental services and reducing financial barriers to dental health care. PSYCHOSOCIAL IMPLICATIONS OF ORAL HEALTH CONDITIONS Oral health and illicit drug use Drug users are likely to experience more dental problems than non drug users, have problems accessing treatment especially if it incurs a charge, and may not perceive dental health issues to be of great importance. Sheridan et al's 2001 study of 125 drug users and 129 non-drug users revealed that drug users self-report considerably more difficulty in accessing dental treatment, are less likely to have visited the dentist in the last twelve months and have a higher level of self-assessed oral health problems than non-drug users. These findings were similar to an earlier Dutch study of drug users (Sheridan, Aggleton and Carson 2001). Illicit drug use is associated with a low expendable income, chaotic lifestyle and poor nutrition (especially the intake of foods high in calories and sugars). Consequently, illicit drug use is also associated with a higher rate of dental caries and periodontal disease compared with the general population. Of 86 women attending a methadone maintenance clinic in Sydney, a high incidence of dental caries was identified (Zador, Lyons Wall and Webster 1996). Barriers to accessing dental care encountered by illicit drug users arise from:
In providing dental health services to illicit drug users, the dental profession may also experience such problems as:
Oral health and HIV status Access to oral health care is extremely important for those affected with HIV because oral findings can lead to early detection and improved management of HIV infection. Oral lesions associated with HIV are often debilitating, causing discomfort or pain, difficulty with swallowing or eating, and psychological distress, however they can be managed effectively with proper oral care. Under-use of dental services is more related to social and economic factors than to stage of infection, and the subsequent unmet need for dental services contributes to problems in the quality of life of patients and impacts on the course of the disease (Marcus, Freed et al 2000). Anecdotally it can be very difficult to find a dentist willing to treat HIV+ patients. Sadowsky and Kunzel (1996) assert that dentists' degree of unwillingness or resistance to treat HIV patients was influenced by:
The attitude of dentists may result in less disclosure by patients to their dentist. Robinson and Croucher's 1993 study of 50 asymptomatic HIV patients found that of the 76% who disclosed their HIV status at a medical care clinic that they had previously been attending, 87% were refused treatment by either the dentist or dental hygienist (cited in Coulter, Marcus, Freed and Der Martirosian 2000). Use of dental services is influenced by socio-economic status. Socio-economically advantaged groups are more likely to use dental services, and those without medical insurance, those low incomes and those with lower levels of school education are less likely to use dental services (Marcus et al 2000). Oral health and children Public access to dental health services for children is essential for the prevention, detection and treatment of oral conditions. Early childhood caries is a lifestyle disease with biological, behavioural and social determinants. If left untreated, the decay of primary teeth rapidly affects secondary teeth and leads to more complex oral, social and financial complications. Dental caries is a preventable transmissible disease with a prevalence in Western societies of 1% to 12% depending on age (Twetman, Garcia-Godoy and Goepferd 2000). A Swedish longitudinal study of the incidence of early childhood caries in Sweden showed 0.5% at 12 months, 8% at 24 months and 28% at 36 months of age (Twetman et al 2000). Their study asserts that preventative measures must start no later than at 1 year of age. Oral health and child abuse Improved access to public dental health services would be valuable in detecting child abuse. It is estimated that less than 1/3 of actual child abuse cases are reported each year (Mills 2001) and as much as 75% of physical abuse in children involves injury to the head and neck. (Colangelo, CareFirst 2001). The oral cavity is a central focus for physical abuse in children because of its significance in communication and nutrition. Oral injuries are commonly inflicted with blunt instruments, eating utensils, hands or fingers, scalding liquids, caustic substances or gags. The oral cavity is also a frequent site for sexual abuse in children. Research shows that many abusing parents avoid returning to the same physician however, they will return to the same dental office (Colangelo, CareFirst 2001). Dental Neglect Further, 'dental neglect', which is defined as the wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health that enables adequate function and freedom of pain and infection, can lead to eating problems, sleep disturbances