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Dental care in Australia is in serious need of radical change

21 September, 2006

MS has recently featured 3 detailed Q&As recently with Hans Zoellner, a dental lecturer at Sydney University, and the Chair of the Association for the Promotion of Oral Health.

His diagnosis is that the dental care industry in Australia is in need of a huge change to save it from decaying any further. This feature brings together the main points made in his interview with Rodney Appleyard.

As an independent think tank for the dental industry, with about 280 members, the Association for the Promotion of Oral Health has carried out extensive research into the Australian dental industry and has found that there are not enough dental professionals available right now to meet community needs. 

Not enough dentists available 

Zoellner says that there is a gross under supply of service capacity in the dental system in both the private and public sectors.

“That under supply of workforce has been there for some time now, and it’s getting much more acute. Within the next 5/10 years it will get even worse in this country too. For example, numerous studies show that there has been a large increase in the amount of untreated oral disease. On one hand, that’s happening really because people have more teeth these days so as a result there is more chance of them catching a disease. Due to the use of fluoride, people are retaining their teeth for longer and into old age, so they are more prone to diseases than ever before.” 

“Separate to that, proportionately, there is less work force available to deliver the services for maintaining the teeth of patients. The projection is that by 2010, relative to 2000, Australia will have about 1,500 dental professionals too short to deliver the services that were already inadequate in 2000.”

In addition, Australia finds itself with less dentists than the OECD (Organisation for Economic Co-operation and Development) average, which is 56 dentists per every 100,000 people. In Australia, this average is only 42 dentists per 100,000 people. When it comes to metropolitan areas, Australia has got 52 dentists to 100,000 people, but in rural areas, this figure goes down to 28 or so. In fact, some parts of rural Australia only have two dentists per 100,000 people, and there’s a place in Western Australia that has only 14 dentists to 100,000 people.

“In relation to community needs”, Zoellner continues, “there’s a gross under supply of service capacity, and that’s the biggest challenge that we face now. That’s going to get much more acute in the future, with baby boomer dentists retiring and also baby boomer patients retiring, all of whom will have their own teeth instead of dentures. They will need fillings serviced, as well as other various historical oral diseases from the past that will have to be maintained. Other people will require dentures to be replaced, so it is going to pose a huge problem in the future.”

Lack of adequate training

In addition, although medical schools have continued to train more nurses as the population has grown, the same has not happened in the dental industry. The reverse has actually happened – there were a 1/3 more trained dentists in the industry 25 years ago. Zoellner believes that the Government has not done enough at a Federal level or even at a state level to really address these growing problems.

“There’s not a shortage of people who want to train in dentistry, but the problem is that the number of training positions have reduced. The University of Sydney had an intake of 112 dental students per year 25 years ago, but that went down progressively until it hit a low point 7/8 years ago, when only 45 dentists were taken in each year.”

The numbers are now being pushed up again towards levels that were comparable about 25 years ago. In fact, next year, there is going to be an intake of 120 first year students again at the University of Sydney. Another issue, which again is the responsibility of the Government, involves the lack of resources available for the dentists trainees to work with.

“All of the traditional academics are now either dead or retired and there has also been a reduction in training facilities available, which means that the infrastructure has been degraded. So now we are seeing a very belated attempt in NSW to increase student positions, but where are the resources to support them? They are simply not available,” says Zoellner.

“The Government has a responsibility to provide the plan for the workforce to service the needs of the community, be that in dentistry, architecture, bridge building or for medical practitioners. But the Government has failed to do so properly in the dental industry. We’ve been looking for some evidence of anybody at the senior level of Government thinking and stopping to consider what the old health workforce is like, and should be for Australia in the future. However, we’ve actually failed to find any thought at all at any level. There’s been a lack of planning, and also a total lack of resourcing.”

In regards to the Federal Government, Zoellner says that it has an important role in supporting University training positions. He says that in the past, they have failed to match those resources to what the community needs, and at a state level, the Government has responsibilities in dentistry, as it does in medicine, for providing the physical training infrastructure for clinical training, although he believes that they have failed to that as well.

“Only last year, the NSW state Government sold the only building that was dedicated to the dental training. There’s just a lack of responsibility at all levels, so yes, I would lay the blame at the Government’s feet. But I would also say that the dentist profession has failed in the past to articulate properly what the needs are of the community, although that problem has changed now. I think the profession is now more appropriately accurate in this field.”

Team based team care

As for what can be done to change things for the better, Zoellner has some ideas that he strongly believes can help save the dental industry from facing these escalating problems in the future.  This strategy involves building a team based model of care that recognises how difficult it is to treat all of the dental diseases in the community, such as providing fillings, scaling, cleaning, preventative treatment and extractions.

“There just aren’t enough dentists now and I can’t see how it is going to be possible to train enough in the future too,” adds Zoellner. “So what you need instead is to develop a system where paradental professionals work together with dentists in teams, and they are being trained in some places right now. If you have one dentist working in a team of three or four other professionals, such as therapists and hygienists, then the dentist can have the responsibility of initially assessing the patient, making the diagnosis, developing the treatment plan, and then he/she can refer the patient to the appropriate paradental professional in the dental chair, which can be physically located right next door.”

The organisation believes that when it comes to prescriptions, which are simply to administer but time consuming, then this could possibly be done by paradental professionals, who do not have quite as much training and therefore do not cost as much to employ. As a result of using this model, the industry would be able to afford to deliver a lot more dentistry to many more people.

