Oral health therapists

oral health therapists

Oral health therapists have much to offer a practice yet many dentists remain confused about what they can and can’t do. By Kerry Faulkner

While the path to becoming qualified as a dentist has been relatively straightforward over the decades, not so the oral health therapist (OHT) whose qualification evolution has been a ‘bit of a dog’s breakfast’ in comparison, according to those teaching in the field.

OHT is a relatively new profession, with the first Bachelor of Oral Health Program created in Queensland jointly by the University of Queensland and Queensland University of Technology in 1998.

OHT courses are now available nationally as three-year courses, combining two previous dental training courses—dental therapist and dental hygienist. The result is that in dental practices across the nation, employees hold at least one of these three different types of qualifications and that’s causing problems according to those working in the field.

The first issue is that qualified OHTs are often under-utilised and are becoming frustrated at not using their full skill set. Secondly, dental practices are running well below optimum efficiency because dentists aren’t delegating work to OHTs that they are perfectly qualified to do.

So how did the mishmash of qualifications come about?

Historically, the dental therapist’s role grew from school dentistry. Today they provide oral health assessment, diagnosis, treatment, management and preventive services from children to adults. The scope of work includes restorative and fillings treatment, tooth removal, additional oral care and oral health promotion.

Dental hygienists provide oral health assessment, diagnosis, treatment, management and education for the prevention of oral disease. Their scope may include periodontal treatment and preventive services.

OHT has evolved to combine the two—dental therapy’s oral health care including restorative treatment and extractions, with dental hygienists’ preventive oral care for all ages, in a degree course that includes additional research and theoretical components.

Very few courses now exist offering just dental therapy or dental hygienist training.

West Australian dental therapist Roseanne Toutountzis has more than 30 years’ experience in the field and says there are so many levels of credentials, dentists themselves are confused.

“Dentists need to sit down and talk to each other and figure out who they want to employ and why. If they want just a hygienist to do scaling and cleaning, then employ one but if you want someone in the practice to do more involved work, then employ someone who can do it and pay them accordingly,” she says.

“As it stands now, new graduates who have all these skills and knowledge are going into practices where they are scaling and cleaning for eight hours. So, there are a lot of frustrated women out there.”

Australian Dental Association president Dr Hugo Sachs agrees that while the role of the dental hygienist is clear-cut, that’s not necessarily the case with therapists.

“Before national registration, many of the state boards defined what a dental therapist could do so there was some form of baseline that everyone could refer to,” he says.

“Of course, they were limited to working with children at that stage. Because there is no defined scope of practice for either a dental therapist and an oral health therapist, coupled with the fact that they are not a homogenous group—some have done a bachelor degree while older therapists were prepared to an advanced diploma level—it leaves the dentist not knowing what should be part of their role and what isn’t.

“Once dentists work in a practice, they know the scope and realise OHTs are actually well trained and then they start to utilise them but it’s a slow process.”—Carol Nevin, lecturer and tutor, Curtin University

“The Dental Board could easily address this by providing clearer advice on what their education and training permits them to do and what they can’t do.”

Curtin University dental therapy lecturer and clinical tutor Carol Nevin explains the confusion is impacting on practice efficiency. Many dentists, she says, are filling their appointment books with work that can easily and efficiently be done by their OHTs.

“Oral health therapists do all the hygiene, periodontal and maintenance. We need to see patients every six, 12 or 18 months and that doesn’t make a lot of money in the practice, but it needs to be done.

“But if a dentist is filling their book making appointments for this and treating children—which takes a lot of time—it’s not cost-effective. So, by not employing a dental therapist, they are limiting themselves and not seeing the broad range of patients that they could.

“Oral therapists are trained in prevention and public health and can spend time with patients talking about hygiene and looking at diets. They can isolate why decay is happening and that’s great but dentists don’t have the time to do that. So, they allow for a more holistic approach to dentistry,” says Nevin.

Nevertheless, research published in the Australian Dental Journal in 2015 aimed at exploring which dentists were most likely to utilise OHTs showed an estimated 62.2 per cent of dentists surveyed did not employ OHTs, hygienists or therapists.

It showed 31.5 per cent of dentists employed either an OHT, hygienist or therapist. Just 12.1 per cent employed an OHT, compared to 18.3 hygienist and 7.4 a dental therapist.

