The NobleDentist Blog

This is an article by Adam Creswell that was recently published in The Australian – Sydney, Australia.

Australia’s proposed dental scheme would achieve affordability at the price of some significant exclusions, writes Health editor Adam Cresswell.

OF all the several bold ideas contained in the interim report from the federal Government’s National Health and Hospitals Reform Commission, released this week, the plan for a universal dental scheme is the one that has, perhaps, captured the public’s imagination the most.

Anthony Burges with patient Nick Talarico, 8, watched by mother Michelle and sister Olivia. Picture: Bob Finlayson
Over the past two years the nation has been bombarded with horror stories of pensioners nursing mouths filled with rotting teeth which they can’t afford to get fixed, and of others lingering for months, even years, on waiting lists for public treatment.

There is wide support for some sort of re-think. But the NHHRC’s proposal has not been greeted with open arms on all sides.

Famously, the Australian Dental Association—the nation’s peak group for private dentists—attacked the plan almost immediately as “impractical, nonsensical, (and) overly simplistic” and declared it “flies in the face of much of the deliberations that have taken place on this issue over the past decade”.

Responses from individual dentists have been more moderate, although still widely diverging. Tony Burges, a dentist in Sydney’s inner-west suburb of Drummoyne, says the NHHRC’s proposal is “a reasonable suggestion” but the “devil will be in the detail”.

The ADA made a number of specific criticisms, including the claim that the costs of the scheme would be “crippling” and unaffordable, potentially costing over $11 billion.

However, a modelling report prepared by consulting firm PricewaterhouseCoopers at the NHHRC’s request, and published this week, makes clear that based on certain assumptions about claiming patterns, the extra cost to government would be just $3.9billion a year. This amount would be more than covered by the proposed 0.75 percentage point increase in the Medicare levy.

But it turns out this affordability comes at a price.

The PwC report outlined three variations of what specific dental services the proposed Denticare scheme might cover, ranging from a fuller coverage to lesser. But none is truly comprehensive.

All exclude root canal treatments, crowns and bridges, periodontic care (involving cases of advanced gum inflammation leading to bone loss) and orthodontic treatments (including braces).

Crowns and bridges have been blamed for the soaring costs of the Howard government’s Medicare-based dental scheme, which the Labor government has so far failed to scrap due to opposition in the Senate.

The existing Medicare scheme pays $2150 in Medicare rebates for private dental treatment per year, provided the patient is referred to the dentist by a GP who has assessed them as having a potentially life-threatening chronic condition that is being exacerbated by their dental problems. An analysis of spending in the Medicare scheme last year showed patients enrolled in it were making claims for crowns and bridges at a higher rate than would be seen in the normal dental patient population: about 7.4 per cent of total Medicare treatments, on a per-tooth basis.

However, the affordability means that basic dental treatment, which would be covered by any of the foreseen Denticare options, would be much more equitable.

At present, individuals going to private dentists spend an average of 0.79 per cent of their income on out-of-pocket charges to private dentists, an amount that rises to 0.96 per cent of taxable income once the cost of private health insurance premiums for dental cover are added in. Together this accounts for 78 per cent of total expenditure on dental services.

Under Denticare, individual funding of dental services would shrink to an average of 0.37 per cent of taxable income, equivalent to 29 per cent of spending on dental services.

The Denticare scheme, funded by the increased Medicare levy, would allow patients to choose cover under private insurance plans, in which case Denticare would pay the premium and the policy would cover 85 per cent of the fees, leaving the patient to pick up the remaining 15 per cent.

Other patients who wished to avoid the 15 per cent gap could elect to be covered under the public system, where treatment would be totally free, with the downside of some waiting.

Patients opting for private treatment would no longer need to pay separately for dental premiums. Overall, the average proportion of income spent on dental would rise from 1.24 per cent at present to 1.3 per cent under Denticare, with the increase due to the expansion of programs such as school dental and oral health promotion.

But this conceals the fact that according to PwC, equity—meaning access for the poorest—would be substantially increased under the proposal.

According to the modelling, taxpayers with annual household income of up to $25,218 currently pay just under 2 per cent of their taxable income on dental costs, or $11.25 per taxpayer per week.

This would fall to $8.94, just under 1.5 per cent of taxable income, under Denticare.

Those in households with annual income between $25,219 and $44,286 would be better off by 74 cents per taxpayer per week, and taxpayers in households with income between $44,287 and $67,129 would be $1.15 better off per week.