“So we can see the development of this team based model for dental care as probably the only way to deliver services safely in the future. In this model, anything difficult or complex, or involving a patient that is medically compromised, can be handled by the dentist. Of course, they require a higher level of training to look after the safely, but by properly engaging paradentals in this sense, you can increase the amount of service delivered, and you can do it in a safer way that is also cost effective. It’s also the only real way that you can live up to community needs.”

Some dental schools are adopting this position already. For instance, the University of Sydney has a new degree called the Bachelor of Oral Health Degree, which involves students training as a paradental professional to deliver straightforward restorations and fillings in children legally. They can also treat adults in other states, at the same as having the skills of being a hygienist.  So these graduates will be incredibly useful in the team. In addition, they only have to study a three-year undergraduate course, which is very different to the four-year postgraduate course that dental graduates have to do. So overall, the cost of employing these undergraduates is relatively less than usual.

Brisbane University in Queensland also has a new dental school that has opened on the Gold Coast based on creating these teams. Zoellner is pleased with these developments, but he still feels that things aren’t moving fast enough.

“We also need a proper internship for dental graduates. We’re yet to see that for paradental graduates as well. This is unlike medicine, where students graduate from medical school and then work as an intern in the public system for a while to develop their technical skills. Then they can be registered later as an independent practitioner. We need to see this happen in dental care too, and we need them to spend more time on practical skills instead of academic study, which undermines their confidence with dealing with complex medical patients.”

New breed of patients

Zoellner also fears that modern day dentists are going to face a different kind of patient than dentists used to work on in the past, and therefore training needs to take this into serious consideration too.

“The patient of tomorrow is not going to be the nice young healthy guy that I was trained to treat when I was a student. The patients of tomorrow are going to include the old, the frail and the medically compromised, who will still have all their teeth. And those dentists are going to need a higher level of medical training to be treated safely. So by freeing up some time in the undergraduate system, they’ll be better prepared for that.”

The dental system in the public sector currently has a 20% vacancy rate of unfulfilled positions. This has resulted in waiting lists across the country reaching about 650,000, or one in 30 people. By using interns in the public system, Zoellner believes this will allow better services to be provided and will mean that dentists will be able to control diseases more easily.

Governments needs to step up action

Zoellner strongly believes that the Government has failed to understand this problem in the past, especially since there have been reports showing that the amount of untreated teeth across all age groups doubled in 25 years, and then doubled again six years later. His organisation approached the NSW Government with a 10-point plan for improvements, when Morris Iemma was the Minister for Health in NSW.

“We said: ‘Here are 10 things you could do at the state level at least, that would make a real difference.’ He said: ‘That’s great, I’ll give you the assistance of my staff, and you go out and work out a costing for how much it will be to fix up.’ So we worked out that it would be surprisingly inexpensive to really start to improve things, at least in this state, in regards to the public sector only. But certainly, the public sector could be substantially improved for a staggered investment, starting off at just $48 million dollars in the first year, rising to $116 million dollars in the 5th year. So we worked out a five-year implementation strategy that involved staggered increases in funding. This included measures such as paying for internships; creating joint initiatives between the hospitals and the University; recruiting specialist services and specialist training and taking care of the cost of improving salaries in the public system to attract dentists and keep them in the system.”

The costings would not only involve paying for dentists but also paradental professionals, therapists, hygienists, registrar appointments and improving the physical infrastructure to make it possible to treat patients. Zoellner believes that if you multiply the cost involved by three then this would provide a rough estimate of how much money would be needed to fix the problems across the nation.

So far, there have been some successful changes that have been put in place. The Minister has announced the introduction of internships, registrar appointments, rural scholarships, improved fluoridation and the introduction of the dental team model for services. However, Zoellner says that the organisation is disappointed that not enough money has been thrusted into the system yet.

”At the moment, it’s just rhetoric, and without money, it’s just nonsense, so he must think that he can just get rid of us. At the state level, the coalition party (the opposition) has fundamentally picked up most of our recommendations, including the important one about increasing salaries. This is essential to be able to attract and maintain dental staff in the public sector. And indeed, they have made these policies the lead of their election campaign for the up and coming year. So at the state level we can certainly see that there’s improvement.  We think that a brisk political debate has developed at a state parliament, which will get us the necessary advancements. But at the national level, we are hoping that many of things that can be done will start to be discussed by the opposition and the Government too.”

Zoellner feels very optimistic, but he is also very impatient too because he says there is not a day to lose on this.

“We have to be prepared for the retiring baby boomer population that’s going to be here in 10 years. It’s going to happen very soon. For us to be prepared for them, we need to be acting right now, getting the public system in place and coping with all those retirees who won’t be able to afford to go to private dentists. There won’t be any available anyway. If you try to find a private dentist in the country now you can’t find one. For instance, if you look in South Western Sydney, you can’t find one either because there are only 32 dentists for 100,000 people in that area. There’s no time to waste and we’re trying to make it clear to all levels of governments that they need to act now.”

Zoellner’s group was instrumental in initiating the NSW dental enquiry, which was submitted last year. He is hoping that the government will respond positively to it and set a precedent for the rest of Australia to follow suit in regards to making a huge step towards permanently fixing the dental problems throughout the nation.

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