The researchers, from the University of Adelaide, said the study was prompted by an increase in the availability of OHTs in the workforce over the past decade.

They randomly surveyed more than 1100 dentists Australia-wide and found those least likely to employ an OHT were those aged over 50, working solely in the public sector, located in Tasmania, Western Australia, New South Wales or Victoria, and who had a single surgery.

Those more likely to employ OHTs were rural dentists, dentists in multiple surgery practices, and those considering practice expansion. It found dentists in the 20-29-year age group were more likely to employ OHTs, suggesting they adopted more of a team approach to service delivery.

Nevin says a team approach to health care, fostered by utilising OHT, is the way forward, pointing to Canada and the United States where she says it’s not uncommon to have three OHTs per dentist. She says it allows them to use the full range of skills in which they have been trained, to stay fresh and have a variety of tasks to make the work more fulfilling.

“Working as a team like this brings about best practice, and the new scope of practice guidelines in Australia talk about ‘structured professional relationships’ which promotes a more collaborative approach,” she says.

Nevin works at Western Australia’s only dental training facility, where courses for both OHTs and dentists are run by separate universities. She believes some existing dentists don’t realise that the OHT training has evolved to the extent that it has, while newly graduating dentists aren’t given a thorough understanding of exactly the scope of what OHTs can do.

“The dental graduates are quite unaware of what the oral health therapist can do. It’s a lack of awareness of their scope of practice,” she says. “It would be good for them to do some integrated treatment planning of a patient as part of their training, using all the dental disciplines.

“Once dentists work in a practice, they know the scope and realise OHTs are actually well trained and then they start to utilise them but it’s a slow process.”

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9 Comments

  1. The dental board of Australia started consultation for the scope of practice of DTs/OHTs on 22/3/18, submissions are due by 14/5/18.

    http://www.dentalboard.gov.au/News/Current-Consultations.aspx

    The Dental Board has proposed removing the structured professional relationship (an incremental step after they have removed the supervision term) allowing OHTs and DTs to operate independent of any relationship with dentists.

    They also recommend that the scope of practice be determined by the individual practitioner based on a”Self Assessment tool”, effectively this means OHTs and DTs can carry out whatever treatment they want as long as they believe they are competent in it and have been adequately trained in this area.

    OHTs and DTs have long claimed the removal of supervision was to allow them to act within a structured professional relationship, however the agenda was always clear they wanted to break free from dentists and operate as a free agent in their own right. Taking this a further step ahead and allowing OHTs and DTs to define their own individual scope of practice is another incremental step the board is taking to blur the definition of dentist and therapist into one “dental practitioner”.

    The services each profession has been trained to deliver are extremely different, and the level of rigor in training also differs immensely. Selection for dental school is competitive and only top ranked students are able to enter the course, although entrance restrictions are present the same is not true for OHT courses.

    Dentists are trained to diagnose all types of oral pathology and have training in oral medicine, pharmacology, and regularly liaise with medical professionals to-co-ordinate treatment plans in medically compromised patients. The same cannot be said for OHTs and DTs who operate on a limited scope of practice and are not trained or qualified to diagnose and treat pulpal pathology, perform surgical procedures (other than removal of baby teeth), treatment plan complex prosthetic rehabilitation, provide advice on tooth replacement options, and interpret full mouth xrays.

    Yet even without this training OHTs are regularly charging 011 codes for comprehensive oral examination where they are not trained to treatment plan anything beyond simple restorations and basic periodontal treatment. These practitioners argue they are performing a comprehensive examination “Within their scope of practice” and they will refer to a general dentist if required. So effectively the consumer has been charged for one “Comprehensive exam” which was in fact not so comprehensive, and did not include key information regarding the prognosis of teeth and the dentition, what restorative options are available (Other than simple restorations), whether they have advanced, moderate, mild, periodontal disease and how to manage it. The creation of a second tier of practitioners adds another layer of cost, inconvenience and confusion and increases the possibility pathology is not diagnosed and not referred as OHTs and DTs cannot be expected to refer pathology they have been trained to identify.

    I have worked in structured professional relationships with a number of dental therapists and oral health therapists, and while I respect their abilities they are limited in scope even within their defined fields of practice.

