Chapter 3Putting the mouth back into the body
3.1Perhaps the most significant message conveyed over the course of the inquiry was the need to challenge the long-held separation of oral and dental health from general health. Put simply, there is a need to 'put the mouth back into the body'.
3.2Inquiry participants commented on the choice to exclude oral and dental health services from Medicare at the scheme's inception, with Mr Corey Irlam, from COTA Australia, saying this led to a 'perverse' belief that 'somehow oral health isn't part of holistic health'. The Australian Network for the Integration of Oral Health (NIOH) submitted that the connection between oral health and 'systemic (general) health' is 'hampered' by the exclusion of oral health services from Medicare.
3.3The Grattan Institute described this exclusion as 'an anomaly' and submitted that there is 'no compelling medical or economic reason to have a universal health care system for the rest of the body but not the mouth'. Mr Tan Nguyen, Chair and Spokesperson for the National Oral Health Alliance (NOHA), said:
Universal access to essential oral health care remains the missing gap in Australia's healthcare system … Essential oral health care should be accessible and affordable for everyone to medically necessary and clinically relevant dental treatment as well as prevention.
3.4This chapter presents evidence of the compelling need to better integrate oral health within Australia's general health system, looking at:
oral health as essential health care;
international campaigns to put the mouth back into the body;
the need to move from reactive, treatment-based approaches, to proactive, preventative care; and
ideas for integrating oral health assessments, preventative care, and basic maintenance into existing health programs and interventions.
Oral health care is essential
3.5Society's understanding of oral and dental health has changed dramatically in the last 50 years, and so have the population's needs. Oral health policy expert, Dr Patrick Shanahan, explained that when Medicare was introduced:
Life expectancy was about 70, and most elderly had full dentures. Now life expectancy is about 85 and most have some of their own teeth and increasingly dental implants. Unlike dentures, these must be frequently maintained and cannot be removed.
3.6With Australians living longer, the need to maintain good oral health has become more pressing. Poor oral health leads to pain and social exclusion—this has been long understood. What medical science now understands is that poor oral health also leads to poor general health and exacerbates disease. President of the Australian Islamic Medical Association Queensland, DrFatimaAshrafi, described the mouth as 'the gateway to the body':
… you really need a healthy mouth to have a healthy body. There are well‑established associations between systemic diseases and dental infection… [poor oral health] can cause premature babies, low-birth-weight babies and even stillbirth. It even goes on to the next generation because, if mothers have poor dental health, children usually have poor oral health too and are three times more likely to miss school. You don't need a Hollywood smile to have a healthy mouth, but you need a healthy mouth to have a healthy heart. So we better start connecting the dots between the mouth and the body.
3.7According to Dr Shanahan, the blanket exclusion of oral and dental health services from health care and allied health services in Australia, fails to 'make the distinction between essential health care and dentistry'. Dr Shanahan, NIOH, and others maintained that, while cosmetic dentistry may be seen to fall outside of the current legislative remit of Medicare, '[p]reventing infection is a medically necessary service and therefore essential health care'.
Box 3.1 Dr Shanahan on putting the mouth back into the body I'm here today to advocate on behalf of the 11.6 million Australians with chronic disease. This is a longstanding gap that affects them and the health system. It is the exclusion of oral health from primary health care. Infection is infection irrespective of its location, and it's generally caused by pathogenic bacteria. The consequences are usually evident clinically but often the cause is not evident because bacteria are not visible and chronic infection is symptomless. So, besides clinical examination, investigation often requires radiography and microbiology, which are available to medical practitioners under Medicare but are not available to oral health providers. … Pathogenic oral bacteria have no boundaries. They can escape from the mouth and cause problems outside it, so this is a medical, not a dental, issue. Medical practitioners are responsible for healthcare outcomes. As soon as bacteria cause health problems, the priority is infection control. Medically necessary care is essential health care and is covered by Medicare legislation, but this is not. It is arbitrarily treated as dental and personal care and therefore excluded from Medicare legislation and health policies. |
3.8A joint submission from disability advocacy groups noted that the 'siloisation' of the dental and health sectors 'continues to this day and is a global concern', despite the World Health Organisation (WHO) working to promote integration of dental care into primary health care since 2007. One consequence of this siloisation is that health systems 'prioritise other medical issues over oral health, resulting in potentially preventable conditions being missed and escalating into far more serious conditions'.
3.9Dr Shalinie King said, now that the connection between tooth loss and gum disease and diabetes, heart disease and cognitive decline are well-understood, there is a need to include oral health as part of chronic disease management:
My own research has shown that people with fewer than 20 teeth—complete dentition being between 28 to 32 teeth—have a 12 per cent to 20 per cent increased risk of developing diabetes and 11 to 24 per cent increased risk of developing diabetes related complications. So we need oral health promotion and basic preventive oral health care to be part of chronic disease management programs.
