Too many Australians 'missing out' on vital dental care

There must be better integration of dental health into Medicare and the primary health care system to avoid too many Australians missing out on vital oral care.

The most common dental problem for children is tooth decay (known as dental caries). Population data show two in five Australian children have experienced dental caries in their primary (baby) teeth (here). Dental problems are one of the leading causes of preventable hospitalisation in Australian children.

Dental caries occurs when bacteria form a mature biofilm on the teeth and feed on sugars over time (here). Social and behavioural factors have a great influence on the occurrence of dental caries (here). At a population level, use of fluorides and accommodating access to dental services can lower the incidence of dental caries (here). Although an individual may minimise the impact of dental caries through tooth brushing regularly and through health and dietary choices, these factors are influenced by one’s environment and may be out of the control of all individuals. People who experience dental caries in childhood often experience a lifetime of dental problems, reiterating the importance of early intervention and prevention. Inequities in dental caries are experienced by children from:

• rural and regional areas (here);
• children from Aboriginal and Torres Strait Islander backgrounds (here);
• children from lower socio-economic backgrounds (here); and
• homes with lower parental education (here).

The dental health system differs from other areas of health. Dental services in Australia are largely delivered in the private sector. Individuals can elect to take out private health insurance extras to partly cover treatment expenses. Eligible individuals, typically those with concession or pension cards, can access free and subsidised dental treatment in the public system. Limited resourcing and substantial unmet dental problems for Australians contributes to the infamous waiting lists for public dental care (here and here).

The recognition of the need to prevent dental disease in children led to the Commonwealth Scheme known as the Medicare Teen Dental Plan (TDP) on 1 July 2008. This scheme provided vouchers for eligible adolescents to receive a dental check-up and preventive services. The low uptake of the scheme and recognition of unmet dental disease saw the TDP cease at the end of 2013, and transformed into the Child Dental Benefits Schedule (CDBS). Under the CDBS, children of families receiving eligible government payments, such as the Family Tax Benefit Part A, can receive up to $1052 of dental services over two calendar years.

Investigating use of the Child Dental Benefits Schedule

In 2014, only 29.5% of the 3 million eligible Australian children accessed CDBS funding (here). Utilisation of the CDBS has remained low throughout its almost decade of operation. It is still unclear why utilisation of the CDBS remains at a third of eligible children on average, when dental caries continues to be an ongoing health issue and there are declining trends in the proportion of children making regular dental visits.

So why isn’t the CDBS dental funding being used when Australian children need it?

There is research showing the CDBS has marginally improved access to dental services for low income groups; however, the funding has largely been subsidising treatment for those who had previously established visiting patterns. The most recent Australian Government review of the CDBS called for further investigation into the utilisation of the funding, especially for children in regional areas, First Nations children and children with disability.

We investigated the use of the CDBS in various locations, including urban and regional areas. In dental appointments, several dental item codes are often claimed in a single visit. Our study used cluster analysis to look at how dental practitioners were claiming in the CDBS in individual dental appointments. We found that urban areas had more claims for preventive dental treatment compared with regional areas. Claims in regional areas were for more complex and expensive invasive treatment (such as fillings and extractions), suggesting that primary prevention may be missed in regional populations. We found that the percentage of “simple restorative” appointments were higher in New South Wales, Victoria, Queensland and Tasmania. The Australian Capital Territory and the Northern Territory had higher proportions of “moderate restorations” than other states and territories.

Vulnerable populations “missing out”

The differences in CDBS utilisation show that vulnerable populations may be missing out on preventive dental care. In addition to this, many vulnerable children are missing out on care altogether. This results in significant pain from toothaches and preventable hospitalisations due to dental infections for Australian children. The CDBS is fighting a losing battle in oral health inequities.

The Commonwealth Senate recently held an inquiry into the provision of and access to dental services in Australia. Thirty-five recommendations were made from the inquiry.

Many of the recommendations from the Senate inquiry were not new: commissioning better oral health research, improving access to the CDBS, implementing a dental funding scheme for seniors, and improving workforce and training.

Interestingly the inquiry recommended better integration of oral health within Medicare and primary health care, as raised in recommendations 4 and 7.

As recommendation 4 reads (here, emphasis added):

“The 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.”

Recommendation 7 (here, emphasis added):

“The 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.”

The dental system is siloed from general health. The underutilisation of the CDBS and maldistribution of services delivered are evidence of this.

Oral health needs to be integrated into health care

Australia’s legislation and funding systems need to catch up to contemporary integrated health care. General practitioners, nurses, pharmacists, speech pathologists and allied health practitioners all have a role in oral health prevention and all Australians need equitable access to these services.

Until our systems and funding support the integration of oral health, all practitioners have a role in screening for oral disease and promoting the utilisation of the CDBS.

Nicole Stormon is a Senior Lecturer at the University of Queensland School of Dentistry and Principal Research Fellow at Queensland Health Metro North Community and Oral Health.

Loc Do is a Professor at the University of Queensland School of Dentistry.

Christopher Sexton is a Senior Biostatistician at the University of Queensland POCHE Indigenous Research Centre.

Matt Hopcraft is an Associate Professor at the University of Melbourne Dental School.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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