    For example in the field of periodontology, OHTs and Hygeinists would have you believe they are fully trained in the management of periodontal disease prevention and management. This could not be farther from the truth, while auxiliaries are trained in disease identification and the physical process of debridement the actual diagnosis and management requires the input of a dentist.

    I have seen multiple cases of active periodontal disease being treated by senior OHTs within our health system have been closed without recall despite on recall having no response to non-surgical periodontal therapy with high bleeding scores and numerous pockets greater than 5mm remaining. This is based on recall information from the OHTs own charting on 3 month reviews.

    I have also witnessed the result of multiple overhanging and poorly filled restorations being placed in the permanent dentition of a child under the age of 18 within the same health service when on recall the patient complained of pain with many of the restored teeth.

    While poor quality work is not the exclusive domain of the OHT and DT, dentists more often restore the permanent dentition, and for some time therapists have been insulated by the safety that the deciduous dentition exfoliates, or is removed and replaced by permanent teeth. It has previously been suggested that the number of notifications to AHPRA for therapists is much lower than that of Dentists and Dental specialists, indicating they are safe practitioners.

    This logic is flawed and ignores key contextual factors as if you turn the argument on its head, the data could be construed to OHTs are safer practitioners, and in fact that reduced training increases public safety. The number of notifications a practitioner receives is not simply a function of their competence, and indeed no barriers exist to place a complaint as there are no filters to weed out spurious accusations against practitioners which are not evidence based.

    Another flawed argument used by proponents of OHT expanded scope of practice has been that they will spread out into rural areas and overcome workforce shortages in these areas. This proposition is not based on evidence and is also flawed logic, what particular characteristics of the OHT make them more suitable for and more motivated to partake in rural practice? Advocating a lesser trained practitioner with limited scope work in an environment with limited referral pathways itself does not speak to logic where the current dentist workforce is facing an oversupply. Instead of creating another oversupply of practitioners who are more suited to practice under supervision wouldn’t it seem more logical to provide incentives to practitioners to practice rural, for example waiving some of the massive fees incurred by dental students as an incentive to practice in under served areas?

    It has been almost 4 years since the scope of practice changed to remove the supervision requirement of OHTs, this happened in a climate where there was no need for it to occur (as there was and continues to be a dentist oversupply), and now the Dental Board wants to go one step further and allow independent practice and self determination of scope. No evidence has been provided by the board, or any other workplace report that these changes have had a positive effect on the community, on rural dental health, or on the dental health of the community in general.

    OHTs the HWA and therapist associations talked a big game on how they would revolutionize the world of dentistry and improve outcomes for patients, the time has come for them to deliver the evidence that expanded scope of practice delivers the returns they promised in light of the significant risk independent practice and expaned scope poses to the community.

  2. OHTs and DTs with commensurate qualifications should be able to practice as independent practitioners within that scope. The vast majority of dental hygienists, dental therapists and oral health therapists are women; with the highest rates of dental therapists in remote/very remote areas (AIHW 2013). Most dentists only have a basic undergraduate degree in dentistry and there are no national guidelines on dental diagnosis/treatment. Thus I can go to multiple dentists and receive completely conflicting diagnoses and treatment. There are also a high number of increasing complaints about dentists’ clinical treatment.

    References:
    Australian Institute of Health and Welfare (2013) Dental and Oral Health Survey. http://www.aihw.gov.au/dental/cost/
    Colyer, S. (2012). Dentists face highest complaint rate. Australian Doctor, 28 September 2012. http://www.australiandoctor.com.au/news/latest-news/dentists-face-highest-complaint-rate
    Jensen, E. (2011). ‘Dentistry faculty does bridge work on high fail rate’, The Sydney Morning Herald, September 9, 2011. http://www.smh.com.au/national/education/dentistry-faculty-does-bridge-work-on-high-fail-rate-20110908-1jztp.html
    Serkan, O. (2015). Lack of dentists drives rural patients to GPs. Australian Doctor, 26 September 2015, p. 9.

  3. Women practicing dentistry now exceed males, it is at roughly 50/50 however if trends continue dentistry will be a female dominated profession.

    OHTs and DTs can already and have already been exercising independent decision making within their scope of practice, the issue is not allowing the to make their own decisions it is whether they should be allowed to practice outside a structured professional relationship with a dentist. A dental exam is more than detecting decay and periodontal disease, OHTs and DTs are trained in a limited scope of practice and therefore are not able to diagnose the full scope with which a dentist is trained to diagnose.

