Systemic reform is needed to address inequities in oral healthcare, and pockets of innovation in the Aboriginal community controlled primary healthcare sector provide some potential pathways to guide wider reform efforts.
But where is the political will?
Alison Barrett reports from discussions at a #CroakeyLIVE webinar this week, which was held as part of #Medicare40Years, a Croakey initiative putting the spotlight on critical health reform issues.
Alison Barrett writes:
When pregnant women and their families attend antenatal and perinatal healthcare at the Victorian Aboriginal Community Controlled Health Organisation’s Koori Maternity Services, they are also supported in navigating access to other essential healthcare services, including preventative oral health and dentistry.
The KMS – which has been operating within ACCHOs for 23 years – “has been instrumental in improving antenatal and perinatal health outcomes for Aboriginal women and babies” by providing this integrated service, says Abe Ropitini, Executive Director of Population Health at VACCHO.
However, as only four of the ACCHOs in Victoria are funded to provide oral health and dental services, there are still significant barriers for pregnant women accessing culturally safe oral healthcare, he said.
“If there is no on-site dental service within an ACCHO, then those services are reliant on mainstream providers, most of which are private clinics,” Ropitini said.
The sector works to provide culturally safe healthcare services that are integrated and multi-disciplinary, in contrast to fragmented models that separate oral healthcare from other services.
ACCHOs put patients and communities at the heart of culturally safe service provision, according to Ropitini.
By contrast, mainstream dental service provision was often standalone, rife with inequities and racism, and was driven by funding models that prioritised throughput and the volume of services rather than wellness, prevention and equitable access and outcomes, he said.
The ACCHO sector’s innovation in integrating oral healthcare into primary healthcare was profiled at a #CroakeyLIVE webinar this week on tackling oral health inequities.
Held as part of Croakey Health Media’s #Medicare40Years project and to mark Global Public Health Week, the solutions-focused webinar was an opportunity to advance health reform discussions about equitable access to oral healthcare in the lead-up to the next federal election, according to webinar Chair and CHM Director Alison Verhoeven.
Webinar participants put forward suggestions for how to increase the political appetite for oral health reform, including through making the public more aware of the importance of prevention, and through building coalitions within the oral healthcare professions, and across sectors.
“Good oral health has a significant impact on our overall wellbeing and our quality of life,” Verhoeven told the webinar.
“It affects our self-esteem, our ability to eat, to speak, to socialise, to participate in the economy, it’s so critical to all of us, yet we don’t include it in our general funding of the health system, we see it as something separate, something different,” Verhoeven said.
“Like me, you probably know adults with poor teeth. You probably know people with missing or decayed teeth. You probably will know people who don’t go to the dentist because they’re worried about the cost of it.
“Up to one third of all adults in Australia have untreated tooth decay, which is something really shocking when we claim to be a country with a high quality health system.”
Engaged audience
The webinar was attended by an engaged audience of up to 98 people, including services, practitioners, researchers, advocates, policymakers, and students.
Participants included representatives from the Office of the National Rural Health Commissioner, Australian Dental Association, COTA Australia, University of Plymouth UK, SA Dental, Canberra Oral Health Services, Sydney Local Health District, Australian Dental and Oral Health Therapists’ Association, Aboriginal Health Services within the Centre for Oral Health Strategy, NSW Health, WA Dental Health Service Safety & Quality Committee, the Oral Health Centre WA, and the Indigenous Oral Health Unit at the University of Adelaide.
The webinar heard about the urgent need to transform systems of care and funding models to better meet the needs of communities, especially under-served populations, who often face exclusion, discrimination, trauma and racism from dental services.
One of the participants, Associate Professor Lilon Bandler, a GP who works with people who are homeless or housing insecure in Sydney CBD, said all of her patients needed significant dental care but struggled to navigate and access complex systems, and were often deterred by previous traumatic experiences.
If we addressed everybody’s dental and oral health needs, “a lot of the other things that we are involved in caring for, for example heart disease, would diminish”, she said.
Speaking in the meeting chat, Dr Brianna Poirier, from the Indigenous Oral Health Unit at the University of Adelaide, said most current models of care “are not fit for purpose for communities who need them most”.
