Will producing more dentists solve all the workforce issues in rural and remote areas?

Australia is one of the most sparsely populated countries in the world, with the majority of its population (88%) living in metropolitan cities, whilst the remainder live in outer regional or remote areas. Like many developed countries, dentistry in Australia faces significant labour force issues, particularly maldistribution.1 The majority of practising dentists work in private settings, mostly concentrated in metropolitan areas.2 A significant variation in the number of dentists between urban and rural regions does exist, with the number of dentists practising per 100 000 population highest in major cities (64.3) compared to remote/very remote areas (21.5).2 The unwillingness of dentists to practise in rural settings is a complex issue, with factors such as access to specialist training, low remuneration and social reasons just to name a few.3 As a result, many rural and remote communities are left underserved, even though people outside capital cities have poorer oral health than people living in capital cities.4 In contrast, mid-level dental providers (MLDPs) such as oral health therapists, are distributed more evenly across rural and remote Australia.2 However, they only represent less than 7% of the dental workforce, accounting for less than 7 therapists per 100 000 population, and with 30% of these therapists working in the private sector.2 It is projected that shortages of this group of dental professionals in rural Australia will continue.5 Previous research identified a number of reasons for Australian MLDPs leaving the profession in rural settings, including family reasons, relocation, career change, poor salaries and lack of access to continuing education.6 Against this background it is important to continue to explore options to address the unmet oral health needs and expand access to care among underserved populations. Labour force substitution in dentistry is not a new concept. The deployment of MLDPs to provide routine and preventive dental care has been well received in many Western countries.7 In Australia, the role of MLDP is well described in relation to their scope and practice.2 Although the practices of MLDP have been limited to under 18-year-olds, their scope of clinical practice has been extended in some Australian states to treat adult patients.8 Substantial evidence indicates that MLDPs are able to provide quality, safe and effective dental care at low cost, and their employment are now being considered rational and cost saving.7, 9 Developing and deploying MLDPs (with the extended duties capacity) from rural communities has been one way to ameliorate the maldistribution issue. Recent reports on the Alaskan workforce model demonstrate that students with a rural background are more likely to return to their villages where they had been raised, after graduation.10 Locally recruited students are more willing to work and live in rural areas on a long-term basis compared to most dentists who were recruited from and trained outside of rural areas.10 This has been seen as true in other health disciplines where the evidence is even stronger than in dentistry, with available evidence indicating that selecting applicants with rural origins and providing exposure to rural experiences during training enhance likelihood of rural practice.11 James Cook University (JCU) College of Medicine and Dentistry was established with a mission to select and educate medical graduates prepared to work as doctors in rural and remote Australia.12 A report on the early career outcomes of JCU medical graduates in the first six cohorts shows that 46% of JCU graduates planned to work in rural towns compared with 16% of graduates from other medical schools.12 This has been supported by early data from JCU School of Dentistry,13 as well as anecdotal reports from other rural based dental schools (MT personal communications). Given that a shortfall in the number of MLDPs in rural Australia is projected to increase, developing and recruiting rural students should contribute to increase the capacity of dental workforce in rural areas.6 Because many patients need first-line access to basic dental care (and if necessary triaging to higher level care), MLDPs with extended duties would be able to provide care to uncomplicated cases, and manage care pathways for more complicated cases to dentists. Similar to other health professions, the deployment of MLDPs would be expected to be more efficient and cost-effective.14 Therefore, the use of MLDPs has the potential to increase care access and reduce disparities in oral health status between rural and urban regions.15 Real-time feedback and communication between practising rural MLDPs and city-based mentor dentists have been a source of frustration among many MLDPs.16 Providing regular training to rural practising MLDPs is essential to build their capacity in treating patients.16 Making use of technologies such as telemedicine to provide consultation and training would reduce the isolation of rural MLDPs and assist them in diagnosis and appropriate treatment planning.17 Based on reports from Alaska's dental health aide therapists programme, the use of telemedicine has proven to be successful in connecting rural MLDPs with ‘supervisory’ dentists, and ensuring they demonstrate competency in their defined (wider) scope of practice.10 Simply producing more dentists is unlikely to completely solve workforce maldistribution problems, but deploying MLDPs (with appropriate scope of practice and support to serve underserved regions), might be an approach to reduce the maldistribution issue. In the longer term, recruiting and training different members of the dental team from rural communities, offer a practical and effective way to increase the retention and recruitment in rural and remote settings. In addition, offering support, consultation and incentives to rural dental practitioners might contribute to workforce retention. These strategies can serve as beneficial tools to ensure equality in provision of oral healthcare services and bridging the gap in rural-urban oral health.