    When a patient presents for a checkup the diagnosis and treatment planning is the hardest part, not charting and deciding whether or not a patient needs fillings or a clean. Although many patients ask for “Just a clean” with no xrays and no exam this defeats the purpose of regular dental visits which are to identify decay early before invasive treatment is required. If invasive treatment is required the patient should be treatment planned by a practitioner who is trained to describe possible options and the benefits and drawbacks of each treatment plan, this forms the basis of informed consent.

    OHTs evolved from an amalgamation of Dental Therapists who provide treatment for paediatric patients, and Dental Hygienists, who provide preventative care such as oral hygiene instruction and debridement. OHTs also provide orthodontic and periodontal services under direction of specialist practitioners.

    OHTs and DTs are not trained in essential elements of diagnosis which dentists are, and are unable to provide patients with treatment plans outside of their scope of simple restorations and periodontal debridement. Dentists have no problem with OHTs and DTs practicing independently within their scope of practice however there is a need for a structured professional relationship with dentists as not all dental pathology is decay and gum disease, simply put you cannot diagnose what you have not been taught.

    Regarding dentists vs OHTs and DTs practicing in rural and remote locations review table 9.3 from the 2015 AIHW report. Only DTs had a higher proportion of practitioners in rural/remote locations, the proportion is not relative to other professionals per capita, OHTs and Hygienists work for the most part in Major cities.

    https://www.aihw.gov.au/getmedia/57922dca-62f3-4bf7-9ddc-6d8e550c7c58/19000.pdf.aspx?inline=true.
    Practitioners per 100,000 people in 2013
    Dentists 63.1- Major cities, 41.1- Inner regional, 38.2-Outer regional, 25.7- Remote/
    Very remote.
    Dental hygienists 5.8- Major cities, 2.8- Inner regional, 3.3- Outer regional 2.5- Remote/
    Very remote.
    Oral health therapists 3.4- Major cities, 2.8- Inner regional, 2.9- Outer regional, 0.7- Remote/
    Very remote.
    Dental therapists 2.9- Major cities, 3.8-Inner regional, 4.4-Outer regional, 5.1- Remote/
    Very remote.

    Treatment planning is a skill that requires integration of many basic principles learnt in undergraduate dental studies, while not all treatment plans are the same what matters is whether they can be justified by evidence based practice. Like anything in life there is never an absolute best way to do anything, however when presenting and justifying a treatment plan to a patient evidence based principles are applied.

    With regards to complaints, possibly introspection may help if you ask yourself why you believe dental practitioners are corrupt, greedy and inept compared to those who you champion who are trained for a lesser period of time, in a more limited scope. Have you ever had a customer tell you that they hate you, for no reason other than you being in your profession and then had them request your help? Have you ever told anyone your job and had them tell you how it is a rip off when they are earning more than you and working less with lesser training? Have you ever had to explain to someone what the costs of running your business are to justify the fees you charge only to have someone claim they bought your car for you?

    The complaints process has no filter and increases the cost of AHPRA registration every year, as more and more baseless complaints are lodged the cost of administration to deal with them increases. This is a separate but important issue as vexatious and spurious complaints are ALL investigated regardless of how moronic they are.

  4. The Senate Committee’s 2017 Report on their Inquiry into Complaint Mechanisms administered under the Health Practitioners Regulation National Law found that the ADA’s inference that the 208 notifications dismissed by the Dental Council NSW “were vexatious,…is not necessarily the case.” (p.14; and see: s2.33; p.16). and that AHPRA’s policy for declarations of conflicts of interest by Board members ‘is not sufficiently robust’. The Dental Board reported a 33.8% increase in complaints about dentists in 2015/16. Those statistics exclude patients who complain directly to the ADAQ/ADA or become frustrated when dentists can’t comment on issues with their peer’s treatment (e.g. see Bite Magazine ‘Bad Mouthing’ 2016). A recommended (i.e. non-mandatory) Dental Fee Schedule should be investigated by the government, as their Dental Relocation and Infrastructure Support Scheme (Dept. of Health) will do little to facilitate rural workforce retention if dentists can earn more in capital cities.

