Croakey readers are invited to join us for a webinar, Tackling Oral Healthcare Inequities, from 5-6pm AEST on Monday, 8 April.
The webinar is part of our #Medicare40Years project and also marks Global Public Health Week. We acknowledge and thank the webinar sponsors: Public Health Association of Australia, Oral Health Special Interest Group; Deakin Health Economics; and the Violet Vines Marshman Centre for Rural Health Research.
Below, Tan Nguyen, spokesperson for the National Oral Health Alliance and co-convenor of the Public Health Association of Australia’s Oral Health Special Interest Group, and Radiya Adam, a public health graduate, provide an overview of the complexities of the oral health workforce, highlighting the importance of systematic reform efforts, including around scope of practice.
Also see the previous article in this series: Please join us in tackling oral healthcare inequities – and here’s a guide to policy challenges and opportunities.
Tan Nguyen and Radiya Adam write:
Like many healthcare systems worldwide, a large majority of dental services (about 85 percent) provided in Australia are delivered in the private sector with mixed funding arrangements footed by governments (federal and state/territories), private health insurance funds, and out-of-pocket expenses and fees paid by individuals.
There are five types of practitioners providing dental services – dentists (including dental specialists), oral health therapists, dental hygienists, dental therapists and dental prosthetists. All of these practitioners are highly regulated by the Dental Board of Australia. Dentists represent 75 percent of the Australian oral health workforce.
Australia’s oral health workforce has a point of difference when compared with countries internationally. It was the first jurisdiction to recognise oral health therapists as a health profession by merging the dental therapist and dental hygienist skillset in 2010.
Oral health therapists are a rapidly growing dental practitioner division and make up about 49 percent of the oral health practitioner workforce (which also includes dental hygienists and dental therapists).
Among Western countries, dental therapists are more widely known to focus on preventive oral health and managing tooth decay, primarily in children, whereas dental hygienists focus on preventive oral health and managing gum disease for all ages.
Changing oral health workforce
It was the Honorable Gough Whitlam, 21st Prime Minister of Australia, who introduced the 1972 policy to offer free dental services to all Australian school children.
The dental program was led by dental therapists from 1973, and made possible by the profession’s introduction, which was based on models in the United Kingdom and New Zealand.
In Australia, dental therapists were traditionally restricted and employed in the public sector to provide School Dental Services. In 1975, dental hygienists were introduced but their employment was naturally confined to the private sector, largely because government funding of dental programs did not make it viable to employ them.
When Australia’s universal public health insurance system, Medicare, was established in 1974, efforts to include dentistry did not eventuate. This has meant that incremental approaches were adopted to expand publicly funded oral healthcare, either through federal dental programs under Medicare, the Department of Veteran’s Affairs, or co-funded state and territory dental programs.
From 2007, as School Dental Services started to merge into community health services, which provided publicly funded oral healthcare for eligible adults in Victoria, demand for adult preventive dental services grew.
As a result, many dental therapists re-trained to become dual-qualified dental therapist and dental hygienist – in other words, an oral health therapist.
Beyond the dental surgery
Dentistry in Australia has shifted from the dentist as the provider for all dental services towards an intra-disciplinary approach within a dental team.
In 2011, a Health Workforce Australia report recommended removing the bar on independent practice for oral health therapists, dental hygienists, and dental therapists within five years. However, policy change took almost 10 years with the Dental Board of Australia publishing a revised scope of practice registration standard in 2020.
The revised scope of practice for the dental profession has important implications.
Firstly, public sector oral health therapists gradually transitioned from only treating children to providing oral healthcare (dental hygiene and dental therapy) for all ages within their broadest scope of practice. Similarly, oral health therapists applied their dental therapy skills in the private sector.
Secondly, it meant that cost-efficiency gains could be made, leading to better resource allocation and increased access to oral healthcare. This is because oral health therapists are less costly to employ, while providing high quality preventive focused oral healthcare.
Although the delivery of preventive dental services by non-dental health practitioners in primary care makes logical sense, there has not been a systematic approach at a national level to translate this into clinical practice.
Ad hoc oral health service delivery models developed in Australia include the Midwifery-Initiated Oral Health Dental Service and the Lift the Lip dental screening program, which can be performed in primary care by medical practitioners, nursing and midwifery practitioners, and Aboriginal and Torres Strait Islander Health Practitioners.
Localised responses to community needs have made progress to address the broader social determinants of health with self-determined approaches by Aboriginal Community Controlled Health Organisations. This includes the expanded role of Aboriginal and Torres Strait Islander Health Practitioners in oral health to apply fluoride varnish on teeth to prevent tooth decay.
Red tape and roadblocks
As global experts have pointed out, there are considerable challenges to improve population oral health, including the design and government funding arrangements for universal access to essential oral healthcare.
Dentistry largely remains interventionist, increasingly adopting technology, and a ‘specialised’ approach to oral healthcare. As a consequence, dental practitioners are incentivised to provide more lucrative dental services (for example, dental implants, orthodontics), including cosmetic procedures, rather than oral disease prevention.
Whilst the Medicare legislation (Health Insurance Act 1973) did not initially include dental services, Section 3 of the Act refers to funding clinically relevant service as “a service rendered by a medical or dental practitioner or an optometrist that is generally accepted in the medical, dental or optometrical profession (as the case may be) as being necessary for the appropriate treatment of the patient to whom it is rendered”.
As such, the Dental Benefits Act 2008, which provides dental benefits under the means-tested Child Dental Benefits Schedule, would appear designed for “cost containment measures”. It has also retained the flawed concept that oral healthcare is the responsibility of the dental profession – that relevant preventive dental services cannot be provided by non-dental health practitioners.
The 2023 independent Health Workforce – Scope of Practice Review on primary care, commissioned by the Federal Government, has made considerable progress in many areas. Unfortunately, oral healthcare is outside the scope of the review, which is relevant to non-dental health practitioners delivering primary care.
Internationally, there are important learnings that would be helpful to inform oral health policy in Australia and the scope of practice review.
These issues will be addressed in the next article in this series.
Author details
Tan Nguyen is an oral health therapist and health economist. He is the co-convenor for the Oral Health Special Interest Group, Public Health Association of Australia, and Casual Research Fellow from Deakin Health Economics.
Radiya Adam is a graduate with Master of Public Health and Bachelor of Science from the University of Melbourne.
The perspectives are those solely of the authors.
Register here to attend the webinar.
Croakey is seeking sponsors for further #CroakeyLIVE webinars as part of the #40YearsMedicare project. Please contact us for more details: info@croakey.org
