Refugee dentistry

Photography by Jessica Marlow
Photography by Jessica Marlow

One Victorian hospital is working hard to restore the smiles of some of our newest—and most vulnerable—residents. Meg Crawford reports

Despite much ranting to the contrary, asylum seekers are among the most disadvantaged members of the Victorian community. For starters, they receive next to nothing by way of income. The Asylum Seeker Assistance Scheme (administered by the Red Cross and funded by the Department of Immigration and Border Protection) only provides a maximum amount of $227 for a single adult per week—that’s 89 per cent of the New Start Allowance and well short of the poverty line of $412 per week. Plus, until working visa rights are granted, asylum seekers are denied access to Medicare.

Thankfully, public hospitals and organisations like the Royal Dental Hospital of Melbourne (RDHM) provide a ray of hope, extending full health and dental care services to asylum seekers.

In fact, the RDHM goes one step further. Under the Victorian Department of Health and Human Service’s public dental fee and service policies, it is required to treat refugees (that is, asylum seekers who have fled their country and are unable to return due to reasonable fear of persecution, because of factors including race, religion or political opinion) and asylum seekers as “priority one” patients. As priority one patients, refugees and asylum seekers must be seen as quickly as possible—specifically, they must not be put on a general care wait list and are entitled to the next available general care appointment. Similarly, if a refugee or asylum seeker has denture needs, he or she is entitled to the next available appointment, failing which he or she will be placed on a priority denture waiting list. Specialist care, on the other hand, can still be subject to a wait list of several months.

According to the RDHM’s CEO Dr Deborah Cole, categorising asylum seekers and refugees as a priority one patient group (other priority groups include children under 12 years of age, pregnant women and homeless people), is a no-brainer. “We know that people who are refugees and asylum seekers have a much higher rate of dental disease than others,” she says. “So, it’s very logical to say, ‘Let’s make them a priority so that we can try to throw the book at them, so to speak, with resources to try and make it better.’”

In line with this policy, the RDHM aims to provide the best possible dental services to asylum seekers and refugees. The ambition is not straightforward, however. There are multiple complicating factors of which dentists need to be mindful when dealing with refugee and asylum-seeking patients, including the horrifying fact that some patients have been subjected to torture. Sadly, numerous cases have been reported of patients subjected to oral torture—including by dentists allied with various regimes and governments—involving bright overhead lights and loud noises. Accordingly, there is a risk that ordinary aspects of dental care could trigger trauma, such as the mere act of reclining a dental chair, which puts the patient in a position of powerlessness.

“Many [children] have spent years in … refugee camps and have huge dental caries—a big need for dental treatment.”—Dr Sophie Beaumont, RDHM

On top of this, many asylum seekers and refugees have not had access to dental care and so exhibit poor dental health as well as an alarming ignorance about the importance of maintaining good oral hygiene.

“Refugees and asylum seekers often come out of an environment where dental and oral health is not highly regarded,” Dr Cole explains. “Often it’s the exact opposite because of torture and things like that, and the fact that people have come out of war-torn countries where they’re just surviving—and having preventive services and looking after their teeth isn’t an option. So, when they arrive here, there’s often been years of neglect, sometimes through malnutrition, poor diets or torture. They’re also in a new environment where they’re worrying about whether they’re going to have a roof over their head, food and education for their kids—dental care is not going to be a priority or the first thing on their minds.”

Dr Sophie Beaumont is one of the dentists treating refugee and asylum seekers at the RDHM. She has spent the past 25 years working in both the private and public sector, although for the past 15 years she has focused on public sector dentistry. When Dr Beaumont moved to Melbourne from Adelaide, she accepted a job in community health and never looked back. “I loved it,” she says. “I feel that you can do a lot more good in the public sector than in private practice. We had a much more needy and more diverse population of patients. I find it more interesting and rewarding to look after that group.”

These days, Dr Beaumont’s weekly work commitments are three days in primary care at the RDHM, and one afternoon in day surgery. She also works at teaching clinics associated with RMIT and the University of Melbourne.

Concerning the RDHM’s focus on refugee and asylum-seeking patients, Dr Beaumont notes that it comes with a unique set of challenges. “We look after a lot of refugee and asylum-seeking patients here, in various different states of oral health,” she says. “I think the most confronting for me are the little children that we see going through the day surgery unit. Many of them have spent years in or been born in refugee camps and have huge dental caries—a big need for dental treatment. Consequently, they end up having a general anaesthetic for their treatment, where there are many extractions that need to be done. It’s always disturbing.”

handsLanguage difficulties and attendant issues of consent also present barriers. “We always have to use a qualified interpreter,” says Dr Beaumont. “We’re lucky enough to have three on site—an Arabic interpreter, a Persian interpreter and another interpreter who speaks Cantonese, Mandarin and Vietnamese. It’s really helpful when you have that face-to-face interpreter. If we’re unable to get by with any of those languages, we have to use telephone interpreter services. It’s more difficult because you don’t have that face-to-face contact and it’s more difficult to establish rapport with patients. It also takes longer to establish rapport when there are language barriers—that’s another consideration. We’re often under quite tight time constraints—especially in primary care—but we just have to make sure that we have enough time to get informed consent. We usually get there, somehow. If it’s too complicated, though, we can re-book the patient and make sure that we have an onsite interpreter.”

To assist with language issues, the RDHM seeks to use staff who speak the language of the patient where possible, and to ensure that information is presented visually.

Distrust of authority figures can often pose a barrier too, Dr Cole says. “One of the key things is to develop relationships really well and I don’t necessarily mean relationships with the patient alone—I’m talking about the organisations and the other settings that they deal with. If we can develop a trust relationship with the organisations that work with refugee and asylum seekers and develop a reputation for being able to help and being non-judgemental, then we find that there are really good referral pathways and good messages sent.”

In light of this, the DHSV’s strategy is to expand the points of contact with refugees and asylum seekers beyond dental practices. “We need to get the word out there, not just by dentists and dental auxiliaries,” Dr Beaumont says. “We need to get the word out more broadly to immigrant groups, kindergartens, schools, maternal and child health centres and pharmacists. I think all of us have a responsibility to do that. We can all spread the word and educate others about the services available and prevention. A few weeks ago, I did a talk at the Australian Breastfeeding Association and none of the mothers even knew that the dental hospital existed.”

One good news story to emerge from what is often a heartbreaking situation is the success of the RDHM’s dental healthcare and prevention program for children in childcare and preschool called Smiles for Miles. “A lot of refugee and asylum-seeker children are in that bracket,” Dr Cole says. “I’ve been out in that environment and seen little kids opening up their mouths to smile with black teeth. I can remember thinking that I hadn’t seen teeth like that for years, because I’m of an age when you did see people with teeth like that. But we’re seeing a change in these kids over a really short period of time. They start by coming to school with lunch boxes with shocking food that they shouldn’t be eating, especially not when their teeth are black. Now, they’re telling mum and dad or carers about good food and what should come in their lunch box. It’s not just improving the child’s life; the whole family is picking up the information. It’s a real success.”

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