Chapter 4Filling the gaps: improving access for priority groups

4.1The goal of the Healthy Mouths, Healthy Lives: Australia's National Oral Health Plan 2015–2024 is to improve health and wellbeing across Australia by enhancing oral and dental health status, and by reducing the burden of poor oral health. The plan outlines ways to improve oral health for people living in Australia, by identifying six foundation areas and four priority populations. The six foundation areas are:

oral health promotion;

access;

systems alignment and integration;

safety and quality;

workforce; and

research and evaluation.[1]

4.2The priority populations are parts of the population that experience the greatest burden of poor oral health and the most significant barriers to accessing oral and dental health care in Australia. The four priority populations are:

people who are socially disadvantaged or on low incomes;

Aboriginal and Torres Strait Islander people;

people living in regional and remote Australia; and

people with additional and/or specialised health care needs.[2]

4.3Australia's National Oral Health Plan will expire soon, with the next ten-year plan commencing in 2025. Although the previous plans have provided guidance and suggestions about increasing access to dental and oral health services, they have been largely driven by experts and not consumers. Deakin Health Economics recommended that funding needs to be directed to genuinely engage with consumers and other key stakeholders in this dialogue so they can provide input to develop the subsequent National Oral Health Plan 2025-2034.[3]

4.4This chapter expands on the unmet need for dental and oral health services that was considered in the committee's interim report,[4] as well as improving access for the following populations:

people who are economically and socially disadvantaged;

older people;

Aboriginal and Torres Strait Islander peoples, including those living in regional and remote areas of Australia; and

disabled people.

4.5Children who are part of these priority groups also face barriers in accessing the Child Dental Benefits Schedule (CDBS). As such, this chapter also looks at improving access to the CDBS for these cohorts.

4.6The chapter briefly considers training and workforce issues directly related to the above priority groups; however, wider training and workforce issues are considered in more detail in Chapter 5.

Economically and socially disadvantaged

4.7The affordability of dental care is a major barrier for many people in Australia, especially for those on low incomes, including people who have concession or health care cards.

4.8The committee has consistently heard that people in Australia delay or avoid seeing the dentist due to the cost of services.[5] Approximately one in five people delayed or avoided seeing a dental practitioner due to cost, which is five times higher than the number of people who delayed seeing a general practitioner (GP). This percentage increases to approximately 28 per cent for those on low income.[6]

4.9This section of the report will look at addressing the unmet need for dental and oral health services for people with low incomes, and those incarcerated in custodial facilities.

4.10Economically and socially disadvantaged people in Australia are further discussed in the following sections in this chapter. Many people who identify as socially and economically disadvantaged, also identify as elderly, Aboriginal and Torres Strait Islander, or disabled.

Low income

4.11Dental services are heavily reliant on direct spending by consumers, unlike other forms of health care such as GP consultations, pharmaceuticals and hospital care. The Grattan Institute reported that 58 per cent of all spending on dental care in Australia, was paid by consumers, which dwarfed the contributions from both governments and private health insurers.[7]

4.12Adults with low incomes are less likely to be able to pay for private health insurance, leaving them reliant on public dental services (if eligible), or paying completely out of pocket for dental services. Public dental is only available for limited selections of the population, with eligibility criteria varying between state and territory. A table of eligibility and fees by jurisdiction for public dental services can be found in Appendix 2 of the committee's Interim report.

4.13A high proportion of people in Australia skipped or delayed dental care because of the cost. Although all income levels are more likely to forego the dentist than other health care professionals, the cost of dental care affects people with low incomes more than those with higher incomes (Figure 4.1).

Source: Grattan Institute, Filling the Gap: A universal dental scheme for Australia, 2019, p. 13.

People who missed or delayed care due to cost at least once in the past 12 months, as a percentage of people who needed care, by equivalised gross household income decile. Please note the figure is for people aged 15 and over.

4.14For those who do attend the dentist, cost is still a barrier to accessing the treatment they need. It is reported that approximately one quarter of people who see a dentist do not get the recommended treatment for their condition due to cost.[8]

4.15The Consumers Health Forum of Australia reported that people on low incomes have poorer oral and dental health, compared to people who can afford regular dental services. People on low incomes are more likely to have untreated tooth decay, fewer teeth, discomfort and have trouble eating certain foods.[9]

4.16The National Child Oral Health Study follow-up in 2019–20 reported that 39.7per cent of low-income families had children with teeth removed due to dental decay, compared to only 3.7 per cent of children with high-income families.[10]

4.17For those who access dental services through public dental clinics, there is often an extremely long waitlist. The Combined Pensioners and Superannuants Association (CPSA) noted that, in January 2023, New South Wales had over 55 000 adults on their waiting list for treatment and a further 25 000 waiting for assessment.[11] Workforce issues affecting waiting list times for public dental is expanded in Chapter 5.

4.18A number of inquiry participants recommended that the public dental care system should shift to focus on preventative care, and called for the establishment of a national program that has consistent eligibility criteria and care.[12]

4.19Submitters have regularly recommended increases to funding by the Commonwealth Government for public dental services.[13] The CPSA further recommended that travel assistance schemes be incorporated into public dental services to ensure that travel costs are not a barrier to accessing dental care.[14]

Prisoners

4.20Prisoners frequently have poorer oral and dental health compared to the general population. Prisoners often come from lower socio-economic backgrounds, which impacts their access to dental services prior to being imprisoned. This results in prisoners needing higher levels of dental care and often more intensive treatment.[15]

4.21People who are incarcerated also have higher rates of tobacco smoking and high-risk alcohol consumption compared to the wider population. There is an established link between tobacco smoking and periodontal disease. TheOfficeof the Inspector of Custodial Services Western Australia (WA) reported that 82 per cent of adults in custody in WA prisons regularly smoke tobacco compared to 11 per cent out of prison.[16]

4.22When offenders who use drugs or drink more alcohol, are incarcerated and start a detoxification process, they become aware of their poor oral health. The analgesic properties of drugs and alcohol can mask oral health issues, such as gum disease. Once detoxified, prisoners often experience extreme pain and require urgent treatment.[17]

4.23In 2021, the Office of the Inspector of Custodial Services WA conducted a review into dental treatments provided by custodial services within a 12-month period. The review found that only three per cent of treatments were preventative, and 22percent were extractions. A high proportion of the extractions were related to high levels of tooth decay, which was exacerbated while in prison (Figure 4.2). The Office of the Inspector of Custodial Services WA reported that at Casuarina Prison, a prison located in Perth, that a prisoner in 2020 waited to see a dentist for several months, and while waiting their tooth had died and the only treatment option was extractions.[18]

Source: Office of the Inspector General of Custodial Services, Submission 4, p. 6.