  5. I read with interest your recent article by Kerry Faulkner regarding the ‘ utilisation of OHT’s ‘

    I note there are some inaccuracies in her article I would like to address.

    Dental Hygienists have ‘ existed ‘ and practiced for about 100 years.
    The profession developed initially in the USA and has since spread to many countries, primarily 1st world countries.

    The ‘OHT’ course was developed in the late 1990’s in Queensland by Queensland Health steering it , with a number of stakeholders involved including amongst others, University of Queensland and Queensland University of Technology ,DHAA, Dental Therapy Association and ADA.

    Queensland Health hitherto employed Dental Therapists/Nurses in the public sector only.
    They worked primarily in Schools in dental vans.
    Their scope of practice was limited to children to the age of 18 years and involved diagnosis and restoration of hard tissue in the mouth and some oral health education.
    Dental Therapists obtained a certificate ( valid in Queensland only and non transferable interstate ).

    Queensland Health wanted/needed a ‘hybrid ‘ dental professional to provide dental/oral care to a wider and also more remote section of the community .This was their driver for a University based course.
    The ‘hybrid ‘ course thus had to incorporate the skills of both Dental Hygiene and Dental Therapy.
    Additionally, a third module was added to include Oral Health Education and Promotion (QUT).
    Both Dental Hygienists and Oral Health Therapists complete degree courses at University.

    The main difference in skills between a Dental Hygienist and a Dental Therapist historically were thus :

    Dental Hygienists treat all ages – soft tissue
    Oral health assessment. Oral Cancer screening.
    Detection ,diagnosis,treatment of periodontal diseases by non -surgical debridement/root planing and ongoing management .
    Preventive services (Fissure sealants , Fluoride applications, oral health education, dietary advice )
    Tooth whitening
    Extended Orthodontic training/skills
    Extra/intra Oral photography
    Radiographs incl OPG and Cone Beam
    Impression taking

    Dental Therapists treat children to age 18-
    Hard tissue
    Assessment, diagnosis, management and preventive services for hard tissue in deciduous teeth.

    Oral Health Therapists combine both of the above disciplines.

    A Dental Hygienist or OHT are both valuable members of the Dental Team .
    Under AHPRA they are Dental Practitioners within their own right and abide by precisely the same Indemnity Insurance and CPD requirements as dentists.

    We do not operate under the ‘supervision and direction ‘of dentists but work within the oral health team.

    It may be useful to point out at this juncture that Dental Hygienists/OHT’s bring skills to the team that dentists have little or no training or experience in.
    Another fact is that men are entering this profession, so we don’t just have a lot of ‘frustrated women out there’ as noted by Kerry Faulkner.

    I agree with Nevin that all dental undergraduates need to have a more integrated approach to their learning and study within the same University setting and in the same Universities .
    Both require extensive clinical and practical time, and this would automatically promote better understanding, both ways, of either disciplines .

  6. The ADA and ADAQ are not regulatory bodies so I’m not sure why these would be investigated by AHPRA, the organizations have nothing to do with each other. If a patient makes a complaint no matter how ridiculous it is it has to be investigated and there are no exceptions. Having no filter for complaints backs up the regulation system and increases AHPRA registration fees for practitioners which in the end must be passed on to consumers.

    What makes you believe the fees charged by a private individual and a private business should be regulated by the government? There are no other examples of this in any other form of business in Australia. Perhaps I believe I pay too much for shoes, or to my accountant, or for bread, should the government step in and fix prices on these goods and services because I believe they are more expensive than I want to pay? Who will pay for and conduct this “investigation” and set recommended prices and what will they base them on?

    General dental practitioners working in rural locations tend to have higher income and higher patient flow in the right location. The relocation support from the government provides incentives to practice rural and to set up rural practices as the start up costs are astronomical for dental practices. That being said rural practices cannot be set up in small towns which do not have the population to sustain the clinic, this is a pretty basic rule of any business, and not unique to dentistry or any other health service and business for that matter. Just as the majority of the population chooses to do some dentists also chose to live (surprise) in major coastal cities. Because major cities have better access to schools, professional networks, goods and services, better public transport, the majority of people live in major cities, this is a very logical and well known fact.

    Suggesting a recommended fee investigation would provide more incentive for dentist to mover to rural locations does not make any sense.