Taxpayers in households with income over $67,130 would be paying more under Denticare ($1.37 per taxpayer per week more, rising to $2.74 per week for income over $108,277).

Yet there are many assumptions in the Denticare modelling, and unexpected changes in consumer behaviour could have a significant effect on the impact of any scheme, should one be approved by the federal government.

For example, it’s not easy to predict how many more dental services will be provided as a consequence of making dentistry more affordable for the less well-off. Also, about 35 per cent of people who visit the dentist do not at present have private dental cover, even though they visit a private dentist. How their needs will be met if they continue to eschew the private option, and rely instead on the public Denticare scheme, is not totally clear.

Burges feels that Denticare will come unstuck in the details.

“My personal view has always been that private dentists are probably best placed to treat most people in the population,” he says.

“The NHHRC has budgeted about $4.5billion (for Denticare) ... but it could easily blow out and be very expensive to run. I think there’s real potential for any universal scheme to blow out and be very expensive, and that might lead the government to cut costs.”

This is an article by Mark Metherell that was recently published in The Sydney Morning Herald – Australia.

THE cost of expanding dental services for all Australians under the proposed Denticare would require a new tax, but most people’s annual dental costs would decline, say estimates prepared for the National Health and Hospitals Reform Commission.

The chairwoman of the commission, Christine Bennett, said that according to commission estimates, “many people will pay no more than they currently pay for dental care” under a 0.75 per cent levy on taxable incomes.

Under Denticare, people could choose to join a dental health plan with a health insurance fund or use public dental services.

At present, about 650,000 adults waited an average 27 months to receive public dental treatment, Dr Bennett said.

Low-income households spent more than 8 per cent of their income on dental services.

According to a consultants’ report prepared for the commission, Denticare would lower people’s out-of-pocket costs for dental care.

On average, the net additional cost per taxpayer a week was estimated to be less than $1.

Those with annual household income below $67,129 would have their dental costs reduced by between $1.15 and $2.32 a week. Those with incomes above $67,129 would have their overall dental costs increased by up to $2.74 a week.

The precise outcome for individuals and families would be dependent on how much they spent on dental care versus how much they would pay under the higher levy, and what insurance cover, if any, they had at present.

The Australian Dental Association, representing private dentists, yesterday dismissed Denticare as “fiscally irresponsible” and unlikely to deliver quality dental care.

This is an article by Mark Metherell that was recently published in The Sydney Morning Herald – Australia.

DENTISTS have condemned a Medicare-style system for free universal dental care being considered by the Rudd Government as impractical, and massively expensive.

The Denticare plan is part of the National Health and Hospitals Reform Commission’s sweeping makeover in hospital and health services, including for indigenous people, the aged and young people with mental illness.

Denticare would be financed by a 0.75 per cent income levy.

In its interim report released yesterday, the commission raised three options for reshaping state and federal governments’ running of the health system.

The proposals range from an improved version of the existing system, through to the development of a European-style social insurance scheme financed by the Commonwealth under which people could choose from health fund plans which would purchase services on their behalf.

The commission is to decide which scheme it would favour in its final report to the Government expected by midyear.

The Health Minister, Nicola Roxon, said the Government was happy to have a debate about the possibility of a new tax to finance Denticare, which she described as a “fairly radical proposal … but we are interested in the community’s response to this”.

But Dr Neil Hewson, the president of the Australian Dental Association, representing private dentists, slammed the Denticare proposal, saying it could nearly double to $11 billion the cost of dentistry to the government and individual patients.

“The recommendation … for a universal Denticare scheme is impractical, nonsensical, overly simplistic and flies in the face of much of the deliberations that have taken place on this issue over the past decade,” he said.

“It shows no appreciation of the real problems facing dental delivery in Australia.”

The association believed the Government should target the 35 per cent of the community who could not access or afford proper dental care and said it would be fiscally irresponsible to introduce a universal scheme for dentistry.

The commission has also proposed an indigenous health authority to upgrade care indigenous Australians get, similar to the special arrangements made for veterans.

It has also called for schemes to boost health funding for rural communities, and for the introduction of more community services to counter mental illness among young people.

The commission strongly urged the introduction of individually controlled electronic personal health records which the commission’s chairwoman, Dr Christine Bennett, described as “one of the most important systemic opportunities we have”.

The report said there was an urgent need to tackle inequities in health status and outcomes and lack of access to health services for many groups in Australia. For indigenous Australians it proposed an increase in funding to reflect the much greater health needs.

A National Aboriginal and Torres Strait Islander Health Authority would purchase services specifically for indigenous patients and focus on results to ensure high quality and timely access to services.

