Free dental care is not the answer to meeting New Zealand’s adult dental health woes, agrees two dental health leaders.
Both argue a new model of care is needed – but one also argues that making greater use of dental therapists is an affordable answer to improving adult oral health.
Dr Assil Russell, the Waikato dentist who founded dental charity Revive a Smile, and Arish Naresh, a Gisborne-based senior dental therapist who chairs the New Zealand Dental & Oral Health Therapists’ Association, have both applauded Helen Clark for highlighting the need for more equitable access to oral health but neither think universal free dental care is the answer.
Both use mobile dental health clinics to deliver care to high needs community, but – under the current Dental Council regulations – Naresh can only repair and fill dental cavities for adolescents up until the day they turn 18-years-old.
Helen Clark last week tweeted her praise of the Revive a Smile mobile bus heading to West Auckland to treat beneficiaries and others with serious dental problems for free because they couldn’t afford regular dental care. In response to a tweet from Health Central she also added that she believed
“dental therapists could play a key role in making dental care available”.
Naresh, who is also Director of Allied Health and Technical of Tairawhiti District Health Board and manages the DHB’s dental services, believes an oral health team-based approach could be one answer. He believed a team made up of not only dentists but also other dental health professionals – like dental and oral health therapists (see definitions and scopes of practice at end of article) – working at the top of their scope could help make adult dental care more accessible and affordable and at the same time improve the country’s oral health.
Russell supports the dental therapist role with young adolescents but believe taxpayer funding could be best invested by subsidising access to dentists by people with community service cards, so people with high oral health care needs and low incomes – like those she cares for with Revive a Smile – can access the urgently needed dental treatment they otherwise couldn’t afford.
Naresh agreed also with subsidising dentistry level care for low-income people but adds that most oral health disease is preventable and “we should take a preventative approach rather than just look at the high tech level of care.” Russell argues though that it might be “easier and cheaper” for the government to invest in preventative care by therapists it was best to invest more in subsidising dentistry care for young adults and low-income people needing dentistry-level care
Currently in New Zealand every child is entitled to free basic oral health services from birth until their 18th birthday. After you turn 18 people on low incomes who have a Community Services Card may, in some district health board areas, get emergency dental care, such as pain relief or extractions but may still have to pay some of the treatment cost.
Free care not answer, are dental therapists?
The free oral health care for children up to the age of 13 is most provided by dental therapists, employed via district health boards’ community oral health services.
At age 13 they are usually referred to a private dentist in the community who is funded to continue providing free basic care until they turn 18.
But Naresh says while more than 95 per cent of children up to the age of 12 receive free care, this drops to as low as 54 per cent in some areas after they are transferred to private providers at age 13.
“From the age of 13 to 18 only those with parents who are highly motivated seek care…even though it is free care, not a lot of people take advantage of it,” said Naresh.
“So I don’t think providing free basic dental care to all New Zealanders is a simple answer – a lot of thought needs to be placed in the model that is created and how to sustain it,” said Naresh.
“It needs to be financially viable and we need the workforce to meet such an initiative and we need the right investment in the right place otherwise we will be using a lot of taxpayer money in the wrong way. And it should be prevention focused otherwise we are failing…”
Naresh – who manages oral health services for a DHB with a high needs population – thinks a staggered approach is needed for increasing access to basic dental health care including updating the Oral Health Strategy which is now 11 years old. He believed a new strategy should include an operational plan looking at addressing access issues for all New Zealanders, including considering how a free basic dental care model could work.
A first step he believed was developing a better service delivery model for 13-18 year olds so more adolescents are utilising the free service already in place.
“As when they don’t look after their teeth at that age group then they are likely to move towards getting more cavities and dental problems further down the line.” Consideration could also be given for providing basic dental care to older people – like prophylactic scaling and basic fillings – particularly those in residential aged care. Also offering seven day-a-week oral health services with evening clinics so low-income workers who can’t afford to take time off to visit a dentist can actually access care.
More complex oral health treatment and care – including root canal treatment, complex restorations or dentures – he believed should be subsidised by means testing but should not be free. “I’m in total agreement with Dr Assil Russell on that – there needs to be some onus on the general population to look after their own teeth as it is a preventable disease.”
Other countries already use adult dental therapist model
Naresh says there are currently about 13 dental therapists in New Zealand who have an adult scope of practice.
These therapists had historically been providing basic dental care to adults in rural and remote communities (under the supervision of dentists) prior to therapists being brought under the Health Practitioners Competence Assurance Act 2003. They were then ‘grandparented’ to continue with their adult scope when the Act came into force.
Naresh said most registered dental therapists were currently employed by district health boards so while all were qualified to work with adolescents up to the age of 18 only about half currently were – mostly in rural regions where DHBs had outreach services. But some, like himself, were also working with dentists in private practice and providing basic dental care for adolescents signed up to the dental practice.
