Rich kids / poor kids

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Changes to included Medicare item numbers in the Grow Up Smiling rules are likely to cause more problems than solutions, dental specialists say. We asked the Department of Health and Ageing what they were thinking. By Chris Sheedy
Under the Grow Up Smiling rules, there are different standards of dentistry for rich kids and poor kids.
Under the Grow Up Smiling rules, there are different standards of dentistry for rich kids and poor kids.

New regulations announced for the Grow Up Smiling child dental benefits schedule have been accused by some thought leaders in the dental field of being a step backwards. It’s a turning back of time, they say, from a system that was leaning towards supporting preventive dentistry to one that virtually enforces invasive treatment and serious future oral health issues onto lower income families.

“When the new regulations were proposed they called for submissions. I was disappointed and responded with suggestions but they were ignored,” says Associate Professor Wendell Evans from the Faculty of Dentistry at the University of Sydney. “It’s supposed to be a preventive program, not a treatment program. In fact the government is removing nearly all of the prevention elements in the program. We’re no further ahead. We’ve actually gone backwards!”

The greatest controversy comes from the dropping of preventive treatment item Medicare numbers that were included on the now defunct Chronic Disease Dental Scheme and that are also currently included on the Australian Government’s Department of Veterans’ Affairs program. The missing items include: 123—concentrated remineralising agent (application to specific teeth); 131—dietary advice; and 141—oral hygiene instruction.

“These three items are crucial to a proper preventive clinical treatment being given to the children according to their individual needs, says Dr Catherine Groenlund, a dentist and former dental lecturer. “When dealing with children, you want to do the least invasive treatment and to treat sustainably. That means changing the challenge the children have for better oral health, speaking to them, and especially to their parents, about diet and individualised instructions about tooth brushing.”

“The new rules are incredibly short sighted. They will result in a lack of oral health education, far greater oral health issues and a greater cost to the taxpayer when it comes to resolving these issues. If I see a child when they’re young and I see evidence of decay, with topical fluoride varnish and time spent looking into their history and habits and discussing oral health options, I can make sure that tooth survives without a filling. Without these options, early decay will turn into a cavity.”

“There are even plenty of safeguards that exist if they want to implement it and monitor it to ensure there is no abuse of the system. But they don’t want to. The cynical view is that they want to let the system run badly as an excuse to close it down.” – A/Prof Evans, Faculty of Dentistry, University of Sydney

In discussing how the new policies turn back time, A/Prof Evans says that in the 1950s and ’60s the average 12-year-old child in Sydney had 10 decayed, missing or filled teeth. “Then fluoridated water and fluoride toothpaste came in and now it’s around 0.5 bad teeth per 12-year-old. But there are some children who still have high rates of decay. Thanks to their exposure to junk food, sugar, frequent eating and cordial, soft drinks and sports drinks, their teeth disappear,” he says.

“Tooth decay can be prevented. If you’ve had almost no exposure to sugar then even without fluoride toothpaste, just the fluoride in the drinking water will do a lot to help. Brush your teeth twice a day, have fluoride in your water and a good diet then decay really can be kept to a minimum. Dentists can easily check the early signs and take action and apply fluoride varnish to stop the decay progressing to become a cavity. In high-risk children we believe this should be done every three months. Early decay needs to be monitored and parents need to be educated about diet and tooth care, and receive tooth brushing coaching. If you do this then the decay will stop progressing and will remineralise and we’ll be back to a good set of teeth again. That possibility to stop decay from progressing to become cavities has been eliminated now because of this rule change.”

And it’s this fact that most upsets Dr Groenlund. These new rules, she believes, will create an oral health chasm between the rich and the poor. It will make the most user-friendly and effective practice of dentistry—the practice of preventive dentistry—something that only the wealthy can afford. And dentists who work in lower socioeconomic areas, she says, will be expected to do endless amounts of pro-bono work if they are to spend time investigating their patients’ lifestyles and educating them and their families about their individual oral health challenges.

“It’s just so ridiculous for a Labor government that is philosophically supposed to be looking after the needy and the poor to take away prevention and communication abilities of the dentists that look after them,” she says. “We can take them out of pain once the problem becomes serious, but if we have to do five fillings instead of two or three series of individualised fluoride varnishes then the child will be traumatised and very unlikely to ever want to return to the dentist for further check-ups and treatment.

Associate Professor Wendell Evans of  the University of Sydney’s Dental School says under the new regime, funding is going backwards.
Associate Professor Wendell Evans of the University of Sydney’s Dental School says under the new regime, funding is going backwards.

