Beyond Scope of Practice: Rethinking the Utilisation of OHTs in Australia

Defining Underutilisation

Before considering whether oral health therapists are underutilised, it is necessary to clarify what the term itself means. Although discussions of underutilisation frequently refer to scope of practice, the two concepts are not synonymous. According to the Dental Board of Australia (2024), scope of practice is determined by an individual practitioner's education, training, competence and the needs of the patient, rather than by professional title alone. Consequently, legal authorisation does not automatically determine what a clinician should, or will, provide in practice.

This distinction is also reflected in the Australian literature. Teusner et al. (2016) examined the applied scope of practice of oral health therapists, dental hygienists and dental therapists, highlighting that the services delivered in everyday clinical practice are influenced by workplace and employment factors rather than professional registration alone. More recently, Carlson-Jones et al. (2026) noted that scope of practice has not been consistently defined or measured across studies of the Australian oral health workforce, making direct comparisons between education, capability and clinical practice difficult.

For the purposes of this paper, underutilisation is therefore defined as the situation in which practitioners possess the education, competence and regulatory authority to provide appropriate care, yet are unable to translate these capabilities into clinical practice because of barriers external to their professional capability. Such barriers may include organisational policies, funding arrangements, workforce structures, referral pathways or employer expectations. Defining underutilisation in this way shifts the discussion away from individual procedures towards the broader systems that translate professional capability into clinical practice.

Importantly, utilisation should not be interpreted as a single measurable outcome. It may be reflected through the range of services delivered, the level of clinical autonomy exercised, the alignment between practitioner competence and clinical responsibilities, or the extent to which practitioners contribute to population oral health. The absence of a single accepted measure reinforces the need to understand utilisation as a multidimensional systems concept rather than a procedural one. This distinction shifts the focus from what practitioners are permitted to do towards how health systems enable professional capability to be translated into patient care.

Underutilisation as a Systems Issue

Defining underutilisation in terms of unrealised professional capability also changes how the issue should be analysed. If underutilisation is viewed simply as the absence of particular clinical procedures, attention is naturally directed towards individual practitioners and the treatments they perform. However, this perspective overlooks the fact that clinical practice is embedded within a wider healthcare system. The opportunities available to oral health therapists are shaped not only by their own competence but also by the mechanisms through which health systems translate professional capability into patient care, including regulation, funding, workforce planning, organisational policies and models of care.

This systems perspective is consistent with contemporary Australian health workforce policy. The Australian Government's Scope of Practice Review argues that enabling health professionals to work to their full scope requires changes beyond professional regulation, including reforms to funding arrangements, workforce design, leadership and organisational culture (Australian Government Department of Health and Aged Care, 2024b). Similarly, Carlson-Jones et al. (2026) observed that the utilisation of Australia's oral health practitioner workforce cannot be understood through scope of practice alone, as the evidence surrounding workforce roles, service delivery and professional deployment remains fragmented. Together, these findings suggest that underutilisation should be understood as a systems issue rather than simply an individual or professional one.

The relationships discussed in this paper are summarised below. The following sections examine the principal system-level factors that influence how the capabilities of oral health therapists are translated into clinical practice, beginning with the workplace in which care is delivered.

Employer Factors: Translating Capability into Practice

Although oral health therapists are educated and registered to provide a broad range of services, the extent to which these capabilities are translated into clinical practice is largely determined within the workplace. Clinical responsibilities are not allocated solely according to professional competence. Rather, they emerge through organisational decisions regarding appointment allocation, referral pathways, supervision, business priorities, patient preferences and models of care. Consequently, two oral health therapists with equivalent education and registration may experience substantially different levels of clinical autonomy depending on the practice in which they work.

Evidence suggests that employer understanding of the oral health therapist role plays an important part in this process. Kempster et al. (2015) found that Australian dentists' willingness to employ oral health therapists was influenced not only by workforce demand, but also by their knowledge of the profession and their perceptions of how oral health therapists could contribute to patient care. These findings indicate that professional capability alone does not determine utilisation. Instead, utilisation depends on whether workplaces recognise, trust and effectively translate those capabilities into everyday service delivery.

Importantly, variation between workplaces should not be interpreted simply as evidence of inappropriate restriction. Rather, differences in clinical autonomy and service delivery are likely to reflect variation in organisational structures, patient populations and models of care. Together with the findings of Kempster et al. (2015), this suggests that underutilisation is not an inevitable characteristic of the profession. Instead, it varies according to how individual practices organise and distribute clinical work.

Funding and Incentives: When Clinical Scope Meets Economic Reality

Employer support alone is insufficient to ensure that oral health therapists practise to their full potential. Even in workplaces where practitioners are trusted and clinically competent, decisions about service delivery are influenced by the financial structures within which care is provided. Healthcare systems do not simply determine what professionals are permitted to do; they also shape what organisations are incentivised to provide (Australian Government Department of Health and Aged Care, 2024b).

This relationship is particularly relevant in Australian dentistry, where oral healthcare is delivered through a combination of publicly funded and private services. The organisation of appointments, allocation of patients and distribution of clinical responsibilities are influenced not only by professional competence but also by reimbursement models, service priorities and the financial sustainability of dental practices. As a result, clinical utilisation may not always reflect the full capabilities of the available workforce.