“Oral health has become a luxury for those that can afford [it], and the gap in oral health continues to widen.”
One of the 35 recommendations of the Select Committee review into the provision of and access to dental services in Australia is to progress opportunities to integrate oral and healthcare into primary healthcare, via an oral health taskforce within the Department of Health and Aged Care, overseen by a Chief Dental and Oral Health Officer.
A comment in the chat highlighted the importance of capacity building of non-oral health professionals such as midwives, maternal child health workers, pharmacists, Aboriginal Health Practitioners, disability support workers and GPs, who could all play an important role and work in partnership with the oral health sector.
Ropitini told the webinar that the ACCHO model of care seeks to integrate dental services into the full suite of primary care services, where the multidisciplinary teams wrap around the needs and priorities of people and communities, with Aboriginal Health Workers as the key interface with patients and their families.
He said that oral health is part of the holistic model of care in the ACCHO sector, practised collectively by midwives, housing workers, mental health clinicians, alcohol and other drug counsellors, GPs, nurses, allied health professionals “like speechies”…and we want occupational therapists and more dentists to be part of that too.
“Multidisciplinary teams are precious and need to be enabled in funding models, both for ACCHOs and more widely,” he said.
Ropitini called for increased and more flexible funding for Aboriginal Community Controlled Health Organisations to develop oral health services, whether through direct employment of dentists and oral health staff, or development of appropriate facilities.
Families needed to be able to visit a service for an Aboriginal Health Check, and see a dentist at the same time, or have fluoride varnish applied during health checks, he said.
“We need to creatively embed preventative oral healthcare into models [of care] that already exist,” he said.
Ropitini reiterated concerns raised in a 2016 Victorian Auditor General’s report, whose recommendations still were not fully implemented, which found the system was focused on an “ambulance at the bottom of the cliff” model, and reliant on dentists and dental chairs, rather than multidisciplinary teams supporting wellness and preventive care.
He also called for a shift in narratives about how mainstream services talked about oral healthcare in ways that often discriminated against Aboriginal patients and reduced their access to services.
Innovation in Queensland
The ‘Yalburru Dirun’ (happy teeth) outreach Dental Truck service delivered by the Aboriginal and Torres Strait Islander Community Health Service (ATSICHS) is an award-winning example of innovation in oral healthcare.
Providing free dental care to Aboriginal and Torres Strait Islander students in Brisbane and Logan, as well as linking families in with other ATSICHS’ services including medical clinics, allied health and social health, Yalburru Dirun highlights the importance of holistic, wraparound healthcare.
Yalburru Dirun was recognised with a Queensland Aboriginal and Islander Health Council Innovation Excellence Award in 2022.
According to ATSICHS, the dental truck visited 14 schools and saw 1,353 students between October 2022 and March 2024, reducing the obstacles young Aboriginal and Torres Strait Islander children face in accessing culturally safe oral health.
Meanwhile, ATSICHS’ Woolloongabba Dental Clinic is showing the way with new technology integrated into its community denture service.
Implementing a 3D printer to create dentures has reduced operational costs, increased productivity and decreased denture production time from six-to-eight weeks to four-to-five weeks.
ATSICHS would like to roll the 3D printer technology to their other dental sites, increase the number of printers at the Woolloongabba Laboratory and set up a standalone, full digital dental service.
“While we have made great strides in providing dental services, we recognise the importance of further funding to drive innovation and expand our reach,” ATSICHS CEO Renee Blackman told Croakey.
“Additional funding to the dental services industry would not only support our existing projects but also bolster the broader healthcare system, ensuring timely access to dental care for all communities.”
Aged care neglect
The oral health needs of older people in aged care are greatly neglected, with poor oral health affecting quality of life, nutrition and risk of falls and fractures, Leonie Short, member of Aged Care Reform Now, told the webinar.
In sharing comments collected by Aged Care Reform Now for the Senate inquiry into the provision of and access to dental services, Short recommended better training for aged care staff, mobile treatment options and assistance with transport to dental practices.
Echoing comments by Ropitini and Bandler, Short suggested a trauma-informed approach to oral healthcare.
