Oral Health Therapists across the Tasman can provide basic dental care to people up to age 26. Arish Naresh asks why they can’t do the same this side of the ditch?
Change is a constant in delivery of oral health services. Since the introduction of dental nurses in New Zealand in the 1920’s, a lot of things have changed in the way we, as health practitioners, deliver care to our consumers.
Our world is set to change once again and so it should. On November 1 New Zealand’s new oral health therapy scope of therapy came into practice and 440 oral health therapists were registered. Oral health degree graduates since 2008 have been trained to have dual scope which basically contains both the dental therapist and dental hygienist scopes. But while oral health therapists can scale the teeth of adults there is still an age restriction – just like their single scope dental therapist colleagues –that means they cannot diagnose and treat cavities or carry out similar dental therapy care in anybody aged 18 years or older.
Not extending the dental therapy scope of practice beyond the age of 18 limits the full potential of this role. It is actually not extending scopes of practice but extending the age that is necessary to meet the needs of the lower socioeconomic groups.
This then raises the question of whether an extended age range for the oral health therapy profession could be beneficial to its consumers?
The average New Zealander has little or no knowledge about the professions that exist within oral health. Oral Health is an integral part of general health but it’s not always at the forefront of health policy agenda setting.
Dental therapists, hygienists and oral health therapists have been the drivers of preventive oral health services in Australia and New Zealand. The School Dental Service has been in existence since the 1920’s and has now moved towards a community oral health service model of care.
However, challenges remain in provision of dental care to the New Zealand population. The mix of private and public dental services is not currently meeting the dental needs of our adult population. This model needs to further evolve to allow more flexibility for new graduates with dual scopes of practice to be able to utilise their training and skills to their full potential.
Patients from lower income groups are not routinely accessing oral health care and increased dental needs in residential care populations also raises the question of extending the scope of oral health therapists/dental therapists to provide dental care to those in most need.
The 2009 National Oral Health Survey evaluated the current state of oral health for the people of New Zealand and acknowledged that dental decay was still one of the most prevalent chronic diseases amongst New Zealanders.
People from middle to high socioeconomic backgrounds tend to visit a dentist after their eighteenth birthday, as opposed to those from lower socioeconomic backgrounds. The 2009 survey also found that only 47% of New Zealanders visited their dentist each year. Similarly, an American study found that 65% of the population visited their dentist each year.
A common factor in both studies was the socioeconomic skew, which translated into the higher socioeconomic groups accessing care while the lower socioeconomic population delayed care until they were in significant pain. People with dental abscesses or facial abscesses from dental origins present at emergency departments across the public hospitals in New Zealand; it is a trend seen in many developed countries.
A study that looked at the distribution of private practices in New Zealand concluded that due to the market being the driver of private practice models, this dental care is concentrated in the areas that least requires it. The higher number of dental clinics in more affluent areas strongly suggests that people with more disposable incomes are accessing regular care, while the people in less affluent areas are not.
Public dental health services for adults in New Zealand are limited. This was also highlighted through the High Needs and Vulnerable report produced by the New Zealand Oral Health Clinical Network Group. The report emphasised the need for systematic changes to address the dental needs of Maori, Pacific Islanders, migrants and people living in disadvantaged or remote/rural communities.
It is essential to look at global solutions that are currently utilised elsewhere, then customise these to suit the needs of the New Zealand population. Another option that requires further investigation is utilising knowledge and learning from other health sectors that have increased access to dental care for deprived communities using extended scopes or advanced practice of allied health professionals. These models can potentially be applied to oral health.
An example of a discipline that has advanced its practice is nursing. This profession has evolved from generalist nursing roles to advanced practitioner roles in New Zealand. The nurse practitioner role evolved in the United States as early as 1965 and is continuing to grow worldwide.
In the United Kingdom, the role was expanded to ease the pressure of general medical practitioners in disadvantaged communities. Nurse practitioners can in some cases prescribe and independently run their practices.
A nurse practitioner employed in residential aged care in Tairawhiti, New Zealand has resulted in fewer admissions to hospitals from rest homes. This results in saving the taxpayer money and reducing pressure on hospitals. Another example is a comparative study in the United Kingdom that found no difference between clinical outcomes for patients when receiving care from nurse practitioners in comparison to those receiving the same care from general medical practitioners.
It is clear that, as a result, the nursing profession has demonstrated that advancing practice for its profession has benefitted its clients and the whole of the healthcare system. It has led to increased access and reduction of costs in primary health care.
The latest report published by the National Health Service titled Fit for Purpose? also identifies the need for investigation into new and extended roles to address the needs of the population. The report recommends an assessment of whether low level work can be designated to unregulated workforces under supervision of credentialed staff.
