Book Review

Looking back looking forward: oral health in Victoria and Australia 1970 to 2022 and beyond

John Rogers and Jamie Robertson, 2023

Published by JR Publishers, Melbourne

First edition, 240 pp.

Free pdf from https://doi.org/10.26188/23721969.v2 or via Trove – https://nla.gov.au/nla.obj-3277008802/view

Hard cover ISBN 978-0-6458191-0-6, soft cover ISBN 978-0-6458191-0-20 available from book distributers or from jgrogers@unimelb.edu.au.

This excellent history exposes the DNA of our current, often widely criticised public oral healthcare system in Victoria and Australia more broadly. As we know, understanding the building blocks of a body or a system is powerful in working out how to strengthen it.

It is a remarkably detailed history and analysis of the growth and development of the public dental/oral health sector in Victoria over the past 50 years. It describes and analyses almost every aspect of public care to try to explain how the current situation came about. For example, it details why the public oral healthcare system is so structured and funded, why it can only offer restricted care despite advances in care more generally, why it cannot meet anything like population demand, and why the current workforce looks like it does.

It also includes chapters on legislation and governance, the school dental services, prevention, the evolution of clinical services, alliances and advocacy, and oral health status. Although much is focused on Victoria, national developments are also painted. All of these domains have been key elements in forging the current system.

Written by two very experienced dentists who have worked in, and been responsible for, public dental care in Victoria, it is the first of its kind, a unique contribution to the field. Overall, it aims to paint a complete picture. There is some repetition, but this is deliberate to enable individual chapters to be used as resources in themselves.

The book highlights inequity. For example, the chapter on oral health status describes the factors behind the steadily improving average status enjoyed by Australians over the past 50 years. However, this good news is qualified by a range of data showing how poorer people are being left behind. Anecdotally, in any crowd, we can all see how people’s oral health status is very often a very public indicator of their socio-economic status, possibly more so than many other signs. The book notes that poorer Victorians are still six times more likely to have no natural teeth than the rest of the population, a higher ratio than 20 years ago. Further, although Victorians’ teeth (in total) are experiencing less decay overall, a greater proportion are untreated now than 20 years ago, and they are more concentrated in the mouths of people with lower incomes. Hence, they state, the ‘tooth gap’ between Health Care Card holders and non-card holders increased from three to six teeth in the 12 years to 2018.

The chapter on the history of the sector is composed using a range of diverse perspectives, and focuses on some key moments in depth. For example, access to public care up to the late 1980s was extremely limited, and predominantly only available from the dental hospital and a few rural hospitals. A major step forward occurred in 1989, when funding was expanded to dozens of community-based health services. Although warmly welcomed by consumers, the expansion has remained only a partial solution. Funding annually still only allows for eligible Victorians to receive care approximately once every 7 years – far from acceptable by any standards. The authors indeed note that access has not changed in almost a quarter of a century. The average waiting time for general (non-priority or urgent) care in 1999 was 21 months, and 25 months for dentures in Victoria, and was pretty much the same in 2022.

Rogers and Robertson describe how reform in the Victorian system has tended to happen much more under Australian Labor Party governments. Even so, improvement relied on the opening of a political window, not just general support for improvement. Case studies of three government initiatives are analysed in detail. These include the increase to funding under the Fairer Victoria policy in 2004, and the inclusion of Smile Squad in the 2018 election platform. Interestingly, both initiatives appeared driven by broader agendas than the population’s oral health status. The Fairer Victoria initiative saw oral health gaps as stark examples of inequity (albeit supported by sector and community advocates), the latter appeared more of a political initiative aimed at pleasing the population in marginal electorates experiencing cost-of-living pressures and longer than average travel times to services.

The chapter on prevention is particularly interesting, using the WHO Ottawa Charter for Health Promotion to frame prevention initiatives undertaken over several decades. The list is surprisingly diverse and describes significant successes. Community water fluoridation has been the standout success, although progress seems to be grinding to a halt with 10% of the (mainly rural) population still not covered. Other advances include training 6300 health and early education professionals who work with parents and young children to assist early childhood services in disadvantaged areas to be oral health promoting. Yet, as the authors point out, many initiatives have often been on a too small scale, and further opportunities for prevention of oral disease and reduction of inequity have not been realised. As the authors note, from a macro perspective, funding for oral health care is considerably misaligned in favour of post-disease treatment, rather than prevention.

Missing perhaps from the prevention chapter are any answers to the question of why decision makers have repeatedly ignored prevention opportunities. Although an earlier chapter does spell out the key barriers to oral health policy development, there are obvious cost-effective benefits from investment in prevention, and particularly in oral health, where oral diseases are among the easiest of all conditions to prevent. Although there have been well-thought out national oral health plans, this has not translated into adequate government investment to implement them.

The book finishes by looking forward, outlining the four goals and six guiding principles of the WHO Global Strategy on Oral Health (2022), and how the Victorian system does and might align with these in the future.

The book is extremely well written, easy to read, includes lots of data and is well referenced, and I highly recommend it. It is a must-read for anyone working in the sector, for those responsible for policy and funding of public care at state and Commonwealth levels, and also for anyone concerned about the inequities in Australians’ and especially Victorians’ health status.