3.10Dr Shanahan said this siloisation 'compromises nursing and medical management' of people with serious, complex illnesses. Such people may have oral health problems that prevent treatment or delay surgery. However, their medical practitioners may not have 'the knowledge, experience, authority, legislation or appropriate support services' to diagnose and manage these issues; and the exclusion of oral health providers from Medicare often means that this medically necessary oral health treatment is delayed due to cost.
3.11In the same way that oral disease worsens outcomes for people with other health conditions, cancer and other diseases can dramatically impact oral and dental health. The committee heard that cancer treatments can do devastating damage to the mouth and teeth:
Box 3.2 Jen Mackay—survivor of Stage 3 oral cancer I was diagnosed with Stage 3 Oral Cancer (specifically tongue cancer) in June 2022, as a younger female, I am one of the unlucky ones … As part of cancer treatment, I underwent 35 radiotherapy sessions, with concurrent chemotherapy and I am currently (fortunately, gratefully) cancer free. Unfortunately, radiotherapy has had a devastating and ongoing impact on my teeth and oral health. I now need to see the dentist every three months and I have a mouthcare routine which includes expensive mouthwashes, tooth [mousse], high fluoride toothpaste etc. I am in the very fortunate position to have employment and private health cover, however no insurer I am aware of will cover the increased frequency of the dental visits I now require, post-radiation treatment, nor the costs associated with attempting to maintain good oral health. There are thousands of people who have been through this cancer treatment, many of whom will be in less fortunate circumstances than myself. Dental treatment for this group is imperative, due to the increased risk of tooth decay, loss of teeth, oral complications and osteoradionecrosis (bone death). There should be increased access to free, frequent dentist visits for head and neck cancer survivors (means testing could be applied). There should also be private health coverage for increased dentist visits for those who have been through radiation treatment for head and neck cancer. |
3.12Clinical Associate Professor Matthew Lim explained that many cancer patients need to have teeth removed to prevent serious complications from surgery. During their recovery and rehabilitation, patients are 'shocked and disappointed' to find out that dental reconstruction is not covered by Medicare, unlike other types of post-cancer rehabilitation:
This can often be prohibitive due to the costs of labwork needed to fabricate complex dental prostheses to allow for rehabilitation and recovery in speech, chewing, swallowing, and basic aspects of self-image and self‑esteem in the survivorship of a cancer patient. It remains about the only area of post-cancer rehabilitation in Australian health care that is not fully or partly subsidised through Medicare.
3.13Dr Peter Foltyn argued there is an urgent need to address the fact that Australians cannot receive support or coverage to address 'an oral and dental health condition which is impacting their systemic health or requires assessment and/or treatment before having a surgery or a pharmaceutical procedure'. Dental services 'required prior to medical or pharmaceutical management or receipt of a Residential or Home Care package' should be urgently integrated into the Commonwealth's Medicare Benefits Schedule (MBS).
3.14Inquiry participants commented on the irony that oral health conditions account for the second highest reason for acute potentially preventable hospitalisations in Australia, costing the health system millions of dollars and leading to substandard outcomes. The committee heard this issue particularly impacts remote Indigenous communities:
Box 3.3 Preventable hospitalisations due to tooth decay [T]he single biggest cause of avoidable or preventable hospitalisations here in the Northern Territory is children being admitted under the age of seven years to have a general anaesthetic and all their teeth removed. It's usually under the age of five years. That is the single biggest cause of preventable hospitalisation here in the Northern Territory. To bring that home, three weeks ago in the clinic, a young mother brought her two children in for a child health check because she was going to move them out to Murray Downs, which is a very remote community. Before she went, she wanted her kids to have a child health check. One was five years old and one was eight years old. These kids were amongst the healthiest kids I've seen. They were developmentally normal. Their skin was fantastic. There were no heart murmurs or anything. When I asked the five-year-old to open his mouth, he had no teeth. He had a general anaesthetic and all his teeth had been removed. So an otherwise perfectly healthy five-year-old had a general anaesthetic and all his teeth removed. This is really quite a major issue for Aboriginal children. |
3.15The Primary Health Care Oral Health Providers Association of Western Australia (PHCOHPA WA) urged the committee to make a finding that oral health is health care—not 'personal care as it is currently considered in settings such as the disability sector, aged care and hospitals': 'We strongly recommend legislative and policy change to reflect oral health as a key indicator of general health in both medical and dental professions'.
3.16The Consumers' Health Forum of Australia (CHF) called for a national, universal approach to oral health to reduce disadvantage and address the 'alarming burden' of oral health issues on the wider healthcare system, saying the current oral health system 'does not align with consumer expectations of health care in Australia'.
More than Band-aid solutions: from treatment to prevention
3.17Inquiry participants identified the need for a 'paradigm shift'—from reactive treatment, to oral health promotion and disease prevention.
3.18The Dental Hygienists Association of Australia (DHAA) noted that most oral health strategies acknowledge the dire need for better prevention. However, few allocate specific funding for this purpose 'in practice':
Until such time that the Government invests significantly in oral health promotion and disease prevention, the paradigm shift required to reduce the burden on restorative treatments and increase the affordability of universal access to dental services cannot be achieved.