4.24At the committee's public hearing in Perth, Ms Natalie Gibson, the acting Inspector of Custodial Services emphasised the importance of continued dental care while in prison:

… in summary, it's important to remember that often prisoners are just passing through the prison system at a point in time. They come from the community. Most will return to the community. As such, the benefits of providing prisoners with adequate and better dental health care extend well beyond their time in custody.[19]

4.25Because prisoners often have poor oral and dental health when they are incarcerated, improving access and provision of dental services for the general population would take the pressure off dental services within custodial facilities, as prisoners would need less intensive treatment.[21]

4.26The Office of the Inspector of Custodial Services WA recommended that prisons should ensure that dental and oral health staff are adequately resourced to provide targeted education and treatment to specific groups such as women and Aboriginal and Torres Strait Islander people.[22]

4.27During its site visit to Casuarina Prison, the committee heard that incarcerated Australians become ineligible for Medicare once they enter prison, as it is assumed the state will pay for their care. This places immense strain on prison health services which are not adequately resourced or staffed to handle complex medical conditions.[23]

4.28The Australian Medical Association (AMA) released a statement in 2012 arguing that this policy is unfair and further damages the health of prisoners, who are generally already socially and economically disadvantaged and suffer from poor health. The AMA recommended better resourcing for prison health care facilities, and said it believes:

prisoners and detainees have the same right to access, equity and quality of health care as the general population;

…

an adequately resourced and nationally coordinated, whole-of-government approach is needed to health in the criminal justice system, which ensures greater consistency of policies and practices across jurisdictions and better integration of health and social support services;

…

prisoners should retain their entitlement to Medicare and the Pharmaceutical Benefits Scheme (PBS) while in prison …[24]

4.29The committee recommends that the Australian Government works with states and territories to find ways to ensure access to adequate general and oral health services for people who are incarcerated.

Older people

4.30Older people[25] make up approximately 16 per cent of Australia's population and it is projected that this number will increase to over 20 per cent by 2026.[26] Oral and dental health is a major issue for older people. Oral health declines across a person's lifetime, with an increased number of dental cavities (caries) per person in relation to age and an increased likelihood of oral disease.[27]

4.31At present, many older people do not receive the routine care that is essential to maintaining good oral health. A 2023 survey conducted by COTA Australia indicated dental services were the most difficult health or medical service for older people to access. Affordability and timely access to dental and oral health services were found to be the biggest challenges impacting older people's ability to successfully manage their oral health.[28]

4.32Oral health is integral to a person's overall health and psychological wellbeing, and this becomes more significant as a person ages. Poor oral health can contribute to aspiration pneumonia, worsen diabetes, and increase the risk of heart attack, lowered immunity and stroke in older people.[29]Ms Leonie Short, Owner and Director of Seniors Dental Care Australia at the committee's public hearing in Brisbane succinctly stated the importance of oral health care for people's general health:

… don't do oral health for oral health. You're actually doing oral health care for general health. And it saves lives because poor oral health kills people.[30]

4.33This next section of the report will look at addressing unmet need for dental services for older people living in residential aged care facilities within Australia, aged care training, and the Royal Commission into Aged Care Quality and Safety's recommendation to introduce a Seniors Dental Benefits Scheme.

Residential aged care facilities

4.34The Royal Commission into Aged Care Quality and Safety Final report found significant issues regarding the provision of dental and oral health services in residential aged care facilities. The commission heard consistently that oral and dental health care is not treated as a priority for people living in residential aged care.[31]

4.35Although it was universally recognised that high-quality oral and dental care is essential for older people, and healthcare professionals understand and accept their responsibility to provide good oral care, it is often considered a lower priority than other competing healthcare demands. As it is up to the aged care providers to determine the type and level of dental care being provided to their residents, and competing demands and limited time and resources often lead to oral and dental care being neglected.[32]

4.36The Dental Hygienists Association of Australia identified the following factors impacting dental and oral health care in residential aged care facilities:

lack of legal or contractual protocols and guidelines on oral health care in residential aged care facilities;

dental practitioners' preference to work in well-equipped practices and challenges in transportation of residential aged care facilities residents to these facilities, particularly in rural and remote areas;

affordability of dental services; and

little focus on an holistic and interprofessional collaborative approach to oral health.[33]

4.37Dementia Australia emphasised the additional struggles that people with dementia face when trying to access dental services, especially in residential aged care facilities. There are several factors that contribute to the challenges of maintaining dental and oral care for people with dementia, although the main challenge is lack of care staff, dentists and other oral health professionals with dementia training.[34]

4.38People with dementia face unique challenges accessing dental care, including trouble communicating their needs; and understanding instructions; and experiencing anxiety and/or resistance when practicing oral hygiene. This can make it very difficult to maintain good oral health or accept dental treatment or care.[35]

4.39Medications used to treat people with dementia can have adverse effects on tooth decay. Dementia medications can lead to reduced saliva production in the mouth, which can lead to a condition called 'dry mouth'. As saliva is important in protecting teeth against decay, dry mouth can lead to increased risk of tooth decay. Additionally, dry mouth can lead to difficulties with wearing dentures by making them less comfortable and less secure in the mouth.[36]

4.40The above issues coupled with a diet high in sugar, which is common in residential aged care facilities, lead to an increased risk of dental and oral health problems.[37]

4.41To improve dental and oral health care in people in with dementia, increased awareness and training among aged care staff, dentists and other oral health professionals regarding the unique care required for people with dementia is essential.[38] Dementia Australia recommended that training and educational sessions are made mandatory for all care staff, including dentists and dental care staff.[39]

4.42For older people, especially those in residential aged care facilities accessibility of dental services is a major barrier. The committee heard evidence that onsite or mobile dental and oral services provide a more accessible option for residents.

4.43Mr Corey Irlam, Acting Chief Executive Officer of COTA Australia summarised this idea:

… bringing the services to the residential aged-care facility? We're seeing more and more acuity problems in people living in residential care homes. Even if we could solve the community transport problem, their physical ability to be transported out is decreasing because they're going into aged‑care homes for longer.[40]

4.44Ms Tamatha Head, the Director of Moviliti Dental Care highlighted the importance and challenges of providing mobile dental services in Queensland:

Our equipment is so portable we've got the option of bedside. We ask the facility for a room that's got privacy, handwashing facilities and power. Most of the time we're set up in hair salons. We find it's beneficial for the cognitively impaired patients—treating them on site, at the facility, where they feel safe and secure, rather than going out and into a clinical environment.[41]

4.45To support flexible care, the Royal Commission into Aged Care Quality and Safety Final report recommended multi-purpose spaces be available in residential aged care facilities to support allied health services, including dental and oral care.[42] When Ms Head was asked if the addition of multi-purpose spaces in residential aged care facilities would be beneficial, she replied 'Hugely…'.[43]

Aged care training

4.46Traditionally, the average resident in aged care facilities had no natural teeth and used dentures. However, this trend is slowly changing. The frequency of people entering residential aged care facilities with their own teeth, and restorative work such as crowns, bridges and implants is increasing. DrPeterFoltyn stated that if oral and dental health care is not prioritised, it can lead to a resident's teeth deteriorating rapidly.[45]

4.47To accommodate this change in demographics, it is crucial to provide education and training on appropriate oral and dental care to all staff and dental professionals treating residents in aged care facilities.

4.48At the committee's public hearing in Brisbane, Ms Short emphasised the importance of twice daily oral health care and how to embed these skills:

… people in aged care actually need good twice-daily oral health care. That's why, again, I'm saying 'basic and simple'. It doesn't matter what expensive, fantastic dental treatment you've had. Even if you've had very expensive dental treatment, that will break down or fail unless you receive twice-daily oral health care. That twice-daily oral health care isn't delivered by dental practitioners or nurses; it's delivered by personal carers. What we see from the lived experiences—I think Tamatha Head from Moviliti also mentioned it this morning—is that we need training of those carers in what I call best‑practice or evidence based oral health care. I think, to start with, that training has got to be done by dental practitioners—I've been lucky enough to be able to train nurses, pharmacists, social workers, aged-care workers, disability workers and allied health—and they need an updating of how oral health care has changed. We can't have the blind leading the blind. So I don't think we can just turn around and say, 'We want nurses to get better training by nurses.' We need to train the nurses first, and then the nurses and others can train the personal carers.[46]

4.49The committee heard that targeting older people well before they enter a residential aged care facility is integral to providing better oral dental health outcomes for older people.[47]

4.50To facilitate longer independent living, the committee heard evidence about the benefits of upskilling GPs or other allied health professionals. Under the Health Practitioner Regulation National Law Act 2009 doctors are allowed to conduct dentistry procedures, although this is rarely done. Upskilling GPs to complete basic dental assessments and oral hygiene education, as part of aged care assessments or regular GP visits, could provide a more accessible option for older people.[48]

4.51More information on the inclusion of oral and dental health care in the Over75Health Assessment or the assessments completed by the Aged Care Assessment Teams can be found in Chapter 3.

