Tooth be told

Tooth be told

The case for universal dental care in Aotearoa New Zealand

Contents 01 02 04

14

20 22

ii

Introduction Some hard facts The state of oral health 05

Extraction and hospitalisation

07

Unmet need

09

Workforce

11

Funding of dental health services

12

Determinants of poor dental health

Oral health-related policies 15

Access

16

Sugar

18

Fluoride

19

Social determinants

The fix References

Tooth be told – The case for universal dental care in Aotearoa New Zealand

Introduction “A national shame” is how one of our dentist members describes access to oral health care in Aotearoa New Zealand.

How can it be that hundreds of thousands of New Zealanders have teeth removed each year due to decay, that a very large percentage of adults never see a dentist, or that for two years the 9,000 residents of Wairoa have not had local adult dental services?

At its annual conference in 2018, the Labour Party voted to adopt a policy of free dental care but there’s been radio silence since. Budget 2022 did fulfil a repeated election promise to boost the emergency special needs grant for dental care after 25 years with no increase at all.

As the Association of Salaried Medical Specialists Toi Mata Hauora, we represent doctors and dentists working in the public health system.

Cost benefit data shows that up front support for free and subsidised access to adult dental care, while carrying a weighty upfront price tag, would save millions of health dollars in the longer term.

Our dentists, along with our oral and maxillofacial surgeons treat people with complex medical and dental conditions. Others co-ordinate and provide dental services in the community.

They are pulling children’s teeth under anaesthetic, they are dealing with a big uptick in referrals for medically compromised patients, and they are turning people away in pain due to long waiting lists and a stark lack of resourcing. Covid has added to the pressures.

Dental treatment in Aotearoa New Zealand is prohibitively expensive and feeds directly into overall health inequity.

Say the words “I have to go to the dentist” to friends and you’ll jokingly be told to “take out a bank loan”.

Teeth and oral health are integral to our general health and wellbeing, yet funding for oral healthcare makes up a paltry 2% of Government health spending.

Introduction

Public health dentistry is also at the sharp end of wider public health debates on the determinants of ill health and issues such as fluoridation, water-only schools, and sugar taxes.

This publication brings together much of what we know about the current state of dental health care in Aotearoa New Zealand and what it looks like on the ground through comments and observations from our frontline dentists.

It doesn’t paint an uplifting picture but does suggest steps towards improvement.

Let’s face it, if we do nothing, the decay will continue to eat into ongoing health inequities.

Sarah Dalton Executive Director Association of Salaried Medical Specialists Toi Mata Hauora

01

Some hard facts Decayed teeth removed in 250,000 adults

Highest unmet need for dental care

Every year about a quarter of a million New Zealand adults have teeth removed due to decay.

New Zealand recorded the highest unmet need for adult dental care among 11 comparable countries in 2020.

Decayed teeth removed in 1-in-10 children About one in 10 children have teeth removed due to decay.

In 2020 well over 1.5 million or 40% of adults were estimated to have an unmet need for dental care due to cost. Among Māori and Pasifika adults the figure is more than 50%.

31% increase in hospitalisations Publicly funded hospitalisation rates for oral health increased by 31% from 2007/08 to 2018/19, while the population increased by 17%.

02

40% of adults can’t afford dental care

Low workforce numbers still falling New Zealand’s dentist and dental specialist workforce is one of the lowest per capita in the OECD. The number of practising dentists and dental specialists has dropped.

Tooth be told – The case for universal dental care in Aotearoa New Zealand

Oral health care gets only 2% of funding Funding for oral health care amounts to just over 2% of Vote Health operational funding.

Sugar problem highest in OECD New Zealand’s level of sugar consumption per capita is one of the highest in the OECD.

Some hard facts

Cost estimated for public scheme Research published in 2019 estimated a public scheme for “basic dental services” for low-income adults would cost between $187 million and $450 million per year.

No plans to address sugar Government policy on sugar consumption is to rely on industry self-regulation and a sugar tax does not appear to be on its agenda.

03

The state of oral health

“

Over history dentistry emerged from medicine but now it is quite parallel to it.

We need to put the mouth back into the greater context of the body and stop treating oral health as a separate entity to the rest of general health.”

