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Quality healthcare for all

20 September 2018

Dr Aditya Shukla looks at the part played by public dental services in meeting the needs of disadvantaged and rural NSW communities

The Australian healthcare system is well-regarded for providing a vast range of medical and healthcare services to its residents through the medical and pharmaceutical benefits of the Medicare organisation. 

Unlike general health services, however, dental services are not covered by the principle of universal access: the general public is therefore reliant on a largely private dental sector and private health funds throughout the country to provide essential dental care. There are also many remote and disadvantaged communities that cannot access or seek basic dental care for their general wellbeing for a large number of reasons. 

This includes, but is not limited to, factors such as socioeconomic status, social disadvantage, cultural background, lack of equity to dental care, geographic isolation from metropolitan cities, lack of education and awareness of oral health-associated lifestyle factors, and also age-related chronic illnesses along with restriction in mobility.

The role of public services 

Public dental services are very instrumental in providing essential dental care for children and eligible adults that are affected by one or more of the factors outlined above. As a dentist that has worked for the public health system in NSW (also known as NSW Ministry of Health) I have been involved in providing both emergency and comprehensive dental care for a range of communities. 

This includes residents around Newcastle city, remote communities around Taree, the Aboriginal community under the Awabakal centre, and also elderly residents at regional nursing homes through the dynamic Hunter New England Local Health District (HNELHD). HNELHD is one of many districts throughout NSW that delivers essential oral healthcare, including emergency and comprehensive care via community health centres, hospitals and contracted services attached to the private practitioners (oral health fee for service scheme). 

NSW Ministry of Health is dedicated to improving accessibility to oral health services, reducing disparities in oral health status and elevating the oral health status of its communities through primary prevention as outlined by their Oral Health 2020 policy. 

This includes prioritising oral healthcare for specific groups such as young children, children and adults with special needs, Aboriginal and Torres Strait islander people, elderly people and those from rural and remote communities. Primary prevention involves integrating oral health promotion with other health promotion activities in areas like smoking, alcohol and obesity prevention. It is a well-known fact that oral health is integral to general health, with poor oral health likely to be prominent when general health is also compromised and vice versa. Hence a philosophy of prevention and population-level interventions (such as water fluoridation) is helpful in achieving the aspirations outlined by the Oral Health 2020 policy. 

Preventable dental disease

As mentioned before, there are several communities and groups of people in NSW that bear a high burden of preventable dental disease. The first group includes young children who are susceptible to a serious dental condition known as early childhood caries (ECC), which is typically experienced during the preschool years of a child’s life, when developing primary teeth are particularly vulnerable within the first 12 months post-eruption. 

This is a devastating condition that can lead to hospitalisation and dental treatment under GA. Children affected by ECC suffer a lot from the resulting pain, psychological trauma and associated health risks, not to mention the cost of having thousands of children requiring treatment under GA. ECC is typically evident in families that have low socio-economic backgrounds as well as unfortunate family circumstances. Hence a holistic family-oriented approach, in combination with early intervention targeting young children, is necessary. 

People with special needs (which include physical and intellectual disability, medical and psychiatric conditions) have a high risk of oral health problems that require a highly complex level of oral healthcare. Oral health promotion activities can play a very important role in reducing barriers toward accessibility of dental care, which often affects the dental health of this group. Within HNELHD, treatment of patients within this particular group is carried out by highly experienced clinicians, with the aid of relative analgesia (RA) where appropriate. 

Aboriginal and Torres Strait islander people bear significantly more of the oral disease burden in comparison to the overall Australian population of similar age. It is also a well-known fact that more Aboriginal people live in NSW than any other state in Australia, so improving aboriginal health is a key focus for NSW Health via the NSW Aboriginal Health Plan 2013-2023. 

Additionally, the Aboriginal community bears a very heavy burden of chronic diseases such as cardiovascular disease, diabetes, mental illness and injury. They happen to be involved in high risk behavioral factors such as smoking, high body mass and alcohol misuse. HNELHD is instrumental in providing culturally sensitive oral health care to the local aboriginal community via its Awabakal community clinic. This involves provision of community oriented dental care, integrated with delivery of primary health care services (which includes the efforts of GPs, counsellors, dietitians, pediatric care, diabetes education and many more relevant services). 

Apart from providing comprehensive and emergency dental care the oral health team at Awabakal also plays an important role in educating the community about prevention of dental disease through preventive measures (including but not limited to smoking cessation, raising awareness of diet and the sugar contents of a large range of processed foods and drinks, promoting use of fluoridated water and advocating appropriate oral health care habits). 

The benefits of water fluoridation

These preventive measures, when addressed effectively, can greatly reduce the burden of dental disease experienced within the community. For instance, drinking fluoridated water has long been proven to reduce the risk of caries and therefore the number of decayed, missing or filled teeth (DMFT scores) throughout NSW. Water fluoridation is very cost effective and cost saving with regards to oral health outcomes. 

For every $1million invested in capital and maintenance over an average 15-year life of a water treatment plant, there are savings of $7million in avoided treatment costs associated with dental caries. Water fluoridation can be easily extended to all communities regardless of their location, accessibility to dental care, socioeconomic background, and health behavior. Consequently, it is proven to benefit all communities equally. 

Smoking cessation

NSW Ministry of Health is also an advocate for smoking cessation and, as per their recommendations, all dentists should take an active interest in checking the smoking status of all patients that are encountered on a daily basis. This includes brief but persistent and non-judgmental discussion with active smokers about the implications of smoking upon their dental health, as well as an attitude of empathy in understanding the challenges faced by smokers during attempts at smoking cessation. Such discussions, along with referral to NSW Quitline (including therapeutic interventions), go a long way in assisting patients to quit smoking. 

Helping the aged

HNELHD is also involved in providing dental care for elderly residents both around the metropolitan Newcastle areas and those residing in rural communities and aged care facilities. This is a group that also requires close attention to their dental health because there is a significant increase in proportion of people over 65 years and this trend is predicted to continue into the foreseeable future around NSW. 

A large proportion of these elderly people are retaining more of their natural teeth than ever before. This has led to an emergence of a range of chronic degenerative dental disorders (including tooth wear, erosion, cuspal fractures, pulp infection, root fracture and periodontal disease). There is also an increased proportion of people within this group that has complex medical requirements, meaning that dentists need to develop a versatile set of clinical skills in order to treat this group which now requires more dental care than ever before in the past. 

HNELHD is closely involved in delivering dental care to these elderly patients via its ‘ResiDENTAL program’ services which involves travelling to regional and remote nursing homes located over 300kms away from the nearest HNELHD clinic. This is typically a one week trip made frequently with a travelling DA and involves setting up a mobile dental chair with limited resources and dental equipment. 

The patients are typically geriatric and are receiving palliative/ongoing care for complex medical conditions such as dementia, heart conditions, physical disability, diabetes, cancer and mental illnesses. Consent for their dental treatment often requires communication with their legal carers/family members and, where appropriate, liaising with caring staff members at the residential facility so that appropriate postoperative care and prevention can be followed up and provided. 

Setting the standard

In conclusion, HNELHD is a well-integrated key player amongst a group of numerous organisations (including NSW Ministry of Health) within NSW, whose purpose lies in providing primary care and preventive oral health care to a vast range of communities and residents from all realms of society. As an organisation NSW Ministry of Health sets a great example in providing the best possible healthcare that meets the needs of its diverse communities, while also maintaining a sustainable set of values and goals that will continue to address the varying requirements of healthcare within these communities in the long term. 

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