Seniors Dental Benefit Scheme

4.52A key recommendation from the Royal Commission into Aged Care Quality and Safety was the establishment of the Seniors Dental Benefit Scheme (SDBS) for people living in residential aged care facilities or in the community.[49]

4.53The committee heard universal support for this recommendation,[50] and that the SDBS should be a collaboration between the Australian and state and territory governments.[51]

4.54As highlighted in the committee's Interim Report, the CDBS only has an uptake of 40 per cent of eligible children.[52] Seniors Dental Care Australia emphasised the importance of communicating an SDBS to eligible participants. There is no guarantee that older people will be informed and/or want to use the services provided. Senior Dental Care Australia made suggestions to ensure the SDBS would be successful if implemented:

… a national consumer-led communication program to inform older Australians about the link between general health and oral health, and the importance of twice-daily oral health care and regular dental check-ups is required for any new scheme to be successful.[53]

4.55Chapter 6 further considers the costs and benefits of introducing a SDBS along with other proposed reform.

Aboriginal and Torres Strait Islander peoples

4.56According to the Kimberley Dental Team (KDT), Aboriginal and Torres Strait Islander people experience poorer periodontal health, have higher numbers of total caries, untreated caries, and missing teeth compared to non-Indigenous people in Australia. Furthermore, Aboriginal and Torres Strait Islander people are less likely to receive the dental and oral health care they require. [54]

4.57Barriers experienced by Aboriginal and Torres Strait Islander people include:

the disproportionate burden that socioeconomic factors have on their health outcomes;

inadequate education about oral health benefits; and

lack of access to public preventative dental services.[55]

4.58Private treatments are financially not an option for many Aboriginal and Torres Strait Islander people, and public dental services are hard to access without transport, often incur a cost, and have no facilities for parents or carers with children.[56]

4.59The National Aboriginal Community Controlled Health Organisation (NACCHO) emphasised that good oral health is essential to a person's overall health and wellbeing. Poor oral health increases the risk of dental caries and periodontal disease, which can cause permanent damage and may result in significant pain, infection, tooth loss, and deteriorated function. These issues can impact a person's ability to eat and drink properly leading to compromised nutrition.[57]

4.60NACCHO also highlighted that the impacts of poor oral health and oral disease on Aboriginal and Torres Strait Islander lives are especially prevalent, given higher rates of comorbidities such as heart disease, diabetes and cancer. This can cause a decreased quality of life and increased risk of mortality.[58]

4.61The next section of the report will examine the unmet need for dental and oral services for Aboriginal and Torres Strait Islander Australians, education and training to improve culturally appropriate care, and the particular difficulties accessing care for people who live in regional and remote Australia.

Regional and remote living

4.62Accessibility of dental and oral health services is a major factor contributing to poor oral health in Aboriginal and Torres Strait Islander populations compared to non-Indigenous populations. The National Oral Health Plan 2015–2024 reports that 43 per cent of Aboriginal and Torres Strait Islander people live in regional Australia, and 21 per cent live in very remote areas.[59]

4.63There is a correlation between declining oral and dental health as remoteness increases. This correlation can be attributed to numerous factors such as:

reduced access to fluoridated drinking water;

increased levels of food insecurity;

increased consumption of carbonated drinks; and

limited local availability of dental services, including limited transport options to travel to receive care.[60]

4.64KDT, who have been providing volunteer based dental services to Aboriginal communities located in the Kimberley region of Western Australia since 2009, emphasised the severity of poor oral health in this region:

The severity of dental ill health was apparent to the KDT upon its first visit fifteen years ago, with almost all children and adults seen by the volunteer dental personnel reporting pain and having significant dental health problems. In the early years of KDT's operation, 55 per cent of treatments were surgical (i.e., extraction of teeth) and 32 per cent were restorative (i.e.,fillings).[61]

4.65National data shows the rate of potentially preventable hospitalisations due to dental conditions is higher for people who live in regional and remote areas of Australia, and for Aboriginal and Torres Strait Islander Australians. Rates for potentially preventable hospitalisations due to dental conditions are especially high for children living remotely and/or Aboriginal and Torres Strait Islander children under ten years of age.[63] Specifically in the Northern Territory (NT), health services see Aboriginal and Torres Strait Islander children under 5 years hospitalised for dental conditions at 4.5 times the rate of non-Aboriginal children.[64]

4.66For those living in regional and remote Australia, workforce is a major barrier to accessing dental care. In central Australia, there are only five state funded dentists. Although they have the capacity to travel remotely, there is no timetable for their visits and limited communication with service providers in these areas. The committee heard that there is the infrastructure available, but no dentists visit:

We've got dental chairs even in Kaltukatjara, Docker River, which is 770kilometres south-east of here. We've got two dental chairs. We took over that clinic a few months ago and asked them the last time they had seen a dentist. It was more than 12 months.[65]

4.67The Aboriginal Medical Services Alliance Northern Territory (AMSANT) recommended that the government provide targeted funding to improve oral health in Aboriginal people, proportionate to the scale of the need and the increased cost of service delivery in rural, remote and very remote areas. It also recommended that the CDBS be increased to one and half times the current rate in remote and very remote communities.[66]

4.68The Central Australian Aboriginal Congress recommended community controlled health services should become the preferred providers of government funded oral health services, especially in rural and regional areas of Australia.[67]

4.69Workforce issues will be further explored in Chapter 5.

Water fluoridation

4.70It is well recognised that water fluoridation programs are effective in reducing the rates of dental decay. A review undertaken by the National Health and Medical Research Council found that water fluoridation reduces dental decay by 26 to 44 per cent in children and 27 per cent in adults, and that there is no evidence that fluoridated water causes any health-related harm.[68] Access to fluoridated water in Australia differs depending on location because it has not been implemented consistently across all of Australia.[69]

Source: The University of Adelaide, Dental Practice Education Research Unit, Water fluoridation maps (accessed13October2023).

Note: Amount of fluoride added to public water in parts per million (ppm) by postcode in Australia in 2012, noting there has not been a fluoridation update since 2012.

4.71Aboriginal and Torres Strait Islander Australians are more likely to live in areas where water fluoridation has stopped, or in areas where fluoridation was never implemented. In the NT, only communities with a population of 600 and above qualify for water fluoridation programs, although not all eligible communities have had their water fluoridated.[70] It was reported that 13communities in the NT with a population of over 600 have not had their water fluoridated.[71] Therefore smaller remote communities, which are often Aboriginal communities, have an increased risk of oral disease coupled with decreased access to dental services.