She noted that many older people don’t have access to private health insurance, and also called for action on the recommendations from the Royal Commission into the safety and quality of aged care.
Of the five recommendations on oral healthcare, some progress had been made on two – a review of the Aged Care Quality Standards, in particular best-practice oral care; and updates to existing oral health skill units in Certificate Three and Four oral health courses.
“I think the Minister for Skills and Training has probably done more than the Minister for Health and the Minister for Aged Care combined,” Short said.
The other three oral health related recommendations from the Aged Care Royal Commission are:
- Residential aged care to employ or retain allied health professionals including oral health practitioners
- Establish a senior dental benefits scheme for people who live in residential aged care or in the community
- Funding for education and training to improve the quality of care including oral health.
Short said her experiences as an ALP member suggested that engaging key trade unions in the need for better oral health policy and services might help drive reform.
“People often ask, why haven’t we had any traction in trying to get better oral healthcare? My answer to that question is that, to get funded programs up, we actually need support of the trade unions, as well as from Members and Ministers of Parliament.”
With 85 percent of dental services provided in the non-unionised, private sector, the dental sector lacks influence with the Labor Party, she said.
“My suggestion, in order to garner that industrial support, [is that] coalitions need to be forged with the public sector health unions, as well as other unions who have a vested interest in improving the skills or conditions of their members.”
Coalitions should be forged with unions representing nurses, aged care workers, disability support workers, teachers and childcare workers and also state and territory public service directors, the professional dental associations and peak consumer and health organisations.
Ways forward
Clare Lin, Director of Policy at Dental Health Services Victoria, said that staged reform efforts are needed to implement universal dental care, to ensure “the mouth is treated like the rest of the body”.
However, immediate gains could come from changes to existing programs, she said.
For example, governments could do much more to promote and enable uptake of the Child Benefits Dental Schedule (CBDS), especially among priority groups. The scheme is currently used by less than 40 percent of the eligible population, she said.
She also recommended that the annual dental service funding agreements (FFA) be increased from two to four-year terms, as this would help significantly with system planning and design, sustainability, workforce recruitment and retention.
Lin also called for an increase in Commonwealth funding for public dental services, noting that around 75 percent of the eligible population – largely priority groups – are not able to access public dental services with existing funding arrangements.
She highlighted the importance of implementing the oral health-related recommendations of the Aged Care Royal Commission and improving value-based healthcare.
Funding models that “incentivise prevention, early intervention and outcomes that matter to patients” will be really important to supporting a pathway towards universal oral health coverage, Lin said, also urging investment in population health initiatives such as water fluoridation.
National action
Given the National Oral Health Plan expires this year, it is imperative that a new plan is developed as a priority, according to Tan Nguyen, co-convenor of the Public Health Association of Australia’s Oral Health Special Interest Group, and Casual Research Fellow, Deakin Health Economics.
In their submission to the review into dental services in Australia, Deakin Health Economics recommended that the National Oral Health Plan 2025-34 should be developed with consumers and other key stakeholders.
Nguyen told the webinar that a National Chief Oral Health Officer and Dental Officer would be beneficial in driving oral health reform, especially the next National Oral Health Plan.
He said federal governments had failed to understand their responsibilities in oral health, and that efforts to drive reform had met with roadblocks. He also noted that private health insurance coverage of dental services is not evidence-based.
However, Charles Maskell-Knight, a Croakey columnist and a former Department of Health and Aged Care executive with responsibility for dental policy, told the webinar that a Chief Oral Health Officer, as a public servant, would be unable to advocate for change, except internally.
Nguyen also highlighted the role of technology, particularly artificial intelligence, in oral health, as “an area of work that we should leverage carefully” to maximise workforce potential.
While some aspects of oral healthcare need to be delivered in person, and issues around confidentiality would need to be managed or overcome, technology can be used to assess and diagnose oral disease, Nguyen said.
Using technology in this way may help address access issues particularly in rural and remote areas, and integrate other health professions into oral healthcare, according to Nguyen.
However, to overcome potential resistance from other professional groups, engagement and collaboration will be essential, he noted.
