This study showed a high prevalence of oral condition-related encounters at GP practices in Australia with an annual national estimation of 1,684,000 encounters. Among the reported oral conditions, dental and mucosal-related conditions were the two most commonly managed types. Medications, referrals to dentists and surgeons, and counselling, advice or education were common management actions for oral conditions. To our knowledge, this nationwide study is the first to provide detailed information about patient and GP characteristics, encounters and management of oral conditions by GPs in Australia.
At Australian GP practices, oral conditions were managed at a rate of 1.19 per 100 encounters. This result of this study may not be directly compared to past UK and Canadian studies’ results on management of oral conditions in GP and physician practice setting due to differences in study design, however the potential disparities in these rates may be attributed to differences in healthcare systems.28 While the UK, Canada and Australia provide universal medical healthcare for individuals, there are differences in how dental services are funded. Dental services in the UK are funded by government and provided by the National Health Service,29 while dental services in Canada and Australia incur solely private contributions and are only funded by the Government for eligible individuals (low-income earners and pensioners).2,30,31 In Australia, out-of-pocket costs have been identified as a major barrier to accessing oral health care in a high proportion of people aged 15 years and over.2 Cost is therefore likely a reason for people to consult GPs for their oral conditions.
Deterioration in general health as individuals age may lead to adverse effects on oral health and the ability to attend health services.32 The present study found that individuals aged 70 years or more attended GPs for the management of oral conditions at significantly lower rates than those aged 54 years or younger. This finding aligns with results of National Study of Adult Oral Health 2017–2018 which reported a decreasing trend in adults of older age groups reporting delays or avoidance of dental care due to costs.33 Older Australians also present more frequently to GPs for general health conditions,34 which in turns decreases the relative management rate of oral conditions despite possibly having a similar rate of oral conditions management to other age groups.
Global studies consistently show that individuals with disadvantaged SES are more likely to have poor oral health and associated pain compared to those with advantaged SES.35–38 The cumulation of low SES, costs for dental services and poor oral health may explain the higher GP management of oral conditions among patients from areas of disadvantaged SES. To reduce public health SES-related inequity, the Australian Government introduced healthcare subsidies in the form of the Health Care Concession Card (HCC), providing free public oral health services to those eligible.33 However, HCC holders reportedly have poorer oral health than non-HCC holders attributable to financial barriers preventing access to private services and long waiting lists preventing access to public services.33 As GP and ED services are more readily accessible, vulnerable Australians may instead seek management through these services instead.
There has been a rise in population of migrants from non-English speaking countries, whom personal oral hygiene practices and health literacy may be different to those raised in Australia.40 Lower oral health literacy and poorer oral health were reported in migrant populations in Australia, Canada, and the US as a result of linguistic and cultural differences.40,41 Poorer oral health, lack of oral health literacy, cultural and linguistic diversities are possible justification for the higher likelihood of seeking non-oral health professionals such as GPs for management of oral conditions.
Similarly, Australian studies consistently reveal poorer oral health among Indigenous people compared to non-Indigenous peers, in spite of the Australian Government’s effort in improving Indigenous oral health care.42–44 This is likely to be correlated to social determinants of health among these communities reflected by the inequalities in education, jobs, and experiences of discrimination.45,46
This study identified significantly higher likelihood of oral condition-related encounters at GP practices located in major cities and solo practices. This observation is unexpected as the dental practitioner to GP ratio per population size has been historically lower in regional or remote areas compared to major cities.47,48 Furthermore, financial barriers may be more prevalent among residents of rural areas compared to major cities, attributed to a higher proportion of people from low socio-economic backgrounds in rural areas.49 The correlation between GP demographics and likelihood of managing oral conditions remains obscure and may need clarification in future studies.
Among the oral conditions managed by GPs, dental and oral mucosal related problems were the most prevalently reported in this study. These findings align well with a study of medical practitioners in the province of Ontario, Canada. This study identified diseases of the teeth and supporting structure, diseases of hard tissues, and diseases of oral soft tissues excluding lesions specific for gingiva and tongue as the most common oral conditions seen by a medical practitioner.12
For the management of oral conditions, GPs prescribed antibiotics and analgesics, referred to a dentists or dental surgeon, and provided counselling, advice, or education. In general, most dental conditions require procedural treatments outside of GP’s scope of practice that involves extensive diagnostic procedures.50,51 In contrast, the prescription of antibiotics in the dental practice has been defined as low-value care, because antibiotics are rarely helpful with relieving the source of infection, symptoms or present harm to the population by antibiotic resistance, and introduces economical and pharmaceutical wastage.52 The correct management of oral mucosal conditions, on the other hand, require accurate diagnostic skills and techniques acquired by education not included in medical education curriculum.53–55
Despite the best intent in addressing patients’ oral conditions, the lack of confidence in managing oral conditions is commonly reported among GPs in Australia.56 As oral conditions are commonly encountered in GP practices, integrating oral health education in medical curricula and continuous professional development of medical practitioners in diagnosis and management of common oral diseases may improve GP’s confidence and accuracy in managing oral conditions while facilitating timely referral to appropriate oral health practitioners.
This study showed that a proportion of patients are consulting GPs for management of oral conditions in Australia. Although the reason for seeing a GP instead of a dentist for managing oral conditions was not explored in this study, past studies have identified high cost and low accessibility as barriers for Australians in accessing oral health care.5 These barriers may explain the higher likelihood of having oral conditions managed by GPs in vulnerable population groups such as HCC holders and people from a non-English speaking background, low SES background or Indigenous background. As there is a lack of public funding in oral health care in Australia, approximately 4 in 10 Australians aged 15 years and over avoided or delayed visiting a dentist due to cost.57 Furthermore, it should also be noted that more than four out of five dentists work in a private care setting.57 Australians who cannot afford or access oral health care may end up seeing a GP for management.
GPs may be exposed to patients who may require urgent management of oral conditions. During these appointments, GPs commonly prescribed medications, provided advice and referred patients to other health professionals such as dentists. As GPs may be involved in oral health care in primary care settings, improving oral health training of GP may in turn improve GPs engagement in the management of oral conditions. Furthermore, a standardised referral pathway from GP to dental practitioner may be developed to improve patients’ rate of dental attendance, which potentially leads to reduction of oral diseases and improvement of self-rated health.58
Although the BEACH dataset provides a large sample size with linkage of GP’s management approach to the oral conditions, this study did not establish the linkage between the management approach and the conditions. While also possible, this study did not report the difference in GP management rates between new and old or recurrent oral conditions. The management of specific oral conditions (new and old) will be examined in subsequent studies. The results of this study are limited to Australian GPs and may not be generalised to other countries. Furthermore, this study has assumed the accuracy of the diagnosis made by the GPs as it is not possible to validate the accuracy.
This study provides a snapshot of current state of oral condition-related encounters in the Australian general practice setting. Findings of this study pave the way for opportunities to improve value and quality of oral health care, and alleviate inequity in accessing oral healthcare. Future studies may be conducted using the BEACH dataset in the investigation of specific oral conditions and management approaches by GPs. Public health initiatives can be developed in educating GPs and other primary care providers (such as nurses and allied health professionals) to recognise, manage, and facilitate timely referral of oral conditions to reduce low-value care and improve overall public health outcomes. Furthermore, policymakers may recognise disadvantaged populations and redirect oral healthcare access to individuals who are susceptible to poor oral health.