One man's mission to deliver smiles

Media item: article

Date published: 18 December 2023

Subject: volunteer and outreach dentistry

This page records the media item. The original article is the property of its publisher and is not reproduced here.

What this page deliberately does not do

No patient is named or described here. People who receive charitable dental care are frequently people in difficult circumstances, and their treatment is health information regardless of what was published about it.

Section 133(1)(c) of the National Law also prohibits advertising a regulated health service in a way that uses testimonials or purported testimonials about the service or business, so an account of grateful recipients cannot be repurposed here.

What follows is substantive information on the underlying problem: the geography of dental access in Australia.

The problem is distribution, not only funding

There is a companion page in this collection on the funding gap — that dental care sits largely outside Medicare and that cost is the leading reason Australians delay care (Labour of Love). The history of how dental came to be left out is in Manchester Unity Building, and the regulatory comparison in Is dental really different to pharmacy?

This page is about the other half: where the practitioners actually are.

Australia's dental workforce is heavily concentrated in capital cities and in wealthier metropolitan areas. The pattern is consistent and well documented across every review of the workforce:

Practitioner-to-population ratios fall sharply with remoteness. Outer regional, remote and very remote Australia have a small fraction of the per-capita dental workforce of major cities.
Within cities, distribution follows income, not need — and need runs the other way.
Public dental services carry the load in underserved areas, with waiting times for non-urgent care that can run into years.

The result is measurable: people in remote areas have more untreated decay, more missing teeth, and far more extractions relative to restorations — because when access is episodic, the treatment that fits is the one that ends the problem in a single visit. See The stages of dental decay and Replacement options for missing teeth.

That last point matters and is rarely stated. In a place a dentist visits twice a year, a tooth that could be root-treated and crowned over three appointments in a city is extracted, because there will be no second appointment. See Everything you need to know about root canal treatment.

Aboriginal and Torres Strait Islander oral health

The gap here is substantial and it is not a mystery.

Aboriginal and Torres Strait Islander people experience higher rates of untreated decay, periodontal disease and tooth loss, and lower rates of preventive care. See What is periodontal disease? The drivers are the same structural ones that produce every other health gap: access, cost, distance, the affordability and availability of fresh food, water fluoridation coverage in remote communities, and the history that produced all of it. On the last of those, see Fluoridated water: is it good for you? and The benefits of fluoride.

What is known to work:

Aboriginal Community Controlled Health Organisations, which deliver care designed and governed by the communities they serve, and which consistently achieve engagement that externally imposed services do not
Continuity rather than visitation — a service that comes back is worth more than one that comes once. See Is it important to have a family dentist?
Cultural safety, which determines whether a service is used at all rather than merely offered — see Dentists & Registered Specialists
Local employment and training pathways into the dental professions — see Careers, Graduate Program and Dental Internship

What outreach and volunteer dentistry can and cannot do

What it does well:

Relieves pain, which is not a small thing when the alternative is years of it — see Tooth Pain and Ache and How do I relieve toothache?
Reaches people who will not otherwise be reached — in remote communities, in homelessness services, in prisons, in aged care. See Oral health care for children with special needs.
Provides prevention at scale — fluoride varnish, fissure sealants and oral health education, which are cheap, fast and effective. See also Preventing dental decay.
Makes the gap visible, which is a policy function as much as a clinical one

What it cannot do:

Provide continuity. Dental disease is chronic. A visit treats what is in front of it; it does not deliver the recall, the monitoring and the maintenance that actually prevent the next problem — see How often should I go to the dentist? and Dental Cleans and Hygienists.
Scale to the size of the need. The number of Australians who cannot access affordable dental care runs into the millions.
Substitute for a funded system. Every major review of oral health in Australia has concluded that the structural answer is funded dental care, not donated dental care.

None of that is an argument against outreach. It is an argument against mistaking it for policy.

Teledentistry: useful, and limited

Remote consultation has a genuine role — triage, post-operative review, specialist advice to a remote generalist, and oral health education.

What it cannot do is examine. Caries between teeth, periodontal pocket depths, and early oral cancer are not detectable over video — see Oral cancer: how a dentist can help with early detection and How safe are dental X-rays? A photograph is not a diagnosis, and a remote assessment that substitutes for an examination is a risk rather than a service. What a real examination covers is set out in Meshel & Tommy Show: Tommy's Appointment.

Where it works best is supporting a practitioner on the ground, not replacing one.