3.19PHCOHPA WA said Australia must move to a system where 'prevention is the primary objective'. One way of achieving this could be to provide universal coverage through Medicare for 'primary oral health care to be delivered by an oral hygienist practitioner'. PHCOHPA WA argued there's a significant 'cost benefit in delivering prevention over treatment'.
3.20DHAA recommended a 'mandated' percentage of oral health funding for oral health promotion and disease prevention. Noting that culturally and linguistically diverse communities are underserviced by existing information, DHAA suggested funding be used to develop 'a multilingual website with oral health information and instruction', including pictorial communication. A grant could also be provided to encourage dental practitioners to develop health promotion activities the service these groups.
3.21Professor Linda Slack-Smith agreed that Australia needs a 'sustained effort in prevention'. However, research indicates 'conventional approaches', which focus on 'individualist theories of human behaviour change', are ineffective:
Evidence has long suggested that providing more knowledge assuming it will change behaviour is largely ineffective and fails to respond to the complexity of people's lives, yet such approaches prevail. … We need to address upstream prevention with public health actions such as—access to fluoride; access to clean healthy drinking water; addressing the focus on highly processed food containing sugar and our food supply processes.
3.22Professor Slack-Smith also noted that even 'excellent' prevention approaches would not address the 'substantial current need' for dental care across Australia, especially among priority groups.
3.23Some participants, including Dr King, suggested that—in recognition that poor oral health is a systemic problem, not an individual behavioural issue—preventative care should be provided as part of Australia's universal health care system, and that Australia needs to run a national oral health campaign, like Japan's 8020 campaign.
3.24Dr Dawn Casey, Deputy Chief Executive Officer of the National Aboriginal Community Controlled Health Organisation (NACCHO), said 'prevention is key' for Indigenous Australians, and does not need to be provided by dentists. Aboriginal Community Controlled Health Organisations (ACCHOs) are well‑placed to provide oral health literacy and support, but require needs-based funding to do so effectively.
3.25Participants from the health sector highlighted the need to reduce sugar in the diets of Australians as a key preventative measure—especially sugar‑sweetened beverages. Dr Michael Bonning, Public Health Chair of the Australian Medical Association (AMA), recommended Australia look to overseas experience and implement taxes and other incentives to encourage food producers to lower the amount of sugar in their products. The AMA is suggesting an excise of 40 cents per 100 grams of sugar:
The tax that is being modelled is a specific excise tax based on sugar content set at 40 cents per 100 grams of sugar. The tax has been chosen based on the World Health Organization's recommendations, which seek to raise the retail price by at least 20 per cent in order to have a meaningful health effect. The tax rate of 40 cents per 100 grams of sugar would raise the retail price of an average supermarket sugar sweetened beverage by about 20 per cent or, in the case of a can of soft drink, about 16 cents.
3.26Representatives from Department of Health and Aged Care (DoHAC) confirmed this is something the Australian Government is looking into as part of the National Preventative Health Strategy:
Under the National Preventive Health Strategy there is talk of a number of things in terms of how we try to reduce sugar intake for the general population, one of the options for which would be to consider a sugar levy, be it on beverages or the like. Other options are reformulation of food more generally and other things that we're doing in that space … The national reformulation work that we're doing with the sector is looking at fats, sodium and sugars. We normally try to reduce those levels rather than necessarily have that replacement.
Education and awareness
3.27Inquiry participants commented on the low levels of dental literary and oral health awareness among many cohorts. Dr Daniel Hunt, from Derbarl Yerrigan Health Service, said:
Our service does not have the capacity to provide any preventative education. We do provide preventative care, if the patient comes in, in regard to scale and cleans and maybe fluoride applications, but at the moment we're just chasing our tail looking after all the poor oral health care that does exist. I think that probably comes down to community-wide education on dental oral health, because it's not limited just to individual patients; it's a community-wide issue. I'm consistently seeing children come in with black root stumps, through to adults who are completely edentulous. I think there needs to be an increased investment in education for the wider community because people are not dental literate. I did not even know that there was a public dental service until I studied dentistry, and I was a doctor at the time. I was not aware of that, and I don't think the greater community are aware of how to access dental services or have the literacy to understand their dental needs.
3.28Professor Slack-Smith, from the School of Population and Global Health at the University of Western Australia, highlighted the need to move away from models of oral health promotion that place blame and stigma on the individual, and move to community centred campaigns:
Community centred, population centred approaches are much more powerful. What I mean by that statement is we tend to almost victimise people—we take the most marginalised people and tell them they're bad for not brushing their teeth, but we might not talk to them about the fact they don't have somewhere to live that night, or they don't know how to pay for their groceries. They've got so many burdens that blaming them for their dental outcomes is not appropriate. Often things are just so much more accessible to people who are well educated and privileged—access to health promotion information, for example. We need oral health promotion—as the Kimberley Dental Team have talked about with toothbrushing—and make sure that gets out into schools and so on, looking at ways that we can reach these marginalised people.
