Doing less but achieving more in dentistry.
Scientific breakthroughs in the prevention and treatment of tooth decay and dental disease have not yet converted dental practice, and consequently dental costs, in Australia. It will take a paradigm shift in how we organise and train our dental work force and how we fund dental services to deliver the benefits if these new prevention-focused treatment modalities. The improvements in outcomes and reductions in costs that are possible offer real incentives for governments to deliver dental care to all Australians.
Scientific advances deliver new treatment modalities
The last major breakthrough in preventing dental caries was triggered by the introduction of water fluoridation in the 1950s. While celebrated widely by public health experts, it has not eradicated tooth decay. More needs to be done in Australia to ensure that that the benefits of fluoridation are available to all, but we now know that the risk factors for dental disease are chronic, multifactorial and complex including not just diet (especially sugar) and plaque but also genetics and socio-economic factors, therefore evading a single-method fix.
Our understanding of the causes of tooth decay, specifically the oral microbiome (bugs in your mouth) and the underplaying biological basis (what these bugs do to destroy your teeth), has advanced and research highlights the extent to which dental caries is a preventable disease. These findings have dramatically changed current evidence-based treatment guidelines and have been widely publicised in the popular press under headlines like “cavity-fighting liquid let’s kids avoid dentists’ drill” and “simple dental treatments may reverse decay”.
There is now strong evidence that non-operative treatment (that saves tooth structure) should be preferred over surgical interventions (drilling) as all invasive treatments place a tooth on an inevitable path of destruction. This fix-and-repair path starts with a small filling that gets replaced by a larger filling followed eventually by a root canal treatment (for those who can afford it), followed by a crown (again, only for patients who can afford it), often followed by an extraction to replace the tooth by an implant with a new crown (for the very few patients who can afford this expensive treatment) ultimately resulting in a denture when the implant fails.
Instead, if found early, we now can “heal” teeth rather than remove and replace natural tooth substance with artificial materials. Such “healing” can be accomplished through various non-operative tooth decay management strategies that include remineralisation of tooth substance and lesion arrest to minimise the loss of sound tooth structure.
There is no scientific evidence that non-cavitated caries lesions (tooth decay that has caused a stain, but not yet made a hole) should be drilled and filled. Instead sealants, like those used to prevent decay in children’s newly-erupted permanent teeth, can be placed over minor carious lesions to arrest tooth decay. The added benefit of these non-invasive treatment options (no drilling) is the avoidance of discomfort and pain, reducing dental anxiety. This in turn significantly influences attendance patterns of patients leading to better follow-up and sustained disease control.
These contemporary strategies are focused at tooth level. They need to be combined with interventions on the patient level, including oral hygiene instructions. Almost half of Australian adults and one-third of children don’t brush their teeth twice a day. Even those who do regularly brush their teeth typically only do so for 45 seconds, which is not long enough to remove the build-up of plaque. More importantly, dental care needs to be seen as not just a cosmetic issue but a key health care issue.
What needs to change to deliver best-practice dental care?
How can this knowledge and these new treatments be factored into dental health care policies? We need a roadmap that guides us from the current fix-and-repair paths towards prevention-oriented dentistry and a focus on early detection and the arrest of tooth decay. Education and training, the structure of the dental care team, and funding mechanisms need to change to encourage these changes in practice. Australia’s National Oral Health Plan 2015-2024 presents an excellent foundation for this work; the problem is that despite its COAG endorsement, little has been done to implement it.
1. Changes in dental workforce planning to accelerate the adoption of new evidence
Today’s dental workforce needs must be assessed in the light of not just numbers, but the skills and competencies (and team approach) needed for an increased focus on prevention and early intervention and new treatment modalities. It is important to look at practical and pragmatic options to cope with over-burdened public services and for the delivery of dental services in areas that are currently underserved.
One option is to broaden the scope of practice for oral health therapists so that, in a structured professional relationship with dentists, they could handle many of the check-ups and simple treatments. This would allow dentists and specialists to focus on complex treatments and populations with special needs.
Another option is based on the fact that modern sealant materials do not require strictly dry teeth or a professional teeth cleaning before placement and that a routine mechanical reparation of the teeth is not recommended. Dental assistants and paediatricians, nurses, pharmacists and other members of the primary health team, can be trained to place sealants to prevent as well as arrest already existing tooth decay. Dental assistants and Aboriginal Health Workers can provide a cost-effective and culturally safe solution to the lack of services and sophisticated dental equipment in remote areas.
Any work force planning must take into account the increasing numbers of older people who are retaining their natural teeth. This will mean an escalation in the need for services and skills to maintain and reconstruct older mouths in a population segment that will also have high incidences of frailty and dementias.
We must start now to ensure that dental students learn how to manage tooth decay based on risk assessment that goes beyond surgical interventions. Accreditation requirements need to incentivise dental schools to adopt contemporary caries management systems that aim to preserve tooth structure through risk-based prevention and patient-centred, evidence-based disease management, reassessed at regular intervals over time.
Such emphasis on preventive measures will inevitably need to come at the expense of teaching surgical treatments in an already overloaded and compacted curriculum. The introduction of a national board examination for new graduates in Australia could ensure consistency in education that will ultimately benefit the public.