4.72The committee heard evidence that water fluoridation is an issue even in larger towns in the NT:

… in Alice Springs they defluoridated the water back in 1988 for very questionable reasons. The average fluoride level here in Alice Springs, the natural fluoride, over the last seven years is 0.49 parts per million, which is well below the minimum level that is acceptable. If we're really going to prevent tooth decay, it should be about eight parts per million.[72]

4.73For communities that are unable to receive fluoridated water, fluoride varnish provides an alternative preventative treatment for Aboriginal and Torres Strait Islander children living remotely. Fluoride varnish can help prevent tooth decay, slow it down or prevent it from getting worse by temporarily strengthening tooth enamel. Fluoride varnish treatment requires accredited training, and for trained professionals to be available to provide treatment every six months.[73]

4.74The Aboriginal Health Council of WA recommended that Aboriginal Health Workers and Practitioners be allowed to provide fluoride varnish programs to help reduce tooth decay and dental disease for Aboriginal and Torres Strait Islander people, especially those living in regional and remote areas of Australia.[74]

Diet and Nutrition

4.75NACCHO reported that 41 per cent of total energy intake for Aboriginal and Torres Strait Islander people is derived from discretionary food and drink items. These discretionary food and drink items are often high in fat, salt, and sugar. The consumption of carbohydrate-based foods, sweetened beverages, and reduced consumption of fruits and vegetables, leads to a substandard dietary intake.[75]

4.76Sweetened beverages are a large contributor to additional sugar in people's diets and negatively affect a person's oral health. They are one of the leading contributors to tooth decay, given that they contain acid that weakens tooth enamel, and produce more acid when the sugar combines with bacteria in the mouth.

4.77For remote Aboriginal and Torres Strait Islander communities, a lack of access to clean drinking water can encourage the consumption of packaged drinks, commonly sweetened beverages. Dr Dawn Casey, from NACCHO stated: '… around 250,000 of Aboriginal and Torres Strait Islander people are not able to access safe drinking water in their communities'.[76]

4.78A study conducted from 2014 to 2018 looked at the positive impact of installing refrigerated, filtered water fountains in schools and communities of a rural town in NewSouth Wales. Over the four years, the study found there was a significant improvement in levels of tooth decay, oral health behaviours, and a reduction of oral health conditions.[77]

4.79The Central Australian Aboriginal Congress suggested that developing a sugar tax alongside a healthy food subsidy model would aid in increasing the consumption of healthy foods and decrease the consumption of high sugar, nutrient-poor foods.[78]

4.80The Australian Dental Association (ADA) also supported the introduction of a sugar tax or a levy on sugary drinks, combined with changing food-labelling laws to require that added sugars be clearly listed on all packaged food and drink products through front-of-pack labelling.[79]

Culturally safe care

4.81The committee heard the dental and oral health needs of Aboriginal and Torres Strait Islander people are unmet due to inadequate and sporadic funding of dental services and the failure to provide services in a culturally safe environment.

4.82At the committee's public hearing in Perth, Dr Daniel Hunt, Deputy Medical Director from Derbarl Yerrigan Health Service (Derbarl Yerrigan) described how services should be integrated to ensure a culturally secure setting for dental and oral health services:

… What it looks like is care that is provided within an Aboriginal community-controlled healthcare service. It is a service that is governed and run by Aboriginal people. Currently about 67 per cent of our staff are Indigenous. That's what it looks like. It provides an environment that is welcoming to the patients. Our patients have very unique needs, whether they be cultural or socioeconomic, and we tailor our approach to them. Our patients come to us because we provide care. Patients are very happy to have an Aboriginal doctor see them. When I was working as a dentist, they're having an Aboriginal dentist. It ensures that there are Aboriginal staff at every step of the way on the healthcare journey that our patients have… It is having someone there who fundamentally understands the patients and understands the cultural safety that they need.[80]

4.83Derbarl Yerrigan has a specific model of holistic primary care for Aboriginal and Torres Strait Islander people. They have an integrated dental oral health model, that incorporates dental clinics within culturally safe and holistic primary health care. All patients that need dental oral health services are assessed first by Aboriginal health practitioners and GPs to review their individual health needs. This provides a unique opportunity for engagement with health services and early intervention for the management of chronic disease. Dentists and GPs work together to ensure the overall health care needs of patients are addressed and managed holistically.[81]

4.84Despite the success of the Derbarl Yerrigan model, it acknowledged the funding and resource barriers it faces when providing care. Currently, it turns away one in three patients due to lack of appointments, is not funded to provide services to children, and predominantly provide palliative dental services. Less than one quarter of patients receive preventative treatments such as a cleaning or fluoride treatment. Derbarl Yerrigan is concerned about the sustainability of its services as there currently is no long-term funding.[82]

4.85The committee heard evidence about the benefits of an Aboriginal health worker and practitioner. The Aboriginal Health Council of WA described an Aboriginal worker as Aboriginal staff from the local community, who are embedded in an Aboriginal community-controlled health service (ACCHS) and are also clinically trained. An Aboriginal health worker or practitionercould assist with bridging the gap in the current workforce. It could be particularly helpful in regional and remote parts of Australia, where there are shortages of health care professionals.[83]

4.86At the committee's Canberra public hearing, Dr John Boffa from the Central Australian Aboriginal Congress Aboriginal Corporation emphasised the importance of community controlled health care in providing culturally safe care for Aboriginal and Torres Strait Islander people:

Fund community controlled health services and the service will be culturally safe because they will make sure it is. Attempts to train health professionals to be culturally safe are only as good as the organisations they are ultimately working in and the environments they are working in. Community controlled health care is a way to achieve cultural safety.[84]

Aboriginal Community Controlled Health Services/Organisations

4.87ACCHS's or Aboriginal community-controlled health organisations (ACCHOs) are an important delivery system for evidence-based, culturally appropriate services, and trauma informed care that addresses the health needs of Aboriginal communities. This model of service aims to build ongoing relationships that give continuity of care so that chronic conditions are managed, and preventative health is targeted.[85]

4.88The Central Australian Aboriginal Congress Aboriginal Corporation emphasised the following structural advantages in the ACCHS delivery model, that lead to improved health outcomes compared to alternative services:

a holistic approach to service delivery;

culturally responsive services;

better access, based on community engagement and trust;

Aboriginal governance;

an Aboriginal workforce; and

high levels of accountability.[86]

4.89ACCHOs are the preferred model of health care delivery for Aboriginal and Torres Strait Islander people. NACCHO reported that 50 per cent of Aboriginal and Torres Strait Islander people prefer to attend an ACCHO compared to a non-Indigenous health care facility.[87]

4.90Currently, dental services are not offered at every ACCHO, however, they are increasingly being offered. In 2020–21, NACCHO reported that there were approximately 70 000 dental service clients of ACCHOs nationwide. These services were provided by 140 paid dentists and dental support staff, however approximately 40 staff were unpaid. NACCHO attributed this increase to the shifting of resources to accommodate the high demand for dental services and are undertaking these services without enough funding to support the demand.[88] To support the increased demand for dental services, NACCHO recommended needs-based funding for ACCHOs to deliver oral health services to Aboriginal and Torres Strait Islander people.[89]

4.91Derbarl Yerrigan similarly recommended that Aboriginal and Torres Strait Islander people's access to dental and oral health care be enabled through dedicated funding of dental services for ACCHS' and ACCHOs across the country.[90]

4.92To increase cultural awareness and safety in mainstream dental services, the Victorian Aboriginal Community Controlled Health Organisation Inc expressed its willingness to promote cultural safety in non-Aboriginal services through partnership and information sharing. Prioritising Aboriginal and Torres Strait Islander values within mainstream dental services with assistance from ACCHOs could result in more equitable access to dental services.[91]