In addition, patient expectations and established patterns of care may also influence which practitioner ultimately delivers treatment, even where multiple members of the dental team possess the competence to provide appropriate care. Patients may preferentially request treatment from a dentist, or organisational routines may reinforce traditional models of service delivery. Consequently, clinical utilisation is shaped not only by funding arrangements but also by behavioural and organisational factors that influence how care is allocated in practice.

Economic evaluations support the importance of workforce design rather than professional substitution. Nguyen, Tonmukayakul and Calache (2019) modelled alternative workforce configurations within Australian public dental services and found that allocating appropriate care to different members of the dental team could improve service efficiency while maintaining quality. Their findings suggest that the greatest gains are unlikely to arise from expanding the responsibilities of a single profession in isolation. Instead, improvements depend upon aligning patient needs with the most appropriate provider within a coordinated team-based model of care.

From this perspective, underutilisation should not be understood simply as a professional issue.

Rather, it reflects the interaction between workforce capability and the incentives embedded within health service funding. A workforce may possess the knowledge and competence to deliver care, yet still be unable to contribute fully if existing funding arrangements fail to support prevention, continuity of care or the effective deployment of team-based practice.

Underutilisation Amid Unmet Need: A Health System Paradox

At first glance, the proposition that oral health therapists may be underutilised appears difficult to reconcile with Australia's ongoing oral health challenges. Public dental waiting lists remain substantial in many jurisdictions, while around one-third (32%) of Australian adults avoided or delayed dental care due to cost (AIHW, 2025). Access to dental care also continues to vary according to geography and socioeconomic status, and preventable oral diseases disproportionately affect disadvantaged populations (AIHW, 2025). If the need for oral healthcare is so great, why should any segment of the dental workforce remain underutilised?

The answer lies in recognising that healthcare need and healthcare demand are not equivalent. Population need refers to the care that would improve health outcomes, whereas service demand reflects the care that is actually sought, funded and delivered within existing health systems. Financial barriers, eligibility criteria, workforce distribution and service capacity all influence whether clinical need is translated into demand for care. Consequently, a healthcare system may experience substantial unmet oral health needs while simultaneously failing to make full use of the capabilities of its available workforce.

A healthcare system may experience substantial unmet oral health needs while simultaneously failing to make full use of the capabilities of its available workforce.

This distinction is recognised in Australian workforce planning. Australia's Future Health Workforce: Oral Health (Australian Government Department of Health and Aged Care, 2024a) noted that workforce projections are primarily based on existing patterns of service utilisation rather than the total burden of untreated oral disease. Accordingly, projected workforce supply and apparent service demand may appear broadly aligned even when significant population needs remain unmet. Improving oral healthcare therefore requires more than increasing the number of practitioners. It also requires ensuring that existing professional capability is deployed in ways that better reflect the oral health needs of the population.

Viewed from this perspective, underutilisation should not be interpreted solely as a workforce problem. Rather, it may indicate a broader mismatch between population health needs, service delivery models and the organisation of the oral health workforce. Addressing this mismatch requires not only sufficient numbers of practitioners, but also healthcare systems capable of translating professional capability into accessible, equitable and prevention-oriented care.

Rethinking Utilisation: Beyond Scope of Practice

The preceding discussion suggests that underutilisation cannot be adequately explained by scope of practice alone. Although regulatory reform remains important, legal authority represents only one stage in a much broader process through which professional capability is translated into patient care. Education develops competence, regulation defines the boundaries of safe practice, yet it is the organisation of health services that ultimately determines whether those capabilities are realised in everyday clinical care.

This perspective also challenges the way utilisation is commonly understood. Discussions of oral health therapists often focus on whether they perform sufficient numbers of restorative procedures or whether they should assume additional clinical responsibilities. While these questions are important, they implicitly measure utilisation according to procedural complexity rather than healthcare value. Such an approach risks overlooking many of the contributions that oral health therapists make through prevention, periodontal maintenance, oral health promotion, patient education and continuity of care. These activities may involve fewer technically complex procedures, yet they remain fundamental to improving population oral health.

Reframing utilisation in terms of value rather than procedure also aligns more closely with contemporary models of integrated, prevention-oriented healthcare, consistent with the World Health Organization's vision for oral health systems that emphasise multidisciplinary, person-centred and preventive care (World Health Organization, 2022). The purpose of a multidisciplinary workforce is not for different professions to perform identical tasks, but for each practitioner to contribute according to their expertise in ways that maximise patient outcomes and system efficiency. From this perspective, the success of oral health therapists should not be judged by how closely their work resembles that of dentists, but by whether their knowledge and skills are being used where they generate the greatest benefit for patients and communities.

Underutilisation, therefore, should be understood not simply as a limitation of an individual profession, but as an indicator of how effectively a healthcare system organises, supports and deploys its workforce.

The central question is no longer whether oral health therapists are capable of doing more, but whether the oral healthcare system is making the best possible use of the capabilities it already possesses.

Conclusion

Whether oral health therapists are underutilised cannot be answered by comparing their legal scope of