3.29The disconnection of oral health from general health across the life-course means chances to provide oral health education, guidance and equipment (such as toothbrushes and floss) are missed:
Box 3.4 Dr Nicole Stormon—the Spider-Man toothbrush One of the most memorable patients that I saw was a boy who was in gradetwo. I asked him if he had a toothbrush; he did not. So I bought him an electric toothbrush out of my own pocket, because [Child Dental Benefits Schedule (CDBS)] doesn't fund that. I gave it to him, and the next day I excitedly went to him and said, 'How did you go with your Spider-Man toothbrush?' And he said, 'I gave it to my younger brother, because my teeth are rotten but he has a chance.' I hadn't seen his younger brother because he wasn't at school yet; he was four. So how do we shift a system to help meet the needs of not just those children but all Australians? We need to be having this discussion now around what it looks like, and that's what we identify as the first legislative barriers to then start to unpick and implement evidence based models of care that meet the needs of various populations. |
3.30Aboriginal health sector representatives highlighted the need for oral health education to be delivered as part of broader health supports. Ms Kim Brewster from the Aboriginal Health Council of Western Australia said:
As with many other health concerns, flexible funding arrangements are imperative for oral care, to shift the current state of affairs in some Aboriginal communities from reactive dental based care to preventive and well-managed oral care. Activity based funding does not suit dental care provision in communities and leaves little room for the dental care that is actually needed in communities and all the wraparound supports that make that possible. Flexible funding arrangements directly to the community‑controlled health sector for our clients would be the ideal situation, as on-the-ground clinical and health staff know and understand patient and community needs and can work together to provide practical oral care through culturally safe service provision, updated and hygienic infrastructure and engaging in culturally safe health promotion and so forth.
3.31Dr King noted that there has not been a substantial national oral health care campaign in Australia for many years and there is no identifiable public 'voice' for oral health promotion:
One of the big things that is missing is a community voice for oral health. There is no consumer-led organisation that advocates for oral health as, for example, the Heart Foundation does for patients with heart disease. Such an organisation would be critical for consumer advocacy, building community awareness, supporting preventive programs and, importantly, funding high-impact research in oral health.
3.32Inquiry participants also acknowledged the key role played by oral health therapists in providing both treatment and education, and suggested this group of professionals may be underutilised at present.
The role of oral health therapists
3.33There are around 3500 registered oral health professionals in Australia who are not dentists. These oral health therapists are qualified to provide 'prevention, examination, diagnosis, treatment planning and radiography … [to] prepare cavities and do restorations'. Oral health therapists can conduct assessments and perform preventative care, referring more work to dentists. Services provided by oral health therapists represent a 'cost-effective alternative' to dental care in many contexts.
3.34Oral health therapists (a traditionally female occupation) have historically been required to work with a dentist. In 2020, there was a change to the scope of practice registration standard for dental hygienists, dental therapists and oral health therapists, which removed a requirement for these practitioners 'to work in a structured professional relationship with a dentist'. According to Dr Murray Thomas, Chair of the Dental Board of Australia, this change 'enables dental practitioners to work to their full scope of practice' and encourages 'a team‑based approach to care'.
3.35However, the Australian Dental and Oral Health Therapists Association (ADOHTA) said there are 'regulatory barriers' preventing these practitioners from working to their full scope:
The federal Poisons Standard defines a dental practitioner as:
… a person who is registered … as a dental practitioner (other than a dental therapist, dental hygienist, dental prosthetist or oral health therapist).
This expressly prevents 20 per cent of the dental workforce from ordering, supplying or applying certain medicaments or treatment options, despite being trained, educated and competent in their use. We have a national dentistry radiation code developed by the Commonwealth Australian Radiation Protection and Nuclear Safety Agency, which requires a dentist to be responsible for overall patient care, suggesting the profession is still restricted in achieving full independent-practitioner status. We have Commonwealth funded dental programs, including the [Department of Veterans' Affairs (DVA)] dental program. And the rollout of the federation funding agreement, via some outsourcing agreements, requires oral health therapists to utilise a dentist provider number, creating further barriers to accessing full independent practitioner status and, most importantly, increasing access issues for some of our most vulnerable populations.
3.36ADHOTA maintained that the Commonwealth has a key role to play in removing regulatory barriers and ensuring oral health therapists are empowered to provide a full range of services. This would require changes to:
the Poisons Standard;
the Code of Practice and Safety Guide for Radiation Protection in Dentistry (Radiation Code); and
DVA Dental Program and the MBS.
3.37In order to allow practitioners to provide more services and 'use their competencies in prescribing and taking radiographs within their recognised scope', ADHOTA recommended the Australian Government:
aligns the definition of dental practitioner in the Health Practitioner Regulation National Law Act 2009with the Therapeutic Goods (Poisons Standard – October 2023) Instrument;
conducts a thorough review of the Radiation Code to address discrepancies with the Dental Board of Australia's registration standards and guidelines;
revises the DVA framework to allow services to veterans to be provided by dental therapists, hygienists, and oral health therapists; and
introduces the definition of dental practitioner (under National Law) into the MBS, 'rather than explicitly limiting claimable services to Dentists and Dental specialists'.