and poor concentration in school (American Academy of Pediatrics 1999). This situation can arise from lack of access to affordable public dental health services. The undesirable outcomes of dental neglect can, in the longer term, adversely affect learning, communication, nutrition and normal growth and development. Oral health and Australia's ageing population The Australian population is ageing and becoming more functionally dependent. In the 1970s, 9% of the population were aged over 65 years, this increased to 12% in 1996, and is projected to increase to 16% by 2016 (Chalmers 2001). With technological advancements in dentistry and attitudinal changes on the part of both patients and professionals, tooth loss is no longer considered to be an inevitable consequence of ageing. Edentulism rates are decreasing in the older age group thus dental needs are changing. There is an increasing requirement for dental services to maintain teeth rather than dentures only. Coronal and root caries are also becoming significant problems. This increasing demand for dental services is a challenge for the public dental care system. A qualitative survey using The Dental Satisfaction Survey questionnaires (AIHW Dental Statistics and Research Unit November 2000) to assess satisfaction with dental health care indicates that older adults have concerns about affordability of services, (levels of dental insurance decrease as age increases) physical access to dental care providers, long waiting lists and the lack of respect shown by some providers to pension or other government card-holders. There is a strong relationship between socio-economic disadvantage and death, sickness and disability from coronary heart disease, stroke and other illnesses. All Australian government card holders (including older pension cardholders) have access to both public-funded and private dental care, however in practice, public access has been compromised by long waiting lists and the costs of private dental service can be prohibitive Furthermore, preventative products suitable for older adults can be expensive and unaffordable, leading to poor compliance with oral treatments. A paper on geriatric oral health issues in Australia by Jane Chalmers (2001) of the AIHW proposes that for improvement in oral health in Australia's ageing population:
Oral health of nursing home residents Dental health service provision to nursing home residents is low (Chalmers 2001). Dentists report being inadequately trained in geriatric and nursing home dentistry, and nurses/carers are provided with little educational support by dentistry professionals (Chalmers 2001). Off-site dental services for those in residential aged care facilities (nursing homes) creates a barrier to the provision of dental care. Nursing homes lack adequate equipment for dental services and dentists must compromise themselves financially when servicing residential aged care residents (time spent on visits, and on travelling to and from nursing homes means less time in their practices). The lack of adequate financial reimbursement and a structured system for care provision makes nursing home dentistry a non-viable option for most public and private sector dental professionals (Chalmers, Hodge, Fuss, Spencer, Carter and Mathew 2001). These barriers are often exacerbated by residents' cognitive status, behavioural problems, financial status and difficulty in obtaining consent for dental care. Oral health and people with disabilities The disability rate in Australia has increased from 15% of the population in 1981 to 19% in 1998 (ABS 1998). Being able to move about easily at home or in the community, to communicate with others without difficulty, to perform basic self care functions such as dressing, washing and eating are all important elements of life. The likelihood of being restricted in any of these functions is greater for older people. Dental care for the disabled is provided by the public dental health service (Desai, Messer and Calache 2001). There is a general agreement that the population with disabilities has higher rates of dental disease than the general population, and particularly problems of poor oral hygiene, gingivitis and periodontitis. Utilisation of dental services by people with disabilities is compromised by limited physical access to buildings, limited practitioner willingness to provide care and associated financial difficulties (Fiske and Shafik 2001). Children with disabilities Desai et al's study of 300 children (9 to 13 years) with disabilities (including learning disability, intellectual disability, speech problems, physical disability, motor incoordination, autism, epilepsy, cerebral palsy and/or visual problems) found a significant association between function level dental health status; a decrease in function was associated with an increase in dental caries and periodontal disease. The study also found that the DMFT (dental health score determined by number of decayed, missing or filled teeth) of 2.2 for 9 to 13 year olds with disabilities was higher than the national oral health target of 1.0 in 2000 but was lower than the WHO global goal of 3.0 for 2000 (Desai et al 2001). This disparity is attributed to disability-related factors such as medications, diet, inadequate oral hygiene and variable access to dental care. In light of these findings, recommendations to improve the oral health of disabled children include:
Similarly, Fiske et al (2001) propose that to obtain optimum dental health in children with Down's Syndrome and to maintain his/her self esteem and quality of life, dental care should be initiated by early contact with a dental team (as early as age 6 to 18 months) and then supported with regular dental visits to build rapport and accustom the child to the dental environment. Oral health and Indigenous status The health status of Indigenous Australians is generally worse than that of non-Indigenous Australians. Recent research shows that the oral health of Indigenous people also lags behind that of the non-Indigenous, with Aboriginal children having threefold the number of decayed teeth at the age of twelve compared with Australian born non-Aboriginal children. Thus Indigenous children have a double disadvantage:
A 1994-96 National Dental Telephone Interview Survey (NDTIS) of 17,691 adults, with 217 being Indigenous, revealed that:
Further, a 1995-96 Adult Dental Programs Survey of 5,926 health care card-holders who attended for public-funded dental care, (with 278 being Indigenous) found that Indigenous people had higher numbers of decayed teeth (DIvffTh3.56) compared to non-Indigenous (DMFT=l .94), experienced poorer periodontal health, especially in the 24 to 64 years age group, and a higher percentage of Indigenous people had teeth extracted (50.6%) than non-Indigenous people (2 1.4%) (DSRU Report, March 2000). Diabetes mellitis is more prevalent in Aborigines (8-19% rural, 24% urban) than in Australians of Caucasian origin (2.3% rural, 3.4% urban). Within the Indigenous community, diabetes occurs mostly in the over 30 years age group, and in some areas, up to one in three Aborigines over the age of 35 years has diabetes. This high rate of diabetes significantly increases the risk of periodontal disease, thereby making the need for adequate public access to dental care crucial (Martin-Iverson, Phatouros and Tennant 1999). The Aboriginal population comprises approximately 2.0% of the total population of Australia, however they make up an even higher percentage of the rural population. Access to dental services is a major concern. The National Aboriginal and Torres Strait Islander Survey in 1994 reported that only 46% of ATI's in rural areas had access to dental services, whereas 68% of people had access to an Aboriginal health worker. The Aboriginal community has taken control of improving health delivery to Aboriginal people in a way that is culturally acceptable, through Aboriginal Health Worker (AHW) programs, however their initiatives lack a significant dental care component. It is envisaged that the establishment of a dental training program implemented through AHWs, will encourage the implementation of long-term preventative measures and the delivery of dental services to improve community dental health (Paeza et al 2001). A bigger public health issue is the fluoridation of water. Areas with high levels of fluoridation have a reduced prevalence of caries suggesting that implementation of fluoride treatment programs for school children, and fluoridation of water sources would be an appropriate public health initiative (Martin-Iverson et al 1999). Oral health and migrants Dental studies indicate that migrant groups are disadvantaged in the use of dental services and have the least favourable results compared with other groups. A 1994-96 series of National Dental Telephone Interview Surveys collected self-report data randomly from all States on the oral health and dental visiting characteristics of 17,691 persons over 18 years of age. The data was classified into 4 groups: 1. Australian-born speaking only English (74.2%) 2. Overseas-born speaking only English (16.4%) 3. Overseas-born speaking a language other than English at home (6.7%) 4. Australian-born speaking a language other than English at home (2.7%) The study found that overseas-born persons who spoke a language other than English generally had the least favourable results, indicating cultural differences in the use of dental services. Although migrants reported lower rates of complete tooth loss, they were also more likely to report:
The report indicates that the ability of migrants to access dental care is mediated by the availability of dental services in terms of affordability and accessibility, and that language may also present as a barrier. Oral health and quality of life Oral disease can have a significant effect on both the social and psychological aspects of an individual's quality of life, impacting on important aspects of everyday life in terms of physical functioning, social functioning and self-esteem. Quality of life in general, relates to the satisfaction of the individual needs for growth, well-being, self-esteem, freedom and the pleasures of meaningful relationships and meaningful work (Chen and Hunter 1996). Oral health and quality of life for older people A 1992 study by Locker (Locker and Slade 1993) of 900 people aged 50+ living independently in two metropolitan areas and two non-metropolitan areas in Ontario found that nearly 40% of the 65-74 aged population have some limitation to their ability to chew, which results in their avoiding choosing to eat with others, or in their being embarrassed about the appearance of their teeth or mouth. Other commonly experienced problems were food catching in teeth or dentures, poorly fitting dentures, sensitivity of the teeth, sore spots in the mouth, painful gums, stale breath, discomfort while eating and having to avoid eating some foods. Poor oral health caused psychological discomfort in 17.3% of the patients in the form of worrying about dental problems, self-consciousness, feeling miserable, feeling uncomfortable with appearance, feeling depressed, having poorer ability to concentrate or experiencing sleep disturbances. Oral health and quality of life for children While children generally have relatively good oral health status, some aspects of their oral quality of life can be adversely affected by oral health problems. Children with decayed teeth, whether treated or untreated, can experience feelings of lower level oral health than children without, which may contribute to their levels of social and physical functioning (Chen and Hunter 1996). Oral health and quality of life for women A study by Watson et al 1998 (cited in Gardiner and Raigrodski 2001) revealed that women comprise the larger proportion of the ageing population, and that they are largely uninsured for dental care. It also revealed that the desire to retain teeth does not decrease as age increases. Tooth loss resulting from lack of oral care can produce serious negative psychological consequences for a patient who has high appreciation for natural teeth. Eating disorders are a serious concern that have been found to negatively impact on women s oral health (Studen-Pavlovich and Elliott 2001). Anorexia nervosa has a 10:1 female predilection, and occurs most frequently in adolescents and young white adults from middle or upper socio-economic strata, however it crosses all socio-economic, ethnic and cultural groups. The eating disorder bulimia nervosa affects a wider socio-economic stratum than anorexia nervosa. Eating disorders can cause enamel erosion on the teeth, dental caries, trauma to oral mucosal membrane and pharynx, xerostomia (dry mouth) and enlargement of the parotid glands. Appropriate dental treatment should be an integral part of holistic therapy (psychological, physiological and dental) for patients with an eating disorder. CONCLUSION There is widespread concern over soaring dental waiting lists and the introduction in some states of co-payments as a result of the government's abolition of the Commonwealth Dental Health Program (CDHP), and the effect this has had on the provision of dental care services to low income and disadvantaged people. Research has shown a link between oral health and medical conditions, and that access to dental services can alleviate the development of costly medical conditions. Poor oral health leads to dental infections that can contribute to adverse medical outcomes and in turn create a larger cost to the health care system. However, dental diseases (especially periodontal disease) are preventable and treatable. Evidence presented by the AIHW indicates that government health card-holders, (the socio-economically disadvantaged), are experiencing an increased incidence of dental problems such as toothache, discomfort with dental appearance and avoidance of particular foods than before. Access to dental services and affordability are the major issues, as the socio-economically disadvantaged are unlikely to have dental insurance to help cover costs. The emerging patterns of the psychosocial consequences of poor oral health and its resulting effect on quality of life, especially in the elderly, signifies the need for new public policy to place more focus on the oral health needs of the elderly. New policies should be aimed at wider accessibility to public dental health services, and should address the broader medical, personal and social consequences of oral health in line with contemporary concepts of health care. This paper substantiates the recommendations made by NCOSS in a March 2000 discussion paper titled 'Access to public dental care in NSW'. Those recommendations were:
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