Extraction and hospitalisation Every year about a quarter of a million adults have teeth removed due to decay. Around one in seven adults have had teeth removed due to decay by the time they reach their mid-20s, with the most-deprived faring worst.i Publicly funded hospitalisation rates for oral health increased by 31% from 2007/08 to 2018/19, while the population increased by 17% over the same period (Figure 1). Dental caries is the main reason for hospitalisation, amounting to 58% of all oral health hospitalisations in 2018/19.

Hospitalisations for other conditions such as heart disease, which may be linked to unmet oral health need, are not included in these statistics. Most oral health conditions are largely preventable and can be treated in their early stages.

16,000 14,000

31% increase

12,000 10,000 8,000 6,000 4,000 2,000 0 2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Figure 1: Hospital discharges for oral health conditions* 2007/08 to 2018/19 Source: NZ Health Surveys * Oral health conditions: ICD chapters K00–K14 (Diseases of oral cavity, salivary glands and jaws)

The state of oral health

05

“

The other day I was in a mobile van visiting a school in a high needs area. In other areas you might see 18 kids during the day with one or two needing treatment. In this van I was only able to see 12 children because of the level of decay and the amount of work that needed to be done. Of those 12 kids, all but two needed dental treatment.”

There is a dearth of information comparing the state of dental health internationally.

What is available is confined to 12-year-old children – a ‘DMFT index’, which describes the extent of dental caries in an individual through calculating the number of decayed (D), missing (M) or filled (F) permanent teeth.

The sum of these three figures forms the DMFT index. Data for many OECD countries is more than 10 years old but from what is available New Zealand appears to be on a par with the OECD average measure for 12-year‑olds.

The most recent New Zealand data (for 2017) shows a DMFT score of 0.7, which is considered a good result and may in part reflect the effects of having fully subsidised dental care for children. Nevertheless, about one in 10 have teeth removed due to decay.

Those in the most deprived section of the population (quintile 5) are almost twice as likely to lose their teeth as those in the least deprived group.

The most deprived children are

1-in-10

children have a tooth removed due to decay

twice as likely to lose their teeth

Unmet need Good oral health is fundamental to wellbeing. Poor oral health can mean living with constant pain, impaired sleep, avoidable hospital admission, higher risk of other chronic conditions and reduced productivity at work. But access to treatment is out of reach for many New Zealanders, especially those in the most deprived communities and who already have the highest health needs.

While children under 18 have free access to basic dental services, more than half of Māori and Pasifika adults and more than 40% of adults overall have an unmet need for dental care due to cost (Figure 2).

42% of all adults

53.7% of Māori adults

51.5% of Pasifika adults

Figure 2: Adults with unmet need for dental care due to cost (2019/20) Source: NZ Health Surveys

The state of oral health

07

2013

2020

60% 50% 40% 30% 20% 10% 0 Quintile 1

Quintile 2

Quintile 3

Quintile 4

Quintile 5

Figure 3: Adults with unmet need for dental care due to cost, by quintile Source: NZ Health Surveys

Across the board, well over 1.5 million adults were estimated to have an unmet need due to cost in 2020. That’s about 40% of the adult population, including nearly a third of adults in the least-deprived quintile and more than half in the most-deprived quintile (Figure 3).

37%

New Zealand

21%

United Kingdom

36%

United States

21%

Norway

32%

Australia

19%

France

New Zealand recorded the highest unmet need for adult dental care among 11 comparable countries in 2020, based on survey of adults in those countries, including 1,000 adults in New Zealand (Figure 4).

27%

Canada

19%

Germany

26%

Switzerland

22%

Sweden

10%

Netherlands

Figure 4: Percentage of adults who skipped dental care or check-up in 2020 because of cost Source: Commonwealth Fund 2021

08

Tooth be told – The case for universal dental care in Aotearoa New Zealand

Workforce New Zealand stopped providing its dentist workforce data to the OECD in 2009, when it was ranked 19th out of 21 countries on the number of “professionally active” dentists and dental specialists per 1,000 population.ii Only Poland and Turkey had fewer dentists.

The data had been sourced from the NZ Dental Council Workforce Survey, which includes all dentists on the Dental Register who are working four or more hours per week.

