It starts as a tiny fissure that slowly grows to a black cavity. It attacks soft tissue and bone, causing painful swelling and bleeding. Left untreated it can develop into full-blown cellulitis and you can end up in hospital, with a hefty medical bill to boot.

It is the most common medical condition in Australia and it isn't diabetes or heart disease. It's tooth decay, followed closely by its related condition, gum disease.

Australians are visiting dentists more often - two-thirds of us now see a dentist regularly, up from 50 per cent a decade ago - yet, according to the Australian Council of Social Service, the oral health of middle-aged Australians is among the worst in the developed world, with tooth decay on the rise.

Australian children enjoy one of the best standards of oral care in the world. However, a report released last week by the Australian Research Centre for Population Oral Health at the University of Adelaide shows the number of children requiring general anaesthetic for dental surgery, most commonly tooth extractions, tripled in the past decade.

Each year more than 30,000 people in Australia are hospitalised because of a dental condition, usually a tooth or gum infection that has been left to fester. So why the neglect for our teeth and gums?

Dentists say a lack of funding and a lack of dentists are just two of the reasons. "Governments treat dentistry as if it is not part of health, as if the human body stops at the mouth," says Hans Zoellner, chairman of the Association for the Promotion of Oral Health. "The mouth is a communication organ, a sexual organ and it is cosmetic - it is not just for eating."

A report published last week in the Medical Journal of Australia predicted that by 2010 Australia will be short 1500 dental care providers. Zoellner says almost a third of the vacant positions will be in NSW.

For those in poor socio-economic or regional areas, the issue of access to dental care is more critical. There are about 9000 practising dentists in Australia, about 43 per 100,000 of population, but in rural areas this ratio drops to 28.

There is no Medicare rebate for dental care. In 1997 the Liberal Government axed the Commonwealth Dental Health Program, designed to lower waiting lists in the public system.

Publicly funded dental care is now provided through the state hospital system but it is restricted to children aged up to 18 years and concession card holders (about 34 per cent of the adult population).

In NSW there are only about 240 dentists working in the public system, compared with more than 3000 private practitioners, and the teeth they see are often in an advanced state of decay.

Last year, an investigation by the Herald found patients in the public system were waiting up to eight years for treatment. That led to an NSW parliamentary inquiry, which found NSW spent less than any other state on dental health.

In response, the NSW Government announced that an extra $40 million would be spent on dental health in the next four years. The funding will be used to reduce waiting lists in the public system and target groups at risk of dental problems, including young children and senior citizens.

Zoellner says the additional funding is not enough to improve waiting list times and staffing levels in NSW. "[The funding] will barely meet the inflation rate."

With about 250,000 public patients in NSW on waiting lists for dental treatment, patients are seeking help from general practitioners and, in some cases, requiring hospitalisation for dental infections.

"GPs are seeing an endless stream of patients coming in for repeated scripts of antibiotics and painkillers for teeth problems," Zoellner says. "This is at a substantial cost to the public purse."

About 85 per cent of dentistry is performed in the private sector. The Australian Dental Association does not recommend a fee schedule for its members but, according to the MJA report, practitioners charge an average rate of $350 an hour, of which overheads account for about 70 per cent.

The president of the ADA, Chris Wilson, says fees vary along with the rebate from health funds, with some funds only paying for treatment from preferred providers. "The decision whether or not to have a treatment comes back to the patient," Wilson says. "The dentist informs them of the risks and the cost."

The report in the MJA estimated 25 per cent of dental patients delay treatment because of the cost. The likes of root canal surgery can cost upwards of $500 at a private practice; surgical procedures can add thousands of dollars.

Delaying the inevitable through the use of antibiotics is also a problem. "This creates a public health issue - the over-use of antibiotics creates strains of resistant bacteria," Zoellner says.

The majority of dental problems are largely preventable. However, the problems dentists are treating are increasingly complex. This is due in part to delayed treatment but also, ironically, to an improvement in oral health since the introduction of fluoride in the 1950s.

Tony Dawson, a Canberra prosthodontist specialising in reconstructive and replacement dentistry, says that while edentulism (people who are completely toothless) is decreasing, the number of people who have some teeth missing is increasing.

The more dental work people have, the more maintenance they may need, such as replacement fillings. "Everything we do has a certain life expectancy - these days we try and do the smallest possible fillings we can," Dawson says.

Dental work such as fillings are often necessary to prevent further tooth decay, but it takes a toll on teeth. Each time a filling is replaced it takes a part of the tooth with it and, eventually the tooth may need to be replaced.

'When you are younger, the problem is likely to be tooth decay," says Mark Schifter, a senior specialist in oral health at the University of Sydney. "But when you are older it is gum disease."

Gum disease is linked to conditions such as diabetes, heart disease and low-birthweight babies. Gum disease that is left untreated has also been shown to worsen a patient's diabetes.

For some, gum disease is unavoidable. Some are genetically predisposed to tooth decay and gum disease - they just have the wrong saliva. "Some salivas have better anti-bacterial properties than others and some [people] have more aggressive bacteria," Schifter says.

Pregnant women are at higher risk of gum disease and, if the condition develops, they risk delivering lower birth-weight babies because of the toxins produced by the bacteria entering the blood stream.

Mothers also risk passing on the bacteria to their babies. When babies are born, their mouths are sterile. It is only when they begin sharing food and utensils, usually with their mother, that bacteria starts to build up in their mouths.

During Dental Health Week, from August 1 to 7, the ADA will be campaigning for better awareness of how the consumption of bottled water - which does not contain the same amount of fluoride as tap water - along with sugary soft and sports drinks, is contributing to a decline in dental health.

In addition to government funding, Schifter believes, there should be more public education campaigns encouraging oral health, and they should be given the same status as the campaigns that encourage people to use sunscreen or quit smoking.

The celebrity smile is a sought-after cosmetic enhancement. In New York, clients are said to browse dentists' books of "red-carpet smiles" in search of Oscar-winning choppers.

Canberra prosthodontist Tony Dawson specialises in restoring lost or damaged teeth and says cosmetic dentistry can have unwanted side-effects. "You can achieve virtually anything if your pockets are deep enough and you are willing to accept the risks," he says.

Starting at about $1000 a tooth, porcelain veneers last about 10 years. But they can damage both your teeth as well as your bank account if not applied properly, Dawson says.

"The harder you cut back teeth to change their shape the more likely you are to have problems such as nerves dying and having to crown or replace the teeth."

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