A/Prof Evans’ greatest disappointment in these rulings comes from the fact that our understanding of tooth decay has come such a long way over the past few years, but the science has been ignored. “I and my colleagues have developed new protocols around how to manage tooth decay in a modern way,” he says. “All the individual methods for managing tooth decay have been tested separately and we’ve put everything together into a protocol to apply to individuals. You assess patient risk then apply a risk-specific treatment strategy to address the issues. Nobody had ever properly tested this but I have just completed trials and we have seven years of results, although only the three-year results have been published at this point. They show that dentists in the real world who wish to practise preventative dentistry can do so effectively.

“So of course this should be made possible and rolled out for everyone. If the government was serious they’d look at our protocols to see how it’s done. They’d want to see first how we assess people to determine decay risk and secondly, how we manage this risk. There are even plenty of safeguards that exist if they want to implement it and monitor it to ensure there is no abuse of the system. But they don’t want to. The cynical view is that they want to let the system run badly as an excuse to close it down,” says A/Prof Evans.

On the topic of abuse of the system, both A/Prof Evans and Dr Groenlund say they have been told that during a phone hook-up with various state dental bodies, a representative of the office of the Minister for Health and Ageing told those listening that the Medicare items have been removed partly because of a fear that dentists will rort the system by overdoing the educational part of their job. But as Dr Groenlund says, the Department of Veterans’ Affairs allows this work to be carried out and paid for by Medicare, and there are already checks in place within that system to ensure it is not abused. Some of the health funds also have these items; they maintain a compliance framework that dentists adhere to.

The government’s response

When an interview was requested by Bite magazine the Department of Health and Ageing did not put forward a spokesperson but instead provided this written response to the concerns that have been raised by our experts. In order to offer the greatest chance for readers to be informed of both sides of the argument, we print it here in full:

child-at-dentist “The Australian Government will be providing an additional $600 million a year into the Australian dental system to assist in the funding of child dental services. This funding is on top of current expenditure on dental preventive and treatment services. It will result in many eligible children getting access to basic dental services (including treatment of decay with basic restorative services) where little or no funding was previously available to them. It should be noted that most children were not eligible for the Chronic Disease Dental Scheme.

“Separate benefits are not included in Grow Up Smiling for dietary advice (item 131) and oral hygiene instruction (item 141) because this information should form a part of normal conversations between practitioners and patients. Analysis of claiming through private health insurance shows that very few claims are made for these items, strongly indicating that dietary advice and oral hygiene instruction already form part of advice provided to patients during examinations.

“Grow Up Smiling provides a benefit for the topical application of remineralisation and/or cariostatic agents (ADA item 121), which is the predominant fluoridation service claimed under private health insurance. Analysis of claiming through private health insurance shows that few claims are made for item 123 (concentrated remineralising agent). It is problematic to make direct comparisons between arrangements for Grow Up Smiling and those for Department of Veterans’ Affairs dental schemes because of the huge differences in patient numbers.

The size of the cohort of patients for Department of Veterans’ Affairs schemes is a small fraction of that for Grow Up Smiling. Mechanisms to ensure compliance with scheme requirements and to prevent substitution and/or over servicing must be appropriate to the much more significant scale of activity that Grow Up Smiling services will represent for dental clinics and individual dental providers.”

In conclusion

It’s difficult to ignore Dr Groenlund’s argument that dentists in lower-income areas will, as of January 2014 when these new rules come into play, now face an entirely new challenge in finding time to investigate lifestyle causes of decay in children’s teeth. It’s also clear that government policy is leaning more towards treatment than prevention, which could prove a costly future mistake. At the same time, an injection of a further $600 million annually into the Australian dental system can’t be completely terrible.

Whether you believe this to be good policy or not, it’s vital that you’re aware of the influence it will have on the time you get to spend with patients and their families discussing and educating in oral health.

1 COMMENT

  1. The DHAA recognises the GUS aims to target children of lower income families who are at the greatest risk of dental caries. However, these children and families also require investment in individual oral health education to facilitate the behavioural change needed to address poor oral health. This should be addressed as a matter of urgency. DHAA Inc. believes any child dental scheme with a claim to deliver preventive care must include the following items:

    131 Dietary Advice
    A recent study published in the American Journal of Public Health revealed that of 16,800 Australian children studied: over 56% consumed sugary drinks daily; 13% consumed more than three daily; and children from lower income families consumed almost 60% more sugary drinks than other children (Armfield et al. 2013). If children from lower income groups are the initial target population in GUS policy, and if the intended outcome is to reduce childhood caries, then it is essential this group of children receives dietary advice from oral health professionals.

    The omission of item 131 is startling. It represents a missed opportunity not only to improve the oral health of each child but also to tackle juvenile diabetes and obesity, both of which cause significant health and financial costs to the individual and the public purse.

    141 Oral Hygiene Instruction
    Oral hygiene instruction is fundamental in oral health care. A policy which is not inclusive of the fundamentals cannot be described as preventive in design. Services provide under item number 141 include individual tooth brushing instruction for plaque control, appropriate information on the use of Fluorides and flossing instruction to care for the gums.

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