Similar data for 2019, published by the NZ Dental Council, indicate New Zealand’s workforce remains among the lowest in the OECD (Figure 5).iii

1.2 1.0 0.8 0.6 0.4 0.2

Poland

Turkey

New Zealand

Slovak Republic

Netherlands

United States

Australia

France

Latvia

Slovenia

Denmark

Finland

Iceland

Japan

Sweden

Italy

Germany

Luxembourg

Lithuania

Norway

Colombia

Israel

0

Figure 5: Professionally active dentist and dental specialists per 1,000 population, 2019 or nearest year Source: OECD Health Data 2022; NZ Dental Council 2019 (NZ data)

The state of oral health

09

“

On the West Coast there are two Lumino dentists in Hokitika and then going south the next one is in Wanaka. From there travelling inland the next one is in Christchurch, so patients are driving more than an hour and a half one way just to get a filling. There needs to be incentives and funding for dentists to work in these more remote or smaller regions.”

Within New Zealand at a regional level, there is a three-fold difference between the bestserved and worst-served districts in terms of the number of dentists and dental specialist per capita (aged 15+) (Figure 6).1

Six territorial authorities (Kaipara, Westland, Hurunui, Mackenzie, Waimate and Chatham Island territories) had no dentists and no dental specialists recorded in 2019. Wairoa is also currently without a dentist.

The number of practising dentists and dental specialists dropped from 68.2 per 100,000 population aged 15+ in 2017 to 61.3 in 2019.

90 80 Three-fold difference

70 60 50 40 30 20 10

West Coast

Hawke’s Bay

Tairawhiti

Whanganui

South Canterbury

Counties Manukau

Northland

Midcentral

Lakes

Wairarapa

Bay of Plenty

Waikato

Hutt Valley

Waitemata

Canterbury

NelsonMarlborough

Capital & Coast

Taranaki

Auckland

Southern*

0

Figure 6: Dentist & Dental Specialists per 1,000 population aged 15+ by DHB, 2019 Source: NZ Dental Council 2019 * Southern DHB figures include dentists and dental specialists employed at Otago University in Dunedin

1

10

Excluding the Southern DHB, where numbers are boosted by Otago University employees.

Tooth be told – The case for universal dental care in Aotearoa New Zealand

Funding of dental health services Funding for oral health care is not included in published Budget documents. However, it was reported to be $197 million2 in 2018/19 including funding to cover free basic dental services for children and hospital dental services.iv That’s the equivalent of just over 1% of Vote Health operational funding.

Over the years there have been repeated calls from doctors and dentists to extend free dental care to adults, including an ASMS remit adopted by the Council of Trade Unions.

The Government’s response has been that it would be unaffordable, but it took a year-longfight and two complaints to the Ombudsman before the officially figures were obtained by Newshub in 2020. It reported a Ministry of Health report in 2018 estimated costs of:

That’s $148 million all up (less than 1% of Vote Health’s operational budget in 2018).

But the report was shelved by then-Minister of Health David Clark. No cost-benefit analysis was reported.

Research from the New Zealand Dental Association (NZDA), published in 2019, estimated a public scheme for “basic dental services” for 380,000 low-income adults would cost between $187 million and $450 million per year – the first based on the ACC fee schedule, the second on an NZDA member fee survey.

•

$96 million to cover everyone up to their 27th birthday

•

$17 million to cover low-income pregnant women

•

$30 million for low-income parents and caregivers

•

$5.5 million for a one-off dental check-up for everyone turning 65

2

DHBs $197.2 million, comprising Community Oral Health Services, $98.42 million, adolescent dental services, $42.17 million, hospital dental services $49.68 million, and emergency dental services for lower income adults costing $7.45 million.

The state of oral health

But using Treasury’s cost-benefit analysis tool, the research found the Government would get a return of $1.60 for each dollar spent.

The key cost savings for Government are other avoided health service costs, reduced benefits, increased employment, and tax revenue, and avoided dental costs incurred by DHBs. The estimated economic benefits for society as a whole were estimated at $4.5 for every dollar spent.v

11

Determinants of poor dental health Factors that contribute to tooth decay include:

Frequent consumption of sugary foods and drinks

Inadequate levels of fluoride in the mouth.

(Drinking fluoridated water provides a continual source of fluoride to saliva. As most people only brush twice a day, fluoride toothpaste does not supply a continual source of fluoride to the mouth.)