The practice he worked for part-time also provided a seven day a week service so Naresh treated adolescents at the weekend and the practice had also ‘borrowed’ the DHB’s mobile dental clinic to offer free basic services to adolescents in some isolated areas of the East Coast.
Naresh said a team model of dental care should be developed based on all health professionals providing the best level of care they can under their scope and not a business model.
“But I don’t blame the dentists for having the business model right now, because they have to operate as a small business and earn a certain amount per hour otherwise they can’t survive. Because the cost of maintaining a dental practice is really high.”
But he said the decision that dental therapists could only provide a basic filling for a teenager up to their 18th birthday – and not the day after – was an historic and arbitrary decision, as there was no clinical reason why a therapist couldn’t keep providing basic dental care to a teenager until they were 20 or beyond.
He said at present there is no formal qualification in New Zealand accredited by the Dental Council to allow dental therapists (apart from the ‘grandparented’ ones) to work with adults aged 18 or over, but there was a pilot project underway at AUT to introduce a postgraduate qualification allowing therapists to gain an adult scope of practice.
Other countries – like Canada, South Africa and the state of Alaska already had “plugged the gap” of meeting adult basic oral health needs in rural and remote communities by successfully using dental therapists, said Naresh. Australia had recently moved to offering a postgraduate qualification for adult dental therapy that allowed therapists to work with people up to the age of 26, and the United Kingdom also has dental therapists providing basic dental care to adults.
“It is a little bit sad that due to patch protection mainly, New Zealand, which was the first country in the world to use dental therapy have not progressed far in this area,” said Naresh.
But many low-income people have high dental needs beyond therapist scope
Russell said while dental therapists play a really important role – particularly up to the age of 17 – she points out they don’t have the training or scope of practice to meet the complex dental needs of the people accessing the Revive a Smile service. That includes people with infected and disease damaged teeth and gums requiring root canal treatment, extraction and other dentist-only treatments.)
Russell believed the answer was not for the Government to consider funding therapists to provide oral health promotion and prevention services to adults, but instead funding subsidised access to dentists to the high needs, low-income people who require dentistry-level care.
She said funding therapists would be an “easier and cheaper way” for the Government to respond to oral health concerns but it wouldn’t meet the need of low-income people who couldn’t afford access to the dental treatments they required – like root canals.
The model of care she promoted was for the Government to extend the age for providing free basic oral health care by dentists up to the age of 19 or 20 rather than the current 18 and beyond that age that dentistry care should be subsidised for community card holders. But she believed adult dental health care shouldn’t be 100 per cent free as it would be a “huge burden” on the taxpayer.
Russell, who has just qualified as an endodontist, set up the dental charity Revive A Smile in late 2011 with the aim of providing free dental care and oral health education – including extractions, fillings and root canal treatments – to disadvantaged and impoverished Kiwis. The charity, which uses a pool of about a dozen volunteer dentists, dental specialists like herself, dentistry students, dental assistants and public health promoters, was initially just based in the Waikato but late last year went mobile thanks to a new mobile dental clinic (funded with the help of the Southern Cross Health Trust) that is going out to high need communities in Northland, the Waikato and urban Auckland.
She said the need was not just limited to a few scattered areas but nationwide so that the charity was “definitely expanding” in the near future. “We have people applying from as far south as Invercargill”.
Russell said it was great that the charity’s work had been highlighted by Helen Clark’s tweets and that Clark had helped highlight just how big a problem oral health was, and the need for greater access to dental care.
“But unfortunately the current Prime Minister Jacinda Adern just shut it down as being too expensive ….,” said Russell, commenting in the wake of both her and Arden being questioned on the issue on the TVNZ Breakfast show this week. “The reporter asked her whether it (dental care) should be free, and I (also) don’t think it can be free for everyone, but I certainly think that more can be done to subsidise it for communities in need.”
Dental health professional roles:
- Dentist: The Dental Council defines the practise of dentistry as “the maintenance of health through the assessment, diagnosis, management, treatment and prevention of any disease, disorder or condition of the orofacial complex and associated structures within the scope of the practitioner’s approved education, training and competence”.
- Oral Health Therapist: Oral health degree graduates from 2008 have a new dual scope which basically contains both the dental therapist and dental hygienist scopes. Including diagnosing and treat dental cavities for patients up to the age of 18 and carrying out dental hygienist treatments on adults (including scaling).
- Dental Therapist: Scope of practice that evolved from the original school dental nurse role which includes oral health promotion, diagnosing and treating dental cavities for patients up to the age of 18 and extracting baby teeth.
- Dental Hygienist: Scope of practice is largely focused on the prevention and non-surgical treatment (e.g. removing tartar) of periodontal disease.
- Dental Assistant: Assistant trained to support dentist in their practice