4.93Tranexamic acid (TXA), which is typically used to stop persistent oral or dental bleeding during minor dental procedures is currently not available through the Pharmaceutical Benefits Scheme (PBS) for dentists. Dentists can access TXA privately; however, it is costly and requires preparation for oral use. This can stop dental practitioners carrying this medication and may mean dental practitioners don't feel comfortable performing certain procedures. NACCHO expressed concern that the PBS' restriction on TXA impinges on the ability of ACCHOs to provide effective and appropriate care those seeking dental care. NACCHO recommended that expanding the PBS to provide access to TXA to dentists would be a simple reform to enable better care for Aboriginal and Torres Strait Islander people.[92]

Disabled people

4.94Disabled people, particularly those with an intellectual disability, experience poorer oral and dental health, greater unmet treatment needs, and less regular dental attendance compared to non-disabled people in Australia. The committee heard this indicates that access to and provision of dental services in Australia is insufficient for disabled people.[93] The Geelong Parent Network emphasised that dental disease is seven times more common in disabled people compared to the general population.[94]

4.95A joint submission by the Australian Federation of Disability Organisations (AFDO), Children and Young People with Disability Australia (CYDA), Down Syndrome Australia, and Inclusion Australia noted the following barriers disabled people face when accessing dental services in Australia (Figure 4.4):

Source: AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 15.

4.96Disabled people are more likely to have poor oral health which can lead to the following illnesses and issues:

sepsis;

compromised airways and swallowing issues;

oral cancers;

diabetes;

stroke; and

cardiovascular disease.[95]

4.97Furthermore, poor oral health can cause economic, emotional and social challenges. These challenges include:

poor self-esteem;

reduced ability to communicate comfortably;

increased social isolation;

difficulties obtaining and maintaining employment;

chronic pain and discomfort;

trauma as a result of distressing and invasive treatments; and

increased economic burden on both the disabled person and their family.[96]

4.98The committee heard that people with intellectual disabilities face additional risks of developing oral health problems, which could be related to decreased regular oral hygiene practice; reduced swallowing and eating functions; teeth grinding; and medications that can affect saliva production.[97]

4.99The following section will look at addressing the unmet need for dental services for disabled people in Australia, including access and alternatives to general anaesthesia (GA), and disability training and upskilling.

National Disability Insurance Scheme

4.100Currently, there are approximately 550 000 participants receiving funding under the National Disability Insurance Scheme (NDIS), compared to the total 4.4million disabled people living in Australia.[99] For those eligible for NDIS funding, there is uncertainty on what services are available under the scheme.

4.101At the committee's Canberra public hearing, Ms Clair Wheeler from the National Disability Insurance Agency (NDIA), outlined the limitations on accessing assistance for dental treatment under the (NDIS):

The NDIA administers the NDIS based on the [National Disability Insurance Scheme Act 2013] and the rules. The rules at the moment specifically state that dental treatment is not funded. However, we do provide a range of supports to help participants maintain their oral and dental health—so personal care activities that can help them with teeth brushing and flossing. We can also provide supports to help people travel to appointments and to be at those appointments with them to help with communication or to help them manage anxiety or behaviours of concern.[100]

4.102Ms Wheeler further clarified that, although the NDIS does not support dental treatment, it can provide funding support for 'assistive technologies' that support disabled people with maintaining their oral health:

There is a particular guideline about assistive technology. The position would be, if someone needed an adapted toothbrush so that they could care for their own dental health, brush their own teeth, that would be considered a reasonable and necessary support, because it's technology that allows them to perform personal care and activities of daily living… A toothbrush that helps you brush your own teeth would not be considered to be dental treatment; it would be considered something that helps you to maintain your overall health and wellbeing and activities of daily living.[101]

4.103This contrasts with evidence the committee heard from Clinical Associate Professor Matthew Lim who said it is 'nearly impossible' for a disabled person to get funding for an electric toothbrush that is recommended by a dentist to provide easier oral care.[102]

4.104Clinical Associate Professor Lim expanded on these conflicting statements saying rules for approval of supports related to oral health and dental care are inconsistently applied, with the individual needs of applicants not always assessed.[103] The inconsistency of NDIS support approvals indicates there could be insufficient guidelines or training for NDIS staff who are approving applications.

4.105At the Canberra public hearing, committee members questioned Australian Government officials about the blanket ban on supporting GA under the NDIS. Ms Wheeler and Mr Peter Broadhead, from the Department of Social Services, advised the committee that dental treatment under GA is not supported by the NDIS as it is considered a dental treatment, more appropriately provided by the health system, and not a reasonable and necessary support the NDIS should fund.[104]

4.106The OneOneTwelve Initiative recommended an increased role for the NDIS in dental and oral health care. Allowing simple oral health procedures, such as check-ups, assessments and descaling, to form part of the NDIS plan would provide greater opportunity for comprehensive health care in general. Including prevention measures under the NDIS could significantly reduce the burden on the current dental system, and specifically reduce the frequency of intensive treatment and the need for GA.[105]

General anaesthesia

4.107The committee has heard that there are inadequate sedation pathways available for disabled people in Australia. Sedation offers a way to minimise distress and anxiety surrounding dental and oral health procedures. Although, in some cases reasonable adjustments can be made to avoid the use of sedation, there are cases where sedation is the only option.[106]

4.108At its public hearing in Canberra, the committee heard that often GA is recommended for disabled people even in situations when it is not required. The waitlist for procedures under GA is much longer than treatments in clinics, and therefore dental problems are exacerbated while waiting for treatment underGA:

…one woman said that she had been on the wait list for two years for some work she needed to have done. She had been told it needed to be done under general anaesthetic. She wasn't sure why. She didn't want the general anaesthetic, so she was anxious about going to the dentist. She was also anxious, quite rightly, about the general anaesthetic. Her condition was worsening… In the process of talking to me, she told me, 'I had my wisdom teeth out at the dentist when I was 18. I don't see why we can't do it again.' I said, 'Was that put to you as an option?' It appeared that it wasn't. She is a self-advocate. After our conversation, she went back to the public dental clinic and got herself a voucher. She went to a dentist and said, 'This is what I need. I need to do it in small doses. I need to start with something where it is easy.' They did that. Now she is no longer on the wait list for a general anaesthetic because she's had all of the work done in a local clinic.[107]

4.109Clinical Associate Professor Mathew Lim emphasised that disabled people should be given the choice to have their procedure under GA or not:

If you or I were going to have our wisdom teeth out, we could choose to have it done under local anaesthetic, but the vast majority of people would choose to have it under general anaesthetic. Why should that be different for a person with a disability? I think it is about having a spectrum and range of services so that there's something at every step along the way to adjust to what every individual person's needs are.[108]

4.110The joint submission by ADFO, CYDA, Down Syndrome Australia and Inclusion Australia supported this point, saying disabled people should be offered a variety of sedation options, or the choice to forgo sedation. Disabled people should be able to provide informed consent about sedation options to the maximum extent possible.[109]

Special Needs Dentists

4.111The committee heard evidence about the importance of Special Needs Dentistry (SND), recognising that not all disabled people need specialist care. Dr Avanti Karve, President Elect of the Australia and New Zealand Academy of Special Dentistry highlighted:

Not all patients with special health needs need specialist care. Many can access care in the community if 'reasonable adjustments' are made to ensure equity of access to care. We need more interest from general dental practitioners … so specialist practice is reserved for the most complex and medically unwell.[110]