3.38PHCOHPA WA similarly recommended government policies be amended to 'recognise oral hygienists as allied health practitioners and include oral health as a practice within existing allied health primary care teams'. Clinical Director of Oral Health Services in Western NSW, Dr Heather Cameron suggested broadening the scope of practice for oral health therapists to include treating patients in residential aged care.
3.39DHAA proposed that the existing Chronic Disease Individual Allied Health Services Medicare Benefits Items be used to 'provide preventive oral health education to this high risk group'. Dental Hygienists, Oral Health Therapists and Dental Therapists can now get a Medicare Provider Number. Adding oral health items to the MBS for oral health therapists would alleviate pressure on GPs, prevent oral disease before it becomes severe, and:
… would allow oral health practitioners assessing the patient's oral health, providing early intervention advice (such as improving their toothbrushing and tailored oral care advice). Occupational Therapists are currently providing this type of service, this is not within their scope of practice. Dental Hygienists and Oral Health Therapists are better suited to provide this specialised service.
Integration
3.40Northern Territory Health, the Western Australia Department of Health, and with many other submitters, advocated for 'the integration of dental care within primary health care and its inclusion in Medicare'. Dr Shanahan suggested oral health practitioners should be part of allied health teams, and Dr Ashrafi suggested dentists should be 'addressed as doctors', like other health professionals, and that oral health should be a specialisation in the health system, like cardiology or oncology.
3.41A number of participants argued dental and oral health services need to be classified as primary health care, not allied health, to reflect the critical, medical nature of oral disease and its impacts.
3.42Dr Shanahan acknowledged the difficulty in 'unscrambling the egg' of the two distinct dental and medical professions, but said the medical profession is supportive of oral health being embedded within primary health care:
The general practice committee of the AMA are very, very supportive of this. Anything that is going to benefit their patients is something they would support. I think the general consensus is for the integration of dentistry into the medical arena … I think dentistry can still work the way it does work, but I think there has got to be some mechanism whereby it can participate with the health profession and be integrated, so that it becomes part of the allied health area. The allied health area is a very friendly way of getting that degree of cooperation without actually having all of the complications that come with trying to bring two professions together. I can understand, and I am sympathetic to, the complexity of the problem that you've got here with government. This has been going on for thousands of years. Basically we're a bit more intelligent now.
3.43Ms Susan McKee, Board Director of the Australian Healthcare and Hospitals Association (AHHA), was concerned that oral health is 'left out of the conversation' when Australians see their general practitioner (GP). GPs talk to their patients about smoking and diet but do not ask or provide advice about oral health: 'It's really about how we change that narrative for the entire community, which is not only the people we serve but also the policymakers at the federal and the state levels'.
3.44NIOH proposed that oral health programmes be 'integrated within broader and coordinated public health efforts', and the broader health workforce be educated to promote oral health. More oral health services should be integrated into Medicare, starting with including an oral and dental health assessment as part of the Medicare funded Over 75 Health Assessment:
A public health approach to oral health requires intensified and expanded upstream actions involving a broad range of stakeholders, including those from the social, economic, education, and other relevant sectors. A public health approach to oral health can maximise oral and general health benefits for the largest number of people by targeting the most prevalent and/or severe oral diseases and conditions.
3.45Professor Hanny Calache, Head, Oral Health Economics Research Stream, Deakin Health Economics, suggested the Commonwealth prioritise upskilling and empowering GPs, diabetes educators, pharmacists and other general health professionals, to conduct non-invasive oral health procedures and assessments, and 'refer appropriately' when required:
They can identify early signs of decay and gum disease and refer them before these conditions become so advanced that they require complex treatment of those patients. That is an area the Commonwealth government could work towards.
3.46Professor Calache proposed that 'cost-effective preventive oral health interventions' be integrated into primary health care, including: combined electronic client management systems; collaborative workforce development; the provision of 'anticipatory guidance for the prevention of oral disease and the application of fluoride varnish and silver diamine fluoride'; and 'remuneration of non-oral health professionals for the provision of non-invasive oral health preventive intervention', under Medicare.
3.47NIOH similarly called for an 'interdisciplinary approach' which would increase non-dental professional involvement in oral healthcare. This would involve joint training and collaboration, and the inclusion of oral health competency requirements for non-dental health professionals. Using pharmacists and other health professionals to provide oral health promotion, fluoride varnish and basic assessments would be especially helpful in regional areas, where workforce shortages are a major issue. According to NIHO, 'good models exist but need to be scaled up', and would include:
capacity building of oral health practitioners to work collaboratively with other professions;
capacity building of non-dental health professionals in 'the importance of oral health management in the management of their clients with complex health needs', including the elderly, disabled people, etc;
capacity building of non-dental health professionals to provide 'anticipatory guidance for the prevention of dental disease and the provision of non- invasive oral health preventive interventions';
capacity building of health workers, carers and disability support workers, including in residential care settings, to provide 'oral health care and referral pathways'; and
capacity building non-dental health professionals to integrate 'simple, evidence-based and cost-effective oral health interventions into routine care to prevent/treat oral conditions among people who experience incarceration'.