Another report comparing dental hygienists advancing practice against the development of the nurse practitioner role in the United States also affirms the potential of advancing mid-level professions within oral health.
Moreover, the use of dental therapists in increasing access to oral health care in Alaska and in Minnesota shows that it does have this potential.
The Australian example proves that New Zealand could progress to this stage as well. A pilot study in Victoria has also demonstrated that dental therapists with appropriate training are able to provide care to adults to a level equivalent to that of a newly graduated dentist (This has since been adopted widely and currently there are no age restrictions for practice in Australia).
In Australia, many dental therapists and oral health therapists can now provide restorative care for people up to age 26 years and there are now three undergraduate Bachelor of Oral Health courses and two postgraduate courses that enable full age range dental therapy scope of practice. In addition, there are dental Therapists and oral health therapists who work in the private sector in Western Australia who provide restorative care to people of all ages on prescription of a dentist. All Australian dental hygienists and oral health therapists, and now an increasing number of dental therapists can undertake comprehensive oral examination, diagnosis and treatment planning for people of all ages and the requirement for supervision was removed from legislation in Victoria in 2006 and nationally in 2014.
Furthermore, Australia and New Zealand have a Trans-Tasman Mutual Recognition (TTMR) agreement for oral health and dental therapists enabling portability of qualifications which is supported by joint accreditation processes between Australia and New Zealand.
This raises an interesting conundrum for practitioners working across the Tasman. For example, a New Zealand registered oral health therapist with appropriate education and competence would be able to practice with all ages in Australia, but an Australian graduate registering in New Zealand would have their practice limited to people up to the age of eighteen. From workforce employability and for practitioners to maintain their competence, this legislation needs to change to accommodate the clinicians desire to work across the Tasman.
The future of oral health therapy could also include prescribing lower level analgesics, antibiotics and any other approved medication that would potentially reduce duplication in healthcare. A child currently requiring antibiotic cover for dental care has to see their general practitioner before prescribing can take place, putting further strain on an already strained primary care service. Therefore, training programs need to be developed in New Zealand that allow mid-level practitioners to prescribe medication that are directly required by their clients.
So where does this leave the dental therapists and hygienists who trained prior to the introduction of dual scopes of practice?
When the new training programmes were introduced, an opportunity was missed to create a bridging programme for dental therapists and hygienists to complete an oral health therapy qualification. The concept was discussed but nothing of substance eventuated. This has now created different workforces within the oral health sector with different levels of skills.
New Zealand employs most of its dental therapists in the public sector while the hygienists work in private practices. Oral health therapists have the ability to work in both sectors but more recently, due to difficulties in finding employment that allows dual graduate clinicians to practice both scopes, clinicians have to make a decision to practice either therapy or hygiene.
Hence, the sector was not ready for the change in my opinion and we have in some ways ended up where we started; we have made progress but the process could have been better. A well thought-out strategy was required with a robust implementation plan so that the profession, the sector, the employer and the consumer all understood the vision behind the change in practice. It takes a lot of planning for theory to change to practice and in this instance, some parts of the change were better carried out than the others.
I conclude the article with more questions for the reader than answers. My questions may or may not lead to innovative ideas but they are designed to provoke thoughts on what the future of oral health care would look like and how our profession would or should evolve to meet those demands. The questions are:
- Will the Community Oral Health Services, currently providing a Monday to Friday, 8-5pm service for children and adolescents, provide a service for adults, as envisioned in the 2006 oral health policy, Good Oral Health for All, For Life?
- Should the scope of practice enabled in Australia for dental hygienists and dental and oral health therapists be replicated in the New Zealand environment?
- Where is the evidence to show that dental hygienists and dental and oral health therapists practice requires age limits imposed on their patient groups?
- Is there potential for the oral health therapist in prescribing medications.
- How do we, as oral health professionals, advocate integrating oral health into all general health agendas?
I hope the above questions lead to some answers but plenty more questions going forward. Our sector has and will continue to be leaders of population level oral health and this requires continuous advocacy for scope of practice that would benefit the consumer.
Unless there is increased access, equity and equality, the business of oral health care is failing in its duties in providing true patient centred care. We have changed the way we work and we will continue to change, let us just not forget the consumer in the process of change.
Arish Naresh* is the Director of Allied Health and Technical for Hauora Tairawhiti (Tairawhiti District Health Board), a dental therapist and the chair of the New Zealand Dental and Oral Health Therapists Association.
This opinion piece is drawn from an article first published late last year in The Australian and New Zealand Journal of Dental and Oral Therapy.
*MHSc (Dist), Dip. Dental Therapy (Hons), PG Dip. in Health Services Management
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