4.112This sentiment was echoed by Mr Luke Nelson, Policy Officer with Inclusion Australia at the committee's public hearing in Canberra:

We believe that people with disabilities should not have to rely on having specialised care to get their oral health needs met. We have the right to be able to access care in the community on an equal basis with others.[111]

4.113As mentioned above, not all disabled people require specialised treatment and can be treated in general dental practice settings with reasonable adjustments, however it can be difficult to find a general dentist willing to treat disabled people without referring to a specialist. The committee heard evidence that there are a range of assumptions, such as that a disabled person cannot understand, has behavioural concerns, high levels of anxiety and cannot be appropriately cared for in general dentist practice settings.[112]

4.114Mr Nathan Despott from Inclusion Melbourne emphasised that even a small amount of preplanning and preparation can lead to a substantial increase in confidence by general dentists treating disabled people, and for disabled people themselves to feel comfortable receiving treatment from general dentists.[113]

4.115The joint submission by AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia highlighted a best practice scenario that looks at the collaboration between SND specialists, and community dental clinics, to enable support and upskilling for practitioners treating disabled people in a community setting. As a result, more people are able to be treated locally, with only more complex cases referred to specialist services.[114]

4.116It was recognised that upskilling dentists to treat disabled people was not included in sufficient detail in the current National Oral Health Plan. The joint submission by AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia notes that it should be added as a matter of urgency, and actualised through collaboration between governments, dental professionals, and the disability support section.[115]

Child Dental Benefits Schedule

4.117The Report on the Fifth Review of the Dental Benefits Act 2008 (the review) identified inequalities under the CDBS experienced by children from the following priority groups—Aboriginal and Torres Strait Islander children, children living in rural and remote areas of Australia, and disabled children. The review reported that these children experience significant barriers accessing appropriate dental services under the CDBS.[116]

4.118The Royal Australasian College of Physicians (RACP) reported that the CDBS attendance rate of Aboriginal and Torres Strait Islander children are 31percent lower than that of non-Aboriginal children. RACP attributed the lower attendance to:

geographical challenges in accessing dental services;

lack of culturally safe care; and

low promotion and access to information about the service.[117]

4.119For children living in rural and remote areas of Australia, availability of dentists is a major barrier to accessing services under the CDBS. The Aboriginal Health Council of WA highlighted that the biennial cap is insufficient to pay for the costs associated with traveling to and from treatment or the operation of the remote child dental program, resulting in a disincentive for dentists to practice in these areas.[118]

4.120For disabled children who cannot undergo dental treatment without sedation, treatment under GA may be required. However, despite being eligible for the CDBS, they are not covered for treatments provided under GA. This leaves parents having to fund a hospital stay and anaesthetist fees—sometimes even when services are being provided in a public hospital.[119]

4.121At the committee's public hearing in Brisbane, Dr Peter King, a retired special needs dentist, emphasised the inequality that is experienced by disabled children under the CDBS:

It seems so unfair that a child with a disability who has a toothache can't use the CDBS under general anaesthetic, whereas a child with a toothache who can cope with sitting in a chair and getting the tooth removed can access CDBS. That's an inequality that I hope can get sorted out.[120]

4.122The ADA recommended the inclusion of the dental component of in-hospital treatment under GA within the CDBS.[121]

4.123The review recommended that the CDBS be modified to improve service access for priority groups, by:

working alongside ACCHOs to determine the level of unmet demand for dental services for Aboriginal and Torres Strait Islander children and using this information to inform activities to improve access to services, and to support CDBS service delivery to Aboriginal and Torres Strait Islander children;

expanding promotion of the CDBS, including targeting priority groups through culturally-safe campaigns, and publishing materials for culturally and linguistically diverse groups;

working with states and territories to improve access to free public sector in‑hospital GA services for disabled children, where clinically appropriate; and

double the benefit cap for disabled children.[122]

4.124Other recommendations contained in the review include:

implementation of strategies to improve utilisation of the CDBS and service delivery for eligible children;

expanding the Schedule to include a selection of preventative treatments, such as oral hygiene instruction; and

adding teleconsultations to the Schedule.[123]

4.125The full list of the review's 21 recommendations can be found on the Department of Health and Aged Care website.

Committee view

4.126Australia's National Oral Health Plan 2015–2024 identified four priority groups that had the highest burden of poor oral health and who experienced the greatest barriers when accessing dental and oral health care in Australia. The National Oral Health Plan is due to expire in 2024, and the committee is concerned about the lack of progress made towards the sixfoundation areas identified in the plan. The committee has consistently heard that the four priority population groups identified in the plan still do not have adequate, timely access to dental and oral health services.

4.127Many adults with low incomes cannot afford private health insurance which leaves them reliant on public dental services, if eligible, or paying for dental and oral health services completely out of pocket. The committee is concerned about the proportion of people in Australia who delay or avoid seeing the dentist due to cost. For those eligible for public dental services there are extremely long wait times, androutine and preventative care is deprioritised.

4.128Although it is consistently recognised that high-quality oral and dental health care is essential for older people, it is often considered a lower priority compared to other competing health demands. The Royal Commission into Aged Care Quality and Safety recommended the establishment of a Senior Dental Benefits Schedule to address the dire state of oral health among aged care facility residents, in particular. This option was supported by many inquiry participants and is costed and discussed in Chapter6 of this report.

4.129The committee recommends that the Australian Government implements the oral health care recommendations from the Royal Commission into Aged Care Quality and Safety.

4.130The committee recommends that the Australian Government considers the establishment of a Seniors Dental Benefit Scheme.

4.131The disproportionate level of poor oral health among Aboriginal and Torres Strait Islander people, particularly those in regional and remote areas, is unacceptable and must be addressed. With almost half of all Aboriginal and Torres Strait Islander people living in regional and remote parts of Australia, many Indigenous Australians lack access to even basic oral health care, and many experience compounding factors that increase the likelihood of disease.

4.132The committee heard there is a shortage of culturally safe care, which further impacts access to dental services for Indigenous people. Aboriginal community controlled health care offers an appropriate way to provide culturally safe dental care and improve outcomes for Aboriginal and Torres Strait Islanders.

4.133The committee recommends that states and territories take into account the need for culturally safe and effective treatment for Aboriginal and Torres Strait Islander Australians.

4.134The committee would support an initiative aimed at upskilling general health care providers in delivering basic and preventative oral health services including, check-ups; cleaning; fluoride application; assessments and referrals; and fissure sealants.

4.135The committee recommends that the Australian Government works with state and territory governments to revise state-based legislation and regulations that prevent non dental health professionals from applying fluoride varnish treatments and fluoride salts, including in regional and remote areas of Australia.

4.136The committee recommends that the Australian Government examines the potential use of fluoride salts in areas that cannot have fluoridated water.

4.137Governments should also work to implement simple, inexpensive reforms that would remove barriers for Aboriginal people, such as by allowing ACCHOs to have access to Tranexamic acid under the PBS.

4.138The committee recommends that the Australian Government investigates expanding access to Tranexamic acid to dentists, such as by adding Tranexamic acid mouthwash to the Pharmaceutical Benefits Scheme.

4.139The committee is deeply concerned about insufficient access to dental and oral health services for disabled people in Australia. Disabled people may experience significant barriers when trying to access dental services, including a lack of accessible and appropriate services. The committee was surprised to learn that there are only 26 practicing special needs dentists in the whole of Australia, with some state and territories having none.