“ 12

Poor oral hygiene

Poor access to services

Social determinantsvi,vii

Somehow, we’ve got to get away from normalising that an everyday diet consists of sugary foods and sugary drinks because it shouldn’t. But a lot of it is affected by environment and life factors around convenience and household stress. Access to oral hygiene products, water fluoridation, water only schools and getting away from normalising sugary drinks can all make a difference.”

Tooth be told – The case for universal dental care in Aotearoa New Zealand

As well as having poor access to dentists and dental specialists internationally (Figure 5), New Zealand’s level of sugar consumption is one of the highest in the OECD/European Union (Figure 7).viii 70 60 50 40 30 20 10

Japan

Norway

Canada

United Kingdom

Mexico

United States

South Korea

Turkey

Colombia

Eurpoean Union

Switzerland

Chile

Australia

New Zealand

Israel

0

Figure 7: Estimated sugar consumption (kg) per capita in OECD/EU countries, 2020 Source: OECD-FAO 2020

The state of oral health

13

Oral health-related policies

“

It would be so good if we had dental clinics in community health hubs sitting alongside GPs, physios and pharmacies.

We need community dentists paid for by the government to bring into these hubs where patients can find all their healthcare in one.”

Access At its annual conference in November 2018, the Labour Party voted to adopt a policy of free dental care. So far, however, the Government has resisted calls to extend free dental care to adults.

There are limited options available for adults who are unable to afford the cost of dental care. The current “safety net” comprises emergency dental services – providing usually only relief of pain and only in some regions.

This did not happen, as the money was instead set aside to help pay for the cost of reforming the health system.ix However the emergency grant was increased to $1000 in the 2022 Budget.

It had not been adjusted since at least 1999.x

The Government had planned a funding boost of $176 million in its 2021 Budget to increase the amount people could claim for an emergency special needs grant for dental care from $300 to $1000, as well as funding for mobile dental clinics, costing $37.5 million.

If cost affects whether or not you can see a dentist, the Ministry of Health recommends that you “shop around”.xi

“

There are evidently no plans to address workforce issues to improve access.

The relief of pain subsidy has only covered the costs of an exam, a couple of x-rays and maybe a temporary filling.

If there was more leeway we could get in and fill the other teeth which aren’t problematic but will be in a year’s time if we don’t address things. We’re committing patients to a lot of teeth in the bucket because the emergency funding has been so low.”

Oral health-related policies

15

Sugar New Zealand government policy on sugar consumption is to rely on industry self-regulation. However, a New Zealand study shows this is not working, and OECD data show sugar consumption per capita has reduced only marginally over the past decade.xii In 2014 a Treasury paper advised: “Based on international evidence and our engagement with academics in this field, we consider that the most promising regulatory approaches to explore further are a sugar sweetened beverage tax, regulation of marketing to children and a mandatory front of pack food labelling system.”xiii The papers point out that taxes on sugarsweetened beverages (SSBs) have been introduced in a number of countries, and evidence has shown these taxes to be effective in reducing consumption.

“A reduction in consumption of these beverages in New Zealand is likely to have an impact on obesity rates as well as reducing diabetes and poor dental health.”

From international experience, industry has opposed sugar-sweetened beverage taxes and in many countries, industry has spent large amounts of money to lobby for the abolition of the tax.”xiv A later paper published by Treasury in 2016 (though not necessarily the views of Treasury) concluded that a tax on SSBs or sugary products would have a regressive impact on the general population and that the review of the literature on the effectiveness of sugar taxes is “inconclusive”.xv

?

Treasury noted one concern about a SSB tax is that the financial implications may be more significant for lower socio-economic groups.

On the other hand, the potential health benefits would also be greater for those same groups.

Another paper published by Treasury also noted: “Opposition to a tax is to be expected from the beverage industry due to the high profitability of sugar-sweetened beverage consumption and significant vested interests.

16

2014

Sugar sweetened beverage tax proposed in Treasury paper

$

2016

Effectiveness of sugar taxes deemed “inconclusive”

Tooth be told – The case for universal dental care in Aotearoa New Zealand

“

No government seems brave enough to take on the food and beverage industry around the sugar tax claiming that it doesn’t work or even take on the supermarkets to change environments for people of low income.”