    Dentists are attracted to rural locations for higher patient flow and income, as well as by rural incentives, you are suggesting by fixing fees AND removing any incentive to relocate to rural locations more dentists will be motivated to work rural?

    Judging by the conclusions you have formed through internet “research” it seems you do not have a good grasp of the issues currently at play within the field of dentistry. I’m not sure it is a good idea to continue to engage in debate over these issues as the pre-conceptions you have formed about the dental industry do not seem as though they will change. Best of luck with your plans to regulate dental fees, if you are able too can you please reduce the price of petrol and electricity as well as these have a far greater influence on my life than dental fees.

    1. Patients commonly complain about dentists’ clinical treatment (eg. Dental Council NSW, 2013, Bite Mag 2012). The Community Affairs Reference Committee 2017 Report on their inquiry into Complaints mechanisms under National Law found that anecdotal claims by practitioners regarding vexatious complaints stood in contrast to independent evidence by the National Health Practitioner Ombudsman and Privacy Commissioner who provided the committee with analysis of complaints lodged. Their analysis found that there are not a significant number of vexatious complaints (1% and 3%) and there is a difference between the practitioner’s (lay) definition and the legal definition of ‘vexatious’. “If vexatious notifications are identified, it is within the power of the national boards to ‘take no further action’ in relation to a notification made under the National Law.” (p.16).

      References

      Bite Magazine, ‘Watchdog releases report on dental practitioners’, October 4 2012. https://bitemagazine.com.au/watchdog-releases-report-on-dental-practitioners/

      Trathen, A., & Gallagher, J. E. (2009). Dental professionalism: definitions and debate. British Dental Journal, 206(5), 249-253.

  7. Consumer that report is written by politicians who have NFI of what is going on, do you believe everything politicians say?
    The report you speak of is not a peer reviewed journal article and it does not paint the same picture as what you have sample from it. You quote it as though it is a hard fact however if I quote other parts of it the meaning can be totally different.

    https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ComplaintsMechanism/Report/c02
    “Evidence of prevalence
    2.22 Most of the evidence the committee received about vexatious complaints was from practitioners who expressed concern that complaints made against them, their colleagues or members of their association were vexatious.

    2.23 For example, the Australian Dental Association (ADA) reported to the committee that of the 421 notifications made against New South Wales dental practitioners in the 2015–16 financial year, 208 were dismissed by the Dental Council of New South Wales.[25] The inference seemed to be that the 208 notifications were vexatious, although that is not necessarily the case.[26]”

    ” However, Ms Georgie Haysom, Head of Advocacy at Avant noted that there is a difference between a lay definition of vexatious and the legal definition of vexatious. Ms Hayson explained:
    The legal meaning of ‘vexatious’ is different from the ordinary meaning, and at law the definition of ‘vexatious’ is very narrow and the threshold for a complaint or other legal action to be considered to be vexatious is high. So the number of complaints that fall within this legal definition is likely to be very small. I think that the ordinary meaning of that is broader, though, and probably the word is used in that broader meaning by many who talk about vexatious complaints.[32]”
    “2.36 All decisions, including those to take no further action, are required to be assessed by the national board or a committee of the national board.[39] In its submission to the inquiry, AHPRA reported that in an analysis of 2718 complaints closed about doctors during the 2015–16 financial year, 64 per cent of complaints were closed following assessment.[40] Complaints were closed in a median timeframe of around two months when regulatory action was not taken.[41] In instances when regulatory action was taken, the median timeframe to close the complaint was three and a half months.[42]”

  8. During the preliminary assessment of a notification, Boards decide whether or not the notification relates to a matter that is a ground for notification [s.149 Health Practitioner Regulation National Law Act 2009]. Boards can take no further action if they believe the notification is ‘frivolous, vexatious, misconceived or lacking in substance’ [s151a] at any time during the assessment or investigation of a notification (Medical Board, Information on Notifications, 20 January 2012). Notifications about dentists increased by 33.8% in 2015/16 (Dental Board Media Release, 10 November 2016) with those referred by the Office of the Health Ombudsman Queensland forming the majority of accepted notifications (see Table 5 Dental Board Annual Report Summary 2015/16).
    Reference
    Health Practitioner Regulation National Law (2018 current) https://www.legislation.qld.gov.au/view/html/inforce/current/act-2009-hprnlq#sec.151

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