No clever answers! Finding the right questions about dental care in AustraliaNov 7, 2018
The significant impact that dental disease makes to the financial and social burdens of preventable chronic illness in Australia is rarely acknowledged, although there is substantial evidence of the inequalities in access to dental care. Dental care is not seen as an essential part of health care as if the mouth is not seen as part of the human body. This situation will not change unless and until answers are found to a series of crucial questions.
There’s a great quote in a recent Atlantic article reporting about X, Google’s innovation centre: “Moon shots don’t begin with brainstorming clever answers. They start with the hard work of finding the right questions.” How could we apply this approach to reforming dental care in Australia? I argue that the “right questions” fall into four categories around
(1) the political debate; (2) the oral-systemic health connection; (3) workforce development, education and training and research; (4) the costs involved and who pays.
Question 1: Why doesn’t dental health have a profile and standing in the political arena?
It is a seminal sign of the problem at hand that the Political Declaration signed at the third United Nations High-level Meeting on Noncommunicable Diseases (NCDs) in September 2018, excludes oral diseases, despite their strong links to the NCDs that are mentioned, including cardiovascular disease, cancer and diabetes.
This omission is compounded when international efforts to tackle obesity through interventions such as restrictions and taxes on sugar-sweetened beverages and improved nutrition labelling fail to include the gains that will accrue to dental health.
Efforts must be made to ensure that between now and 2025, when the UN will next discuss NCDs, targets for oral health and dental diseases are on the agenda. But Australia cannot be an international leader on these issues if it fails to take actions at home.
In the ramp-up to the forthcoming federal election, there will be policies and proposals about what the various political parties will do to improve health and health care in Australia. Affordable access to essential dental care and oral health services must be seen as part of that debate. They must be on the table whenever prevention, primary care, avoidable hospital costs, mental health disorders, disability and aged care services, and poverty and disadvantage are discussed and addressed.
Question 2: Why isn’t the mouth seen as part of the human body?
WHO Assistant Director General for NCDs and Mental Health Dr Svetlana Axelrod said recently that “good oral health is a crucial element of overall health and as such part of the human right to health”.
There is a raft of evidence that highlights the many dependencies between oral health and systemic health. It is neither wise nor cost-effective to ignore these, especially when there is growing recognition of the need for a patient-centred approach to care that sees the health care needs of the whole patient. This is particularly true for patients with diseases like diabetes, cancer and HIV / AIDS, Crohn’s disease and for those on certain medicines that cause dry mouth.
This holistic view of the human body will not change unless dental health care professionals become part of the health care team, both in primary health, in hospitals and in residential care facilities. At the same time, public health campaigns around smoking, breastfeeding, obesity and cancer screening should also include the dental health aspects. At the same time, Australians must be made aware that a healthy mouth is not just a cosmetic issue; both, so they are driven both to agitate for affordable care and then to use it when it becomes available.
It is also clear that bridging the current “dental divide” will require evidence and data to support the value (economically and in health outcomes) of integrated dental and systemic care, along with health services research to indicate how this integration might be achieved efficiently and effectively.
To date, research in this area is sadly lacking. So too are initiatives from the dental and medical professions to move beyond the protection of traditional professional turf to a more team-based approach.
Question 3: What does the dental health care team look like?
The dental health profession includes dentists, dental hygienists, dental prosthetists, dental therapists, and oral health therapists. Key dental workforce discussion must include developing answers to question like:
- What are the appropriate numbers for each category and how are these best planned for long term?
- How to address workforce shortages and geographic maldistributions?
- What is the composition of the ideal dental team, and what is the composition of an acceptable dental team?
- Do the current scope of practice criteria reflect current training, technologies and population needs?
- How to best address preventive dental care; dental treatment in the community and residential facilities; acute care needs in hospital emergency departments; and the special dental needs of individuals with disabilities?
None of these questions have easy, straightforward answers, but if Australian dental health outcomes are to improve, answers must be found; the status quo is no longer appropriate for today’s needs, let along those of tomorrow.