4.140Poor access to dental services for disabled people is exacerbated by an inconsistent approach to funding oral health-related supports under the NDIS. NDIA staff who are approving applications for support must be provided with clear and consistent guidance on what can be funded under the NDIS to avoid the current inconsistency and confusion.

4.141The committee recommends that the National Disability Insurance Agency clarifies that dental and oral health supports that are directly required because of a person's disability can be funded under the National Disability Insurance Scheme (NDIS), and provides specific training and guidance for NDIS decision makers. The kinds of supports that could be funded include:

oral splints that assist with speaking or swallowing;

modified toothbrushes and flossing devices; and

any other reasonable and necessary oral health care consumables.

4.142The committee acknowledges that not all disabled people are eligible for the NDIS, and supports recommendations aimed at upskilling all oral health practitioners to provide care for disabled people. This would enable disabled people to access more timely, local care, where appropriate.

4.143 The committee recommends that the Australian Government supports the dental industry to incorporate new training and competency requirements for dentists and other oral health professionals in treating people with disabilities and complex needs.

4.144The committee recommends that the Australian Government makes the necessary changes to National Disability Insurance Scheme (NDIS) regulations to allow assessment, recommendations, and support to be provided by dental hygienists, oral health therapists and other oral health professionals, under the NDIS, for people whose disability directly impacts their oral health.

4.145The committee notes the recommendations in the Report on the Fifth Review of the Dental Benefits Act 2008. These recommendations can be progressed now, without waiting for the broader national reform process to be completed. The committee was encouraged to hear that the Department of Health and Aged Care is redesigning the letter that goes out to eligible families to tell them about the CDBS. The committee encourages the Australian Government to further invest in promoting the CDBS, and implement creative, integrated approaches, such as using GPs to promote the scheme to their patients.

4.146The committee recommends that the Australian Government implements the recommendations from the Report on the Fifth Review of the Dental Benefits Act 2008.

4.147The committee recommends that the Australian Government develops a plan and timeline to expand access to the Child Dental Benefits Schedule to all children, over time, initially targeting better access for disadvantaged and vulnerable children.

4.148The committee recommends that the Australian Government introduces a remote area loading for services delivered under the Child Dental Benefits Schedule in remote and very remote areas of Australia.

4.149Governments must also work together to find the most appropriate solution to funding GA and other forms of sedation for affected disabled people. Where state and territory health systems are unable to fund timely, accessible dental treatment for disabled people, including sedation when required, the NDIS should fund it. Sedation should be seen as 'a reasonable adjustment' to enable a person with a disability to access critical oral health care; it should also be funded for children under the CDBS.

4.150The committee recommends that the Australian Government works with the states and territories to ensure access to general anaesthetic, and other forms of sedation, can be provided in an accessible and timely way. This will support access to dental care for persons with disabilities and/or complex needs who require sedation.

4.151Regardless of any reforms that may ultimately be supported by governments as part of the current national reform process, the need for specific initiatives to support these priority groups will remain. The next National Oral Health Plan must be developed in close consultation with experts, key organisations, and those with lived experience, and must be evidence-based.

Footnotes

[1]Council of Australian Governments (COAG) Health Council 2015, Healthy Mouths, Healthy Lives: Australia's National Oral Health Plan 2015–2024, 17 February 2016 (last updated 8 May 2023), p. viii (accessed 27 October 2023).

[2]COAG Health Council 2015, Healthy Mouths, Healthy Lives: Australia's National Oral Health Plan 2015–2024, 17 February 2016 (last updated 8 May 2023), p. ix (accessed 27 October 2023).

[3]Deakin Health Economics, Submission 10, [p. 4].

[4]Select Committee into the Provision of and Access to Dental Services in Australia, Interim report,June 2023.

[5]Australian Islamic Medical Association, Submission 168, p. 1; Professor Jane Hall, Professor MichaelWoods, Professor Kees van Gool and Dr Phillip Haywood, Submission 134, p. 2; and Department of Health and Aged Care, Submission 18, p. 5.

[6]DHAA, Submission 38, p. 2.

[7]Grattan Institute, Filling the Gap: A universal dental scheme for Australia, 2019, p.10 (accessed 1November 2023).

[8]Grattan Institute, Filling the Gap: A universal dental scheme for Australia, 2019, p. 16.

[9]Consumers Health Forum of Australia, Submission 13, p. 8; Grattan Institute, Filling the Gap: A universal dental scheme for Australia, 2019, p. 18.

[10]Population Oral Health at University of Queensland, Submission 103, p. 1.

[11]Combined Pensioners and Superannuants Association (CPSA), Submission 119, p. 5.

[12]CPSA, Submission 119, p. 4.

[13]National Oral Health Alliance (NOHA), Submission 15, p. 1; National Rural Health Alliance, Submission 105, p. 2; CPSA, Submission 119, p. 4.

[14]CPSA, Submission 119, p. 4.

[15]Office of the Inspector of Custodial Services Western Australia (WA), Submission 4, p. 4.

[16]Office of the Inspector of Custodial Services WA, Submission 4, p. 4.

[17]Office of the Inspector of Custodial Services WA, Submission 4, p. 4.

[18]Office of the Inspector of Custodial Services WA, Submission 4, p. 6.

[19]Ms Natalie Gibson, Acting Inspector of Custodial Services, Office of the Inspector of Custodial Services WA, Committee Hansard, 14 August 2023, p. 2.

[20]Australian Dental Prosthetics Association, Submission 24, p. 11.

[21]Ms Gibson, Office of the Inspector of Custodial Services WA, Committee Hansard, 14 August 2023, p. 4.

[22]Office of the Inspector of Custodial Services WA, Submission 4, pp. 2–3 and 9.

[23]See Appendix 4, p. 4.

[24]Australian Medical Association (AMA), Position Statement on Health and Criminal Justice System, 2012, p. 4 (accessed 21 November 2023).

[25]The definition of 'older' varies depending on the organisation. COTA Australia classifies 'older' as people over 50, and the Australian Bureau of Statistics and Australian Institute of Health and Welfare classify 'older' as people 65 and older.

[26]Australian Dental Foundation (ADF), Submission 14, p. 4.

[27]Australian Healthcare and Hospitals Association, Submission 76, p. 6.

[28]COTA Australia, Submission 11, p. 5.

[29]ADF, Submission 14, p. 4.

[30]Proof Committee Hansard, 20September 2023, p. 36.

[31]Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect, 1March 2021, pp. 117–120 (accessed 16 October 2023).

[32]Dental Hygienists Association of Australia (DHAA), Submission 38, [pp. 2–3].

[33]DHAA, Submission 38, [p. 2].

[34]Dementia Australia, Submission 9, p. 4.

[35]Dementia Australia, Submission 9, p. 5.

[36]Dementia Australia, Submission 9, p. 5.

[37]Dementia Australia, Submission 9, p. 4.

[38]Dementia Australia, Submission 9, p. 4.

[39]Dementia Australia, Submission 9, p. 9.

[40]Proof Committee Hansard, 20September2023, p. 39.

[41]Proof Committee Hansard, 20 September 2023, p.9.

[42]Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect, 1March 2021, pp. 24–25.

[43]Ms Tamatha Head, Director, Moviliti Dental Care, Committee Hansard, 20 September 2023, p. 9.

[44]Seniors Dental Care Australia & Aged Care Reform Now, joint document (received 18September2023).

[45]Dr Peter Foltyn, Submission 12, [p. 4].

[46]Ms Leonie Short, Director and Owner, Seniors Dental Care Australia, Proof Committee Hansard, 20September 2023, pp. 35–36.