In 2017 a panel of public health experts reviewing the case for a “sugary drinks” (SD) tax concluded: “The proposition that a SD tax be adopted is not new and is becoming standard practice in many parts of the world. The health benefits of reducing sugar intake provide compelling reasons for why a SD tax is necessary.”

The panel countered the contention that such a tax would be regressive, arguing that a similar rationale has been used against taxes on tobacco, and “the health complications of high sugary drink intake are significantly more regressive as these diseases disproportionately impact on poorer communities”.

2017

Renewed call for a tax on “sugary drinks”

July 2017

New Zealanders on the lowest income bracket most supportive of a SD tax

Oral health-related policies

“Furthermore, revenue from a SD tax could create new programmes to promote child health and wellbeing in challenged communities.”

A UMR poll from July 2017 found that New Zealanders on the lowest income bracket were most supportive of a SD tax.xvi At the time of publication, the Department of Education was seeking public feedback on a proposal to ban sugary drinks in primary schools. This is reported to have already been adopted as policy in many primary schools.xvii,xviii

2022

Ministry of Education seeking public feedback on a proposed ban on sugary drinks in primary schools

17

Fluoride Currently only around 2.3 million New Zealanders have access to fluoridated drinking water.xix According to the Dental Association children living in areas with fluoridated water have 40 percent less chance of having tooth decay.xx The Health (Fluoridation of Drinking Water) Amendment Bill introduced into Parliament in 2016, was finally passed in November 2021 and gives the Director-General of Health the power to direct local councils to add fluoride to drinking water. Funding is to be made available to support local councils to do this.

However, while councils are expected to start issuing fluoridation orders this year implementation in many areas could take several years. For example, Christchurch is the largest city in the country without fluoridated water and it remains unclear when it will get a fluoridated supply.

Children living in areas with fluoridated water have a

40% less

chance of having tooth decay

There has also been recent controversy in Wellington, with some parts of the region not receiving fluoridated water due to a fault at a treatment plant since last year. The public was not told for months, and the problem won’t be fixed until later this year.

“ 18

Even water fluoridation is problematic in terms of what you think is happening and what’s really happening.

I feel slightly cynical about how quickly fluoridation is going to get into water across the country.”

Tooth be told – The case for universal dental care in Aotearoa New Zealand

Social determinants Oral diseases are both a cause and consequence of poverty. They have a negative impact on educational and employment opportunities.xxi As part of the Government’s child poverty reduction strategy, Budget 2021 lifted weekly benefit rates. However, an analysis by the Child Poverty Action Group found few families receiving benefits would be lifted over the poverty line and commented: “This is not yet the transformation that WEAG (Welfare Expert Advisory Group) hoped for three years ago.”

ASMS has written about the social determinants of health in two reports, Creating Solutions, Te Ara Whai Tika and Health Matters: Framing the full story of health.xxii,xxiii They discuss core issues such as housing, employment, education, environment, and equity.

“

Some of the actions and recommendations in these reports include: •

Remove cost barriers to health care services

•

Set a goal of achieving health equity by 2040

•

Adopt proportionate universalism

•

Adopt a ‘health in all’ policy approach

•

Strengthen policies to address poverty

•

Fund policies to match wellbeing goals

When a child has a mouthful of dental caries all the markers of social deprivation play into it. They may be living in a crowded home, mum or dad might not be around, they might not have a toothbrush, and for many of our whānau, dental care is just way down the list.”

Oral health-related policies

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The fix Key recommendations for the future of dental services in Aotearoa New Zealand

1

2

Extend fully subsidised basic dental care for children to adults. This could be implemented incrementally, beginning with low-income adults.

3 Make options available for dentists to be employed on a salary as part of the public health service, and co-locate community dental services alongside other primary and hospital providers.

20

Urgently develop a dental workforce plan which includes strategies to ensure services are fairly distributed nationally, in partnership with local communities, and based on local needs.

4 Increase the oral health learning component in medical curricula and promote more collaborative and multi-disciplinary approaches between doctors and dentists.

Tooth be told – The case for universal dental care in Aotearoa New Zealand

5 Routinely collect and report data on the state of dental health and access to dental care.

7 Fully implement the recommendations of the 2019 Welfare Expert Advisory Group (WEAG), with emphasis on the call for the Government to “urgently increase the incomes of people in receipt of a benefit and in low-wage work and maintain these increases over time so that they keep pace with the incomes of the rest of the community”.