The chief executive of the Australian Health Insurance Association, Dr Michael Armitage, said insurers would consider the dental care proposal and other recommendations and compile a response to the reform commission.

“The industry would support any plan to improve access to dental care for Australians but it is about more than that – it’s about quality, safety and achieving better health outcomes – not just health financing,” he said.

The Opposition’s health spokesman, Peter Dutton, said taxpayers would pay billions of dollars in extra taxes for a national Denticare scheme.

“Almost 11 million Australians or 50 per cent of the population would pay more than they currently do to meet the costs of the Denticare scheme,” he said.

This is an article that recently appeared in the Augusta Daily Gazette – Augusta,KS,USA.

The fields of dentistry and medicine have historically evolved along separate tracks. But some dentists and medical doctors are recognizing that there is an unbreakable link between the two fields and that oral health directly impacts systemic health.
Dr. Paul Mitsch with Augusta Family Dentistry explained, “Dentists see patients routinely in non-acute situations. It’s the perfect avenue to evaluate and refer out. Dentists should be the primary screeners for airway issues and tonsils…they can be the first line of defense.”

A local lad having sleep difficulties was helped by a check up at the downtown dental office.
Both Dr. Mitsch and his partner, Dr. Robert Colt would like to see more dentists and doctors working closer together in order for patients to receive the most optimal care.

Medical and dental professionals are working together in treatment of Sleep Apnea

If parents notice that their child is congested and breathing through the mouth, tonsils may be the source of the problem. Tonsils and adenoids swell when they mount an immune response to fight germs.

Dr. Colt advised, “Snoring in children is not normal, and neither is labored breathing during sleep. When this happens it is due to obstruction in the airways and their sleep is being disrupted.”

The local dentists have researched Childhood Obstructive Sleep Apnea Syndrome (OSAS). The syndrome occurs in children of all ages. It is the most common in the preschool age group, due to the presence of adenotonsillar hypertrophy—fat deposits in the tissues of the throat and tongue—making the airway smaller.
Sleep apnea and airway problems contribute and lead to significant medical problems and the prevalence is increasing due to more numbers of childhood obesity.

In children, disrupted sleep often manifests as hyperactivity and difficult behavior rather than overt sleepiness. OSAS may result in attention deficit hyperactivity disorder (ADHD) and poor school performance.
Dr. Colt explained that children are often prescribed Ritalin or another psychostimulant drug and asked, “Why do we treat the symptoms of poor sleep habits and not treat the disorder?”

Dr. Colt advised that OSAS should be suspected in any child with persistent snoring as well as labored breathing during sleep. During periods of complete obstruction, the child can be observed to be making respiratory efforts, but no snoring is heard and no airflow is detected. Obstructive episodes are usually ended by the child gasping, movements or waking up.
Both dentists emphasize that snoring in children is not normal and would always merit an evaluation by a doctor.
The first line of treatment for children with OSAS is adenotonsillectomy—the removal of tonsils and adenoid.
Five-year-old Blake Bush was having problems sleeping at night. He was displaying breathing problems and usually awoke with a dry throat.

His father, Kent Bush explained, “Dr. Colt was giving Blake a regular check-up and mentioned that we should take him to a doctor to have his tonsils checked out. Blake got sick shortly after that and we took him to see Dr. Christopher Bird, pediatrician, at Susan B. Allen Medical Clinic in El Dorado. He referred us to Dr. Leitner with the Wichita Clinic, who removed Blake’s tonsils and adenoids.”

Before the swelling even went down from the effects of surgery—within the first 48 hours—Blake’s breathing was better. “Even he noticed it. There has been a big difference. He sleeps all night now. No more being sleepy during the daytime,” Bush added, “the idea of the surgery can be scary, but it’s really worth it.”
Dr. Mitsch stated, “Dentists are routinely screening patients for dental problems and airway issues. When professionals can share knowledge and expertise effectively, new ideas can come into consideration. If we don’t have that, the public suffers.”

This entry by Larry L. Cunningham Jr, DDS, MD; Doug D. Damm, DDS was recently published in The American Journal of Hematology / Oncology.

The authors were invited to provide this perspective on the research findings reported in Kyrgidis A, Vahtsevanos K, Koloutsos G, et al. Bisphosphonate-related osteonecrosis of the jaws: a case-control study of risk factors in breast cancer patients. J Clin Oncol. 2008;26:4634-4638.