Changing the education of new dentists will deliver a slow, and only generational, change. An accelerated translation of new scientific evidence into practice and to address the current large variations in practice is needed. If we are to ensure that the 16,000 dentists currently registered in Australia are up-to-date with evidence-based practice, then the current system of counting hours of attended Continuing Professional Development events, regardless of topic, relevance and quality, needs to be replaced with something more meaningful. There must be mechanisms to ensure that dentists continue to keep up-to-date with guidelines and quality and safety requirements.
2. Aligning incentives with evidence to guide behaviour
There are never sufficient resources to satisfy all health needs, but upfront investments in prevention deliver much better value and help ameliorate the demand for much more expensive treatments for unchecked disease. This is classically the case for dental caries, which, with the right behaviours and services to young children and their families, can be prevented. We know this can be done: data from the Oral Health Tracker show that in 2004-06, 24.1 percent of all Australians aged 15 to 34 years have no dental decay.
Currently resources in the public dental services are allocated by activity-based funding (ABF) models based on the type and number of services provided. Dentistry poses a specific challenge for ABF as the measurement of activity is based on item codes designed for monetary compensation rather than diagnostic-related groupings identifying the complexity of care provided.
This results in a low reimbursement for preventive items as opposed to treatment items, the favouring of “more fillings” over “less fillings”, and the under-funding of special needs dentistry that requires more time.
Policy changes of the magnitude needed to incentivise prevention over treatment will require substantial debate and the involvement of various stakeholders inside and outside the dental profession. Most preventive approaches require frequent follow-up visits, so these must also be appropriately compensated and, crucially, efforts made to ensure reductions in waiting times for public dental services.
Changes in the incentive structures for private dentistry will be even more complex. A culture change is required so that private health insurance, dentists and patients come to accept that a dental visit without X-rays, drilling, local anaesthesia and the use of a restorative material to substitute lost tooth substance, is more valuable (and rewarded as such) than one in which “a lot happens”.
To back such changes, we need an oral health campaign, led by oral health professionals and supported by other community members, such as teachers and community leaders, to educate the general public that paying for preventive advice and treatment is more important than paying for high-end restorative, cosmetic and complex treatments later. Oral health promotion, led by oral health therapists and other trained professionals, must start with infants, continue into child care and pre-school, and should be an integral part of the school curriculum, perhaps incorporated into Personal Development, Health and Physical Education classes alongside sex education and smoking prevention.
3. Measuring what matters to improve health outcomes
“What gets measured gets done” certainly applies to dental care. Current systems of quality assurance, such as the Clinical Indicator Program by the Australian Council on Healthcare Standards focus on process and the quality of care provided, but not on the improvement of the dental health of the population.
In public dental clinics the measures are “bean counting” items (how many fillings) that are more provider-focused than patient-focused and do not give meaningful assessments of what has been achieved, such as the number of patients with no fillings. An accurate assessment of risk for tooth decay is also required for determination of the appropriate individual recall interval for a patient. An interval too short burdens the dental care system, an interval too long could harm the patient.
The routine collection of caries risk assessment and dental diagnostic codes using standardised terminology and a comprehensive set of clinical protocols that address all diagnostic, preventive and restorative decisions in an electronic health record (EHR) system (such as the currently-stalled NSW Titanium dental e-health record system) could measure what has been achieved and provide significant benefits for patient safety and the reduction of adverse events.
Electronic health records can be employed to push changes in dental practices, thus expanding their usefulness beyond billing and scheduling. Clinical decision support systems can be embedded in cloud-based EHRs to support best-practice decision-making.
Patient-generated health data (PGHD) – for example, about diet or medicines – can be valuable in supplementing clinical data, filling in gaps in information and provide a more comprehensive picture of ongoing patient health. If we manage to connect the PGHD data of consenting patients with clinical health outcomes data from EHRs, we will be able to accelerate research that might discover more causes of dental disease and how to prevent tooth decay more effectively. My Health Record might be able to be the connecting bridge between the PGHD and the dental EHRs.
4. A better partnership between dentistry and medicine
Dental and medical professionals must become partners in delivering health care services. This should entail some shared training, a recognition that dental services are an integral part of primary care, inclusion of dental information on patients’ records and professional courtesies around patient referrals.
Specialists treating patients with conditions such as cancer, diabetes and HIV/AIDS that place them at increased risk for dental problems, GPs who see patients with poor dental health and risk factors such as polypharmacy, and paediatricians and baby clinic staff will all have occasion to refer patients to dental services. Conversely, dental professionals are often the first to recognise systemic diseases, such as diabetes, leukemia, acid reflux and heart disease.
Better integration of medical and dental services is an important aspect of primary care reform and the focus on patient-centred care. Integrated services could feasibly grow from the expansion of community health services, or from the creation of new multi-disciplinary services between dentists and GPs where teamwork, not just co-location, is encouraged. Such two-pronged development would have the added benefit of bringing the public and private dental systems closer together. (This proposal was first put forward by Tony McBride in 2012.)
This presents two key challenges: how to encourage primary health care practitioners and governments to put these models into place, and what funding models are needed to sustain them. None of these challenges is insurmountable.
Heiko Spallek is Head of School and Dean , The University of Sydney Dental School