3.48It is critical to educate health professionals on the 'important relationship [of oral health] to systemic health' because, according to Dr Foltyn, this is currently ignored in undergraduate medical training; this means 'many doctors have a limited working knowledge of oral and dental anatomy and the close relationship between oral health and general health'.
Box 3.5 Siloisation—ADHOTA's perspective … Aboriginal health practitioners have preventive oral health skills within their scope of practice. We need to be working with them. We're siloed as a dental system, so it's almost impossible for me to work with my Aboriginal health practitioner colleagues—to go into the community, do the preventive screening and apply fluoride varnish, for example, and then work with, for example, an Aboriginal oral health therapist to do that diagnostic screening and look for those risk factors. We have the scope to do that, but the system doesn't then support it. |
3.49The Australian Dental Association (ADA) said an easy step towards integration would be to provide easy access for dental practitioners to digital health records, such as My Health Record: 'This would enhance patient safety through dentist awareness of drug or procedure interactions and assist in tracking patients over time and across services, improve triaging processes'.
3.50In terms of the aged care sector, Ms Tamatha Head from Moviliti Dental Care argued oral health education should be 'a core unit of the competency of the aged-care courses at a certificate III level', and the ADA agreed that priority should be given to upskilling aged care workers, who are 'already in the building', to provide basic oral health care.
3.51Dr Ashrafi called for the establishment of 'emergency dental services' as part of hospital emergency departments (EDs). Conversely, large national dental services provider, ForHealth said the system should be set up to avoid dental presentations to ED. Chief Executive Officer, Mr Andrew Cohen, said governments should expand urgent care clinics to include a relationship with a private dental clinic, where a 'voucher system' can be used to avoid patients 'bouncing around' the health system for dental concerns:
The typical journey is that, effectively, someone wakes up and they're in acute pain for some reason. They go to the ED because that's the first place that they will go. The ED basically gives them pain relief. Then they find out that they've got to book an appointment with a public dentist and it's going to take up to two years to get in—probably 20 months. In that two years, what we're seeing is that they're going back to the GP every few months in acute pain and getting pain relief. With the amount of money that we're spending—in the ED in the first instance, and all those times in MBS in terms of the GP—this person is costing us a fortune. They're a frequent flyer in the system.
3.52Mr Cohen suggested instead that patients be referred to the urgent care clinic, treated for pain and infection, and given a voucher to attend the dentist, 'which is literally on the same site', for treatment of the dental issue: 'That person is out of the system. They're not coming back all the time. I guess in business we would call it "first response time". In a lot of ways, the way the system is set up is actually costing us so much more than it should'.
Box 3.6 Integrated care for dental emergencies—Dr Anusha Gopathy, ForHealth I do work with urgent care in Epping in Victoria, and I'm so grateful that we have the emergency care physicians available. Just last week—very topical—I had a patient with Ludwig's angina, which is a spreading dental infection, from his wisdom tooth. He came in and his face was fully swollen. He wasn't able to open his mouth up. With a limited examination, I could see where the abscess was and see where the infection was coming from, but in that moment I wasn't able to provide the treatment for him. I walked him right across the road—it was just a corridor—and I had a chat to the emergency care physician. I was like: 'This gentleman is going to need [intravenous (IV)] antibiotics [as soon as possible (ASAP)]. We'll send him to the ED, or are you happy to do the IV antibiotics here?' They did that, and the swelling came down. He was monitored for the next couple of hours. And then two days later he came in, we took the tooth out and we dealt with that. So it's a very good integration of medical professionals, the nurses and the dental staff. |
3.53Integrated models are particularly successful for reaching disadvantaged priority cohorts. ProfessorSlack-Smith suggested 'community centred programs'—like that provided by Derbarl Yerrigan or at the St Pat's Oral Health Centre in Fremantle—are successful because they 'have dental services within a multidisciplinary model in locations and settings where the relevant clients feel comfortable'.
3.54The committee heard that the integration of oral health assessment with general health assessment for children is working in Tasmania:
There are a range of factors that likely contribute to Tasmania's positive child dental statistics, and these include factors such as the strong integration of oral health into our general health assessments for children, our focus on preventive care from birth to five years of age and the provision of fluoride varnish in a dental setting.
3.55Some of the barriers to better integration are regulatory and administrative. Inquiry participants noted with concern that the independent health workforce scope of practice review, being undertaken in 2023, does not include dental or oral health practitioners as part of its terms of reference, and suggested the committee recommend this be rectified.