The recent article by Kyrgidis and colleagues, describing a case-control study of risk factors for bisphosphonate-related osteonecrosis of the jaws (BRONJ), was read with interest.1 Although the number of patients included in this study and the variety of investigated risk factors are low, the results and conclusions confirm further the data presented in numerous previously published reviews.2-6

Oral health and bisphosphonates

The current investigation suggests a link between BRONJ and tooth extraction and supports root canal therapy as a secure treatment option. The evidence associating BRONJ with invasive osseous surgery of the jaws is strong and is largely responsible for the current standards of care, which advise against any procedure that would directly manipulate bone in cancer patients receiving IV bisphosphonates.2,3,6 Except for active abscesses and teeth with 3+ mobility, endodontic therapy is preferable to surgical extraction. For nonrestorable teeth, endodontic therapy combined with crown amputation is recommended.

The suggestion by Kyrgidis and colleagues that denture use is a risk factor for BRONJ has been previously discussed.5,7,8 Denture use is an important consideration; one should not assume that a patient who wears dentures does not need to continue follow-up and maintenance care with a general dentist. However, Kyrgidis and colleagues did not review other important clinical characteristics associated with denture-related cases of BRONJ, such as whether the dentures were complete or partial, the age of the dentures, the presence of primary mucosal ulcerations before the development of BRONJ, and the length of time since the last dental visit.

The final paragraph of the current report represents the pearl of this publication and provides excellent advice for all practicing oncologists. As mentioned in the position papers of numerous dental specialty organizations, the current standards of care strongly advise that patients obtain optimal oral health before the initiation of therapy with IV bisphosphonates.5,6 If these actions are noninvasive (ie, if no osseous surgery is involved), bisphosphonate therapy may begin immediately. If invasive osseous procedures are necessary, the initiation of bisphosphonate therapy should be delayed for 1 month so that adequate osseous healing can occur. After the initiation of bisphosphonate therapy, the maintenance of optimal oral health remains paramount, and regular professional dental care every 3 to 4 months is recommended.

Final thoughts

Although the reported prevalence of BRONJ varies, prospective studies have demonstrated a frequency of approximately 6% to 7%.7 Continual review of the literature allows practitioners to provide the best care possible, especially with disease processes that are not yet fully understood. It is unfortunate that predatory legal practices often surface in the wake of newly understood complications. Numerous personal communications with practicing dentists reveal the receipt of letters from attorneys attempting to recruit clients with BRONJ. The use of the suggestions presented in the conclusion of the report by Kyrgidis and colleagues and the standards of care described in the associated references of this review may dramatically reduce the morbidity rates associated with IV bisphosphonates and may also reduce the potential liability associated with the cases that will inevitably arise.

References

1. Kyrgidis A, Vahtsevanos K, Koloutsos G, et al. Bisphosphonaterelated osteonecrosis of the jaws: a case-control study of risk factors in breast cancer patients. J Clin Oncol. 2008;26:4634-4638.
2. Marx RE, Sawatari Y, Fortin M, et al. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg. 2005;63:1567-1575.
3. Ruggiero SL, Fantasia J, Carlson E. Bisphosphonate-related osteonecrosis of the jaw: background and guidelines for diagnosis, staging and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102:433-441.
4. Ruggiero SL, Mehrotra B, Rosenberg TJ, et al. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 2004;62:527-534. 5. Woo SB, Hellstein JW, Kalmar JR. Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med. 2006;144:753-761.
6. Advisory Task Force on Bisphosphonate-Related Osteonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2007;65:369-376.
7. Bamias A, Kastritis E, Bamia C, et al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol. 2005;23:8580-8587.
8. Yarom N, Yahalom R, Shoshani Y, et al. Osteonecrosis of the jaw induced by orally administered bisphosphonates: incidence, clinical features, predisposing factors and treatment outcome. Osteoporos Int. 2007;18:1363-1370.

Author disclosures: No relationships with industry were reported.

As you may know, NobleDentist has been endeavouring to make several improvements to the website in response to suggestions from members. Stage 1 of these improvements are virtually complete. Of particular benefit to members and potential members is the Frequently Asked Questions (FAQs).

Roughly 20 new questions have been added to the list of Frequently Asked Questions. The list of questions have also been organised into several headings – Membership Questions, Dental Fee Questions, Payment Questions, NobleDentist with Private Health Insurance Questions, Participating Dentist Questions, Treatment Questions, and Miscellaneous Questions.

We encourage everyone to use the Frequently Asked Questions to find an answer to their question before Contacting Us. We hope this will assist you and save you a good deal of time waiting for our response.