The fix

6 Introduce a tax on sugar-sweetened beverages, regulate marketing to children and have a mandatory front-of-pack food labelling system. Put the additional revenue towards policies to address the social determinants of ill health.

8 Implement the recommendations from ASMS’ two reports Creating Solutions - Te Ara Whai Tika, and Health Matters: Framing the full story of health.

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References i

NZ Health Survey 2019/20.

ii

OECD Health Data. Health Care Resources Dataset, 2022.

iii

NZ Dental Council. Workforce Analysis 2018-19. Dental Council 2019.

iv

Coughlan T. The state can afford free dental care, so let’s get it done, Stuff, 28 October 2020. https://www.stuff.co.nz/national/politics/300142781/the-state-can-afford-free-dental-care-so-lets-get-it-done

v

NZDA. Access to Oral Health Services for Low-Income Adults, October 2019.

vi

WHO. Oral Health Fact Sheets. Accessed March 2022. https://www.who.int/news-room/fact-sheets/detail/ oral‑health

vii Sanders AE 2007. Social Determinants of Oral Health: conditions linked to socioeconomic inequalities in oral health and in the Australian population. AIHW cat. no. POH 7. Canberra: Australian Institute of Health and Welfare (Population Oral Health Series No. 7). viii OECD/FAO. OECD-FAO Agricultural Outlook 2021-2030, OECD Publishing, Paris, 2021. ix

Coughlan T. Pleas mount for Government help, with dental grants not increased in decades, NZ Herald, 19 Jan 2022.

x

Sowry M (Hon). Gazette Notices, Special Needs Grant Programme, 28 Jan, 1999. Accessed March 2022, https://gazette.govt.nz/notice/id/1999-go563

xi

Ministry of Health. Publicly funded dental care. Accessed March 2022, https://www.health.govt.nz/your-health/ services-and-support/health-care-services/visiting-dentist/publicly-funded-dental-care

xii

Robertson K, Thyne M, Green JA. 2018. Supporting a sugar tax in New Zealand: Sugar sweetened beverage (‘fizzy drink’) consumption as a normal behaviour within the obesogenic environment. PeerJ 6:e5821 https://doi.org/10.7717/peerj.5821

xiii NZ Treasury. Options for regulatory responses to the growing obesity problem, Treasury Report, 17 November 2014. xiv NZ Treasury. Regulatory responses to address the growing obesity problem in New Zealand - Final Report, February 2014. xv Gardiner A. Implications of a Sugar Tax in New Zealand: Incidence and Effectiveness, New Zealand Treasury Working Paper 16/09 November 2016. xvi New Zealand Beverage Guidance Panel. Policy Brief: A Sugary Drink Tax for New Zealand, August 2017. xvii MoE. Discussion document: Proposed changes to the promotion and provision of healthy drinks in schools, April 2022. https://consultation.education.govt.nz/te-puna-kaupapahere-policy-governance-legislationand-accountability/promotion-and-provision-healthy-drinks-in-schools/ xviii Thomas R, Kenny L. Fizzy drinks could be banned at primary schools under Government proposal, Stuff, 7 April 2022. xix Verrall A (Hon). Strengthening water fluoridation decisions, media release, Associate Minister of Health, 18 March 2021. xx

https://www.rnz.co.nz/programmes/the-detail/story/2018835534/wellington-s-fluoride-fail

xxi Mathur MR, Williams DM, et el. Universal Health Coverage: A Unique Policy Opportunity for Oral Health, JDR Clinical Research Supplement, Vol 94, Issue 3; suppl no. 1, March 2015. xxii ASMS- CCHT. Creating Solutions, Te Ara Whai Tika, ASMS & Canterbury Charity Trust Hospital, 2021. https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final xxiii ASMS. Health Matters: Framing the full story of health, October 2020. https://issuu.com/associationofsalariedmedicalspecialists/docs/health_matters

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Tooth be told – The case for universal dental care in Aotearoa New Zealand

Report author

Lyndon Keene, ASMS Health Policy Analyst

Report design Gusto

Report title

Cassey van Riel, ASMS Support Services Administrator

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