[47]Ms Head, Moviliti Dental Care, Proof Committee Hansard, 20 September 2023, p. 8.

[48]Ms Short, Seniors Dental Care Australia, Proof Committee Hansard, 20September 2023, p. 37.

[49]Royal Commission into Aged Care Quality and Safety, Final Report: List of Recommendations, 1March2021, p. 249.

[50]See for instance: Seniors Dental Care Australia, Submission 3, p. 9; COTA Australia, Submission 11, pp. 3–4; Aged Care Reform Now, Submission 95, p. 7; Public Health Association of Australia, Submission 26, pp. 3–4; and NOHA, Submission 15, p. 1.

[51]COTA Australia, Submission 11, p. 3.

[52]Select Committee into the Provision of and Access to Dental Services in Australia,Interim Report, 20June 2023, p. 18.

[53]Seniors Dental Care Australia, Supplementary Submission 3.1, p. 1.

[54]Kimberley Dental Team Ltd (KDT), Submission 46, p. 2.

[55]Derbarl Yerrigan Health Services (Derbarl Yerrigan), Submission 29, [p. 2].

[56]Derbarl Yerrigan, Submission 29, [p. 2].

[57]National Aboriginal Community Controlled Health Organisation (NACCHO), Submission 63, p. 5.

[58]NACCHO, Submission 63, p. 5.

[59]COAG Health Council 2015, Healthy Mouths Healthy Lives - Australia’s National Oral Health Plan 2015–2024, 17 February 2016 (last updated 8 May 2023), p. 55 (accessed 12 October 2023).

[60]KDT, Submission 46, p. 2.

[61]KDT, Submission 46, p. 2.

[62]KDT, Submission 46.1, [p. 1].

[63]Australian Institute for Health and Welfare,Oral health and dental care in Australia, Aboriginal and Torres Strait Islander Australians, 17 March 2023 (accessed13 October 2023).

[64]Aboriginal Medical Services Alliance Northern Territory (AMSANT), Submission 66, p. 2.

[65]Dr John Boffa, Chief Medical Officer, Central Australian Aboriginal Congress Aboriginal Corporation, Proof Committee Hansard, 20 October 2023, p. 29.

[66]AMSANT, Submission 66, p. 1.

[67]AMSANT, Submission 66, p. 1.

[68]National Health and Medical Research Council, Public Statement 2017: Water Fluoridation and Human Health in Australia, p. 2 (accessed 13 October 2023).

[69]NACCHO, Submission 62, p. 13.

[70]NACCHO, Submission 62, p. 13.

[71]AMSANT, Submission 66, p. 3.

[72]Dr Boffa, Central Australian Aboriginal Congress Aboriginal Corporation, Proof Committee Hansard, 20 October 2023, p. 28.

[73]AMSANT, Submission 66, p. 3.

[74]Aboriginal Health Council of Western Australia (WA), Submission 104, pp. 12–13.

[75]NACCHO, Submission 62, p. 12.

[76]Dr Dawn Casey, Chief Executive Officer, NACCHO, Proof Committee Hansard, 20 October 2023, p.27.

[77]NACCHO, Submission 62, pp. 12–13.

[78]Central Australian Aboriginal Congress, Submission 65, p. 3.

[79]Australian Dental Association (ADA), Submission 19, pp. 21–22.

[80]Dr Daniel Hunt, Deputy Medical Direction, Derbarl Yerrigan, Committee Hansard, 14 August 2023, p. 23.

[81]Derbarl Yerrigan, Submission 29, [pp. 2–3].

[82]Derbarl Yerrigan, Submission 29, [p. 3].

[83]Ms Kim Brewster, Senior Policy Advisor, Aboriginal Health Council of WA, Committee Hansard, 13 August 2023, p. 23.

[84]Dr Boffa, Central Australian Aboriginal Congress Aboriginal Corporation, Proof Committee Hansard, 20 October 2023, p. 30.

[85]NACCHO, Submission 63, p. 6.

[86]Central Australian Aboriginal Congress Aboriginal Corporation, Submission 65, pp. 7–8.

[87]NACCHO, Submission 63, p. 6.

[88]NACCHO, Submission 63, p. 6.

[89]NACCHO, Submission 63, p. 7.

[90]Derbarl Yerrigan, Submission 29, [p. 3].

[91]Victorian Aboriginal Community Controlled Health Services Inc, Submission 69, p. 4.

[92]NACCHO, Submission 63, p. 10.

[93]Australian Federation of Disability Organisations (AFDO), Children and Young People with Disability Australia (CYDA), Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 11.

[94]Geelong Parent Network, Submission 2, p. 2.

[95]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 15.

[96]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 15.

[97]Geelong Parent Network, Submission 2, p. 2.

[98]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 44.

[99]The OneOneTwelve Initiative, Submission 69, p. 5.

[100]Proof Committee Hansard, 20 October 2023, p. 42.

[101]Ms Clair Wheeler, Branch Manager, Service Guidance and Practice, National Disability Insurance Scheme (NDIS), Proof Committee Hansard, 20October 2023, pp. 44–45.

[102]Clinical Associated Professor Matthew Lim, Private capacity, Proof Committee Hansard, 20 October 2023, p. 18.

[103]Clinical Associate Professor Lim, response to questions on notice, public hearing 20October 2023, Canberra ACT (received 9 November 2023)

[104]Ms Wheeler, NDIS, Proof Committee Hansard, 20October 2023, p, 47; Mr Peter Broadhead, Group Manager, NDIS Participants and Performance, Department of Social Services, ProofCommitteeHansard, 20 October 2023, p. 47.

[105]The OneOneTwelve Initiative, Submission 69, p. 5.

[106]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 34.

[107]Dr Elizabeth Evans, Senior Manager, Advocacy, Council for Intellectual Disability, Proof CommitteeHansard, 20 October 2023, p. 20.

[108]Proof Committee Hansard, 20 October 2023, p. 24.

[109]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 9.

[110]ADA, Special needs dentistry spotlight (part 1), 15 April 2022 (accessed 1November 2023).

[111]Proof Committee Hansard, 20 October 2023, p. 16.

[112]Mr Nathan Despott, Head of Policy, Research and Advocacy, Inclusion Melbourne, ProofCommitteeHansard, 20 October 2023, p. 19.

[113]Mr Despott, Inclusion Melbourne, Proof Committee Hansard, 20 October 2023, p. 19.

[114]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 46.

[115]AFDO, CYDA, Down Syndrome Australia, and Inclusion Australia, Submission 120, p. 29; DrPeterKing, Private capacity, Proof Committee Hansard, 20 September 2023, p. 30.

[116]Department of Health and Aged Care, Report on the Fifth Review of the Dental Benefits Act 2008, March2023, p. 1 (accessed 10 November 2023).

[117]The Royal Australasian College of Physicians, Submission 99, p. 6.

[118]Aboriginal Health Council of WA, Submission 104, pp. 14–15.

[119]ADA, Submission 19, p. 17.

[120]Dr King, private capacity, Proof Committee Hansard, 20 September 2023, p. 29.

[121]ADA, Submission 19, p. 17.

[122]Department of Health and Aged Care, Report on the Fifth Review of the Dental Benefits Act 2008, March 2023, pp. 3–4 (accessed 10 November 2023).

[123]Department of Health and Aged Care, Report on the Fifth Review of the Dental Benefits Act 2008, March 2023, pp. 3–4 (accessed 21 November 2023).