What would actually change it

The measures repeatedly identified in Australian workforce and access reviews:

Expanding the scope and deployment of oral health therapists, dental hygienists and dental therapists, who deliver most preventive and much restorative care and are cheaper to train and place than dentists. See What do dental hygienists do? and What is the difference between a dental therapist and a dental hygienist?
Rural training placements, because where practitioners train strongly predicts where they practise
Sustained funding for public dental services, rather than programs that begin and end
Community-controlled delivery for Aboriginal and Torres Strait Islander communities
Water fluoridation coverage in communities that still lack it — still the most cost-effective population measure available
And, structurally, bringing dental care into the general health funding system, which is the recommendation that recurs in every review and has never been implemented

If you need care and cannot afford it

Check public dental eligibility. In Victoria, contact your local community dental agency or the Royal Dental Hospital of Melbourne. Concession and health care card holders are usually eligible. Emergency care is triaged separately from general care and the wait is far shorter — see Emergency Dentistry and What is considered a dental emergency?
Aboriginal Community Controlled Health Organisations provide or refer for dental care in many areas.
The Child Dental Benefits Schedule covers eligible children; check through Services Australia or myGov. It is substantially under-claimed — see Child Dental Benefit Schedule and how the scheme operates.
Dental schools and teaching clinics provide treatment at reduced cost.
If you have facial swelling, difficulty swallowing or difficulty breathing, go to a hospital emergency department now. That is a medical emergency, not a waiting-list matter — see Can a dental abscess affect your general health?

Common questions

Who can get the Child Dental Benefits Schedule, and what will it pay for?

Three conditions have to apply together. Services Australia states that a child can get the scheme when they're eligible for Medicare, they're between 0 and 17 years old for at least one day that calendar year, and you or they get an eligible payment at least once that calendar year — an eligible Centrelink payment received by the child, or by a parent, carer, guardian or approved care organisation. There is no form to lodge: You don't need to apply or register for CDBS. If your child is eligible we'll send you a letter.

The benefit is up to $1,158 for each eligible child over 2 calendar years for basic dental services, and the covered list is check-ups, X-rays, cleaning, fissure sealing, fillings, root canals and extractions. Three things are excluded outright: orthodontic dental work, cosmetic dental work, and any dental services in a hospital. Source: Services Australia, Child Dental Benefits Schedule.

If we don't use the whole amount, does it carry over?

Into the second year, and then it is lost. The cap runs across 2 consecutive calendar years, and Services Australia is explicit about both halves of that. You can use the full amount up to $1,158 for each eligible child in the first calendar year. This will leave no funds for the second year. If there is a balance, you can use it in the second year if your child is still eligible — but if you don't use the full amount within the 2 calendar years, you can't use the remaining funds, and you wait for a new two-year period to start.

One timing detail is easy to miss. The cap amount is indexed yearly on 1 January, and an increase will only apply to a child or teenager who received their first eligible service in that calendar year. There are also item and time restrictions on individual services, which is worth asking about before treatment starts rather than after. Source: Services Australia.

Is there a number on the gap that work of this kind is trying to close?

The sharpest one is hospital admissions. The Australian Dental Association, citing its Children and Young People Oral Health Tracker, reports that nearly 11 (10.8) in every 1,000 children aged 5-9 are hospitalized for potentially preventable problems due to dental conditions, and that for Indigenous children this rises to 14.3 per 1,000 children.

The same source records how late care typically starts: only 56% of children visit the dentist before age 5, and one third (32%) of parents reported their child's first visit was for pain or a problem — a first appointment made because something already hurts. The economic scale is on the record separately, where the ADA quotes Professor Jamieson that dental caries imposes a large cost on the Australian economy. That cost is estimated to be up to $1 billion per year. Sources: ADA, Dental Health Week #3: Kids' dental issues mostly preventable, and Children's oral health under the microscope.

Can an oral health therapist or dental therapist do a dentist's work?

Not beyond their training, and that limit is a registration requirement rather than a courtesy. The Dental Board of Australia registers dental hygienists, dental therapists and oral health therapists in their own right, and publishes a Scope of practice registration standard — the current version in force from 1 July 2020 — which applies to all practitioners registered with the Board and requires dental practitioners to practise within the scope of their education, training, and competence at all times. A referral onward is the correct step when a case sits outside that scope, not a failure of the service.

Which is why the deployment argument above is about placement rather than substitution. A submission to the parliamentary inquiry on private health insurance and dental fees, citing an Australian Institute of Health and Welfare survey, records that the highest rates of dental therapists were in remote/very remote areas — that part of the workforce is already closest to where dentists are not. Sources: Dental Board of Australia, Registration Standards and FAQ: Specialist registration; and that parliamentary submission.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment. See also Our Location and Contact Us.

Every practitioner's registration can be verified free on the AHPRA public register at ahpra.gov.au.

This page records a published article and its date, with general information. It is not a diagnosis or a treatment plan. Child Dental Benefits Schedule figures are quoted from Services Australia and the cap is indexed annually; eligibility for public dental services and government programs is determined by the relevant government body and changes, so confirm current eligibility and the current cap with them. Figures attributed to the Australian Dental Association are that organisation's, and material attributed to a parliamentary submission is one submitter's argument rather than a finding. No individual's clinical information is published here. Third-party published content is not reproduced.

Smile Solutions trades under ABN 28 193 514 103.