3.56Mr Nguyen argued that oral health care should be integrated within the National Health Reform Agreement, noting that current agreements for hospital care generally 'exclude oral health because it's dealt with separately as a separate line item for funding'.
Indigenous Australians
3.57While integrated oral health care would benefit all Australians, inquiry participants maintained it is especially important for Aboriginal and Torres Strait Islander communities.
3.58Dr Hunt explained that Derbarl Yerrigan operates 'a holistic model of primary health care', which is Aboriginal health-practitioner-led, and integrates 'general practice, primary care, allied health, specialist care, environmental health, health promotions and, of course, dental services'. While Derbarl Yerrigan can provide a comprehensive range of dental services, extractions remain the primary treatment provided. The service has to turn away one in three patients and runs at a financial loss.
3.59While the dental service has been running for 35 years, it has only recently been provided with dedicated funding from the Western Australia State Government. The funding is activity-based and retrospective and does not even cover one dentist or dental nurse.
3.60Dr Hunt proposed that the model of care provided at Derbarl Yerrigan be used more widely, saying as well as being integrated, the model is culturally-safe.
3.61The committee heard how better integration of oral health within Aboriginal Community Controlled Health frameworks would have the following benefits:
Dental health promotion would be more effective and holistic if it was incorporated into broader health promotion programs instead of focusing just on a single disease. Incorporation of dental services into [Aboriginal Community Controlled Health Services (ACCHSs)] would allow for better targeting of high-risk patients (such as patients with rheumatic heart disease) for urgent dental care. Integration would also improve clinical safety, program effectiveness, outreach to more marginalised or vulnerable members of the community and coordination. Integrating dental services into ACCHSs would also support greater Aboriginal employment and facilitate better use of Medicare to supplement and grow available funding.
3.62Ms Jo Tester from the Primary Care Division at DoHAC, agreed that primary health networks are 'well placed' to assist in the delivery of basic oral health care:
They have a regional footprint nationally and could play a role certainly in understanding needs and gaps for service provision on the ground … if considered appropriate. I think that's something that's being considered by the [national Dental Reform Oversight Committee] in terms of the different mechanisms that we have available to get services on the ground.
Adding oral health to periodic health checks
3.63Participants pointed to numerous opportunities to integrate oral health checks into existing health assessments. Mrs Eithne Irving said the ADA has identified a number of periodic health checks where there is an opportunity to include an oral health check:
Now, oral health is not a compulsory component of those health checks, so the [MBS] immediately could be amended to say that it is not an optional extra for the GP to actually lift the lip and have a look. Use the GP to say, 'Let's have a look in your mouth while you are here'—whether you are elderly, Indigenous, whatever your status is—because that is already covered under Medicare.
3.64MBS Item 707 (Health Assessments) states that the following categories of people are eligible for a comprehensive government‑funded health assessment:
(a)People aged 40 to 49 years (inclusive) with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool.
(b)People between the age of 45 and 49 (inclusive) who are at risk of developing a chronic disease.
(c)People aged 75 years and older.
(d)Permanent residents of a Residential Aged Care Facility.
(e)People who have an intellectual disability.
(f)Humanitarian entrants who are resident in Australia with access to Medicare services, including Refugees and Special Humanitarian Program and Protection Program entrants.
(g)Former serving members of the Australian Defence Force including former members of permanent and reserve forces.
3.65Item 707 provides a 100 per cent benefit to GPs who provide this service, currently $295.90 for a 60-minute assessment, which includes:
(a)comprehensive information collection, including taking a patient history; and
(b)an extensive examination of the patient's medical condition, and physical, psychological and social function; and
(c)initiating interventions or referrals as indicated; and
(d)providing a comprehensive preventive health care management plan for the patient.
3.66Related item numbers allow for shorter assessments for these categories of people. Details are provided as to who can conduct the assessments and what the assessments should include for each category of person. The only assessment category which currently includes a dental health check is the assessment for persons with an intellectual disability.
3.67There is a government-mandated health check for children in families that receive an income support payment, and are eligible for Family Tax Benefit PartA. The Services Australia website clarifies that an 'age-appropriate health check must be undertaken' for any child turning four, or a family's payments may be affected. The 'Healthy Start for School' health check can vary by jurisdiction, but generally includes 'an assessment of [the] child's physical health… their height, weight, hearing, sight and general wellbeing'.
3.68The ADA suggested these, and similar Medicare items, be amended to incorporate a mandatory oral health check. Geelong Parent Network suggested the oral health component should be provided by an oral health professional. The GP, or other primary health care professional, should be able to 'arrange for a [Medicare-funded] dental health assessment' to be provided as part of these health checks, to ensure 'a more holistic assessment than does current practice'.
Committee view
3.69As a nation, Australia is proud of its universal health care system, Medicare. When they are injured or sick, Australians have an expectation that the system will be there for them. This falls down when it comes to oral health.
3.70For cultural, economic and political reasons, oral and dental health care services were excluded from Australia's universal health system—the mouth was left out of the body.
3.71This decision was made at a time when the average Australian lived around 70years, and few elderly people had their own teeth. In contrast, life expectancy today is over 83 years, and many older Australians have natural teeth that need to be cared for well into their later years.
3.72Medical and biological sciences have advanced to reach an understanding that oral health is intimately connected with general health. Poor oral health is linked with heart disease, diabetes, cognitive decline, and dangerous, life-threatening infections. It is no longer appropriate or acceptable to see the mouth as separate from the body.
3.73However, the long-standing separation of the mouth from the body has led to a 'siloisation' of the medical and dental professions. The professions and care systems are governed by separate regulatory frameworks, different funding mechanisms, separate education and training, and disparate workforce structures.
3.74If Australia is to see real improvements in oral health across the population, this egg must be unscrambled. Governments must work together to integrate essential oral health care into primary health care across the system.
3.75The committee recommends that the Australian Government formally recognises that oral health is an essential part of general health.
3.76The committee believes the Australian Government needs to lead a paradigm shift in the way oral and dental health is discussed, regulated and funded. Oral health care must be understood as primary health care.
3.77The committee believes that oral health should be considered whenever general health assessments are undertaken; and health care workers must be trained and equipped to assess oral health, provide basic care, and refer as required. A health assessment that fails to consider the health of the mouth is not comprehensive.
3.78The committee believes there is substantial benefit in co-locating dental and oral health services with urgent care and community medical services, especially in underserviced regional areas. People experiencing dental pain and infection should be able to access timely, effective and affordable treatment.
3.79The committee would support the establishment of an Integration Taskforce, to be supported by the Department of Health and Aged Care, which would identify opportunities to integrate oral health assessment and care into existing health settings.
3.80The committee recommends that the Australian Government establishes a taskforce within the Department of Health and Aged Care, overseen by a Chief Dental and Oral Health Officer, to identify and progress opportunities to integrate oral and dental health care into primary health care. Opportunities could include:
Adding an oral health assessment to existing targeted health assessments provided under Medicare, such as the Health Assessment Items 701, 703, 705, 707, and the children's Healthy Start for School assessments.
Introducing an oral health assessment as a standard component of the residential aged care intake process, and for residential disability care intake.
Incorporating emergency dental services into nurse-led walk-in centres and/or hospital emergency departments.
Providing mandatory training in basic oral health assessment and care to general practitioners and other health professionals.
Funding and empowering pharmacists and non-dental health professionals to apply fluoride varnish in regional and remote areas.
Adding 'oral health practitioners' to the terms of reference for the independent health workforce scope of practice review, being undertaken in 2023.
Integrating oral health and dental care within the National Health Reform Agreement.
3.81Nationally, Australia needs to move from reactive, emergency treatment-based approaches, to proactive, preventative care approaches. This will require substantial reforms, made in conjunction with the states and territories, along with public awareness and education campaigns.
3.82The committee heard that a number of Commonwealth regulations and programs limit the provision of certain oral health services to dentists; this includes the Poisons Standard and the Code of Practice and Safety Guide for Radiation Protection in Dentistry, the DVA dental program, and Medicare Benefits Schedule. These should be reviewed and, where appropriate, amended. Oral health therapists should be supported to practice to their full potential, and this workforce should be increased. This will help meet a growing future need for preventative care and maintenance.
3.83The committee recommends the Department of Health and Aged Care works to increase the role of dental hygienists and other oral health therapists in providing preventative and basic oral health care.
3.84The committee recommends the Department of Health and Aged Care assesses—with a view to reducing—regulatory barriers which limit the scope of practice for oral health practitioners who are trained and certified to proscribe and take radiographs. This could include reviewing provisions and/or definitions in:
the Poisons Standard; and
the Code of Practice and Safety Guide for Radiation Protection in Dentistry.
3.85The committee recommends the Department of Health and Aged Care works to increase the role of dental hygienists and other oral health therapists in providing preventative and basic care by adding a number of preventative oral health service items to the Medicare Benefits Schedule, under the category of Allied Health Services; and to the Department of Veterans' Affairs dental schedule.
3.86Better referral pathways must be established to ensure patients who are referred for more complex treatment can actually access that treatment, and do not forgo it due to cost.
3.87The final chapter of this report looks at options for reforming the way in which dental and oral health services are funded and delivered, with a particular focus on the role of the Commonwealth.
3.88The committee recommends that the Australian Government considers commissioning a study into:
the impact of cancer and cancer treatment on dental and oral health; and
the need to provide coverage for oral health treatment, including restorative services for cancer survivors, including survivors of head, neck and oral cancers.
3.89The committee recommends that the Australian Government reviews the Medicare Benefits Schedule with a view to improving the accessibility of oral health treatment, including restorative services, for cancer survivors, including survivors of head, neck and oral cancers.
3.90The committee recommends that the Australian Government provides seed funding for a national oral health promotion and advocacy body, similar to the Heart Foundation.