Yet, the Dental Board of Australia’s proposal to remove the requirements for dental hygienists, dental therapists and oral heath therapists to work within a structured professional relationship was not received well by the Australian Dental Association. How long will the dentistry profession be able to sustain the argument that all services need to be provided or overseen by dentists?
An obvious example of where change is needed is in the delivery of preventive dental care to children. There are potential roles for early childhood nurses, social workers, care coordinators and care navigators, school counselors, pediatricians and other non-dental healthcare workers. At the same time, there are primary health care tasks that can could be undertaken by dentists who routinely give injections, measure vital signs and have the potential to be able to prescribe a range of medicines.
Whatever the answers to the questions above, the education and training of dental professionals must be responsive, thus generating a whole cascade of new questions.
- How should applicants for dental school be selected? Is superior academic achievement in high school or college the only criteria – what about potential students’ empathy, social consciousness and sense of social justice? How can these qualities be measured?
- Should Australia introduce a national board exam for all dental graduates and certified continuing education requirements as many other countries do and as is the case for the medical specialties? Should we require an “apprenticeship year” (or two?) under the supervision of an experienced dental clinician who can mentor and guide freshly minted dentists?
- How can the education and training of dentists, doctors, nurses, pharmacists and other health professionals be better linked to help with the development and functioning of comprehensive health care teams?
Two thorny issues remain: how to integrate the public and private dental sectors so that public dental services are well staffed and access to quality dental care is available to all? And how to address geographical workforce maldistributions? Associated issues include whether the increased corporatisation of dentistry in Australia, that has moved private practitioners into larger corporate settings, improved the quality of oral health? Does it make dentistry more or less affordable? Will it eventually limit choices?
These issues remain unresolved in the medical arena, so perhaps the “right questions” have yet to be asked.
Question 4: Who pays?
The right answer to this question might also deliver many of the answers to those posed previously. In 2015-16 Australia’s total expenditure on dental services was $10 billion – the majority of which (some 60 percent) was paid by individuals.
Out-of-pocket costs are a major barrier to the timely access of care, even when people have dental cover as part of their private health insurance. As it currently stands, public dental services are so under-resourced that most people unable to afford private care either see a GP or a hospital Emergency Department or resort to dangerous self-treatment.
While the federal government currently funds some dental services for veterans and children and contributes to public dental care for adults through the National Partnership on Public Dental Services (which is due to expire next June), successive governments have resiled from accepting major responsibility for dental care.
In part, this reluctance is driven by the potential costs and the difficult tasks of determining who is covered and for what. Given the huge unmet need for dental care, the cost of improving dental services will inevitably be substantial, at least initially. However, there will also be significant cost offsets from elsewhere in the health care system and in terms of productivity and workplace absences. For example, what are the additional medical costs caused by the one-third of Australians who delay seeing a dentist due to high out-of-pocket cost?
The current public debate over medical out-of-pocket costs rarely include dental costs, and the government’s tentative efforts to ensure Private Health Insurance (PHI) delivers better value for purchasers does not encompass in inadequacy of the capped costs paid for approved dental treatments.
In theory, it is possible to completely prevent tooth decay and tooth loss. But currently, a filling—even a very small one—results in a higher fee for the dentist than a sealant that arrests the disease. As in medicine, preventive measures and early interventions must be made more desirable for oral health professionals and for their patients.
Finally, and controversially, how long will Australia be a country where dentists have unrestricted freedom to set their own fees? Any proposals to expand access to dental care that involve government funding must address this thorny issue.
Concluding question: Will the dental profession and dental academics move from being part of the problem to being part of the solution?
Not taking care of the oral health needs of the population is shortsighted for a variety of reasons that far exceed our collective aspirations to reduce human suffering. Unlike many other chronic diseases, dental disease is often visible, and people face discrimination in employment and social relationships. Will the dental profession and dental academic centres take up the challenge to address this critical health and societal need?
Let’s start with answering some of these wicked questions to move affordable dental care for all from impossible to imperative to inevitable.
Professor Heiko Spallek | Acting Head of School and Dean, The University of Sydney School of Dentistry, Honorary Associate | Sydney Health Ethics, Faculty of Medicine and Health.