Adjunct Professor Dr Lesley Russell said change will occur in a series of steps – the lesson from previous failed efforts to drive reforms such as Denticare is that “we can’t get there in one step”.
Russell urged the oral health profession to work together and develop a collective commitment to delivering healthcare to those who now are excluded, whether for reasons of geography or cost.
“We need some public education about the fact that dental caries is a totally preventable disease,” Russell said.
“Dental care provided by a dentist or by somebody else is not something that you do when something goes wrong, but something that you do from the very beginning, starting with kids.”
If the public could be educated, they would serve as a driver and a mechanism for getting politicians into line, Russell added.
Webinar participants also emphasised that more in-depth discussions on oral healthcare are warranted to explore the social and commercial determinants of oral health, with some panel members and attendees noting the significant impact, for example, of housing insecurity and junk-food marketing on oral health.
Plans and timelines
Below are responses from a spokesperson for the Department of Health and Aged Care to questions raised at the webinar:
Q1. What is the plan and timeline for the development of the National Oral Health Plan 2025-34?
Response:
Health Ministers agreed to develop the next National Oral Health Plan (NOHP) 2025-34 at the June 2023 Health Ministers Meeting. The Department of Health and Aged Care is consulting with states and territories on the development of the next plan.
The current NOHP 2015-2024 will remain active and in effect until the new NOHP is endorsed and released.
Q2. When will the Department respond to the final report and recommendations of the Select Committee into the Provision of and Access to Dental Services in Australia?
Response:
The Government is finalising its response to the Senate Select Committee into the Provision of and Access to Dental Services in Australia. This is due to be tabled shortly.
Q3. Five oral health related recommendations were made in the Royal Commission into Aged Care Quality and Safety. What is the plan and timeline for implementation of the following three recommendations:
Q3a. Rec 38: Residential aged care to employ or retain allied health professionals including oral health practitioners
Response:
The Government is committed to ensuring allied health services are provided in residential aged care. Residential Aged Care providers are required to provide allied health services to residents in accordance with their obligations under the Aged Care Act 1997 and the associated Quality of Care Principles 2014. This includes access to allied health services as part of an individual therapy program aimed at maintaining or restoring a resident’s ability to perform daily tasks. Residential Aged Care providers are funded to deliver these services as part of their Australian National Aged Care Classification (AN-ACC) funding. Oral health services are not currently required to be delivered by residential aged care providers, but Residential Aged Care providers are responsible to maintain oral hygiene, and arrange dental appointments as required.
Q3b.Rec 60: Establish a senior dental benefits scheme for people who live in residential aged care or in the community
Response:
The National Dental Reform Oversight Group, represented by each state and territory and the Commonwealth, is currently conducting analyses to consider improved access to public dental services for priority groups, including people in residential aged care and older Australians living in the community. Options will be presented to Health Ministers during 2024.
Q3c.Rec 114: Funding for education and training to improve the quality of care including oral health.
Response:
Certificate III in Individual Support has been reviewed, and a new version of the qualification was released in November 2022. As a result of the review, a core requirement of the Certificate III in Individual Support now includes students to demonstrate oral hygiene and assisting with oral care knowledge. Specifically, how to look after natural teeth and gums, denture removal, cleaning and insertion, recognising ill-fitting dentures, and effective brushing and alternatives to brushing.
Watch the webinar
Further reading
• See Alison Barrett’s X/Twitter thread from the webinar
The ‘Tackling oral health inequities’ webinar was co-sponsored by the Public Health Association of Australia’s Oral Health Special Interest Group, Deakin Health Economics and the Violet Vines Marshman Centre for Rural Health Research.
We invite applications from organisations interested in sponsoring future #CroakeyLIVE events on key health reform topics.
congratulations to all on this robust discussion – with half of Australians unable to a access dental care it is time to do something about it. Put dental into Medicare and treat the mouth like the rest of the body!
Croakey’s article on oral health inequities is a compelling call to action. It sheds light on the profound impact of exclusion and discrimination on dental health outcomes, emphasizing the urgent need for systemic change. This piece underscores the importance of addressing social determinants to achieve equitable oral health for all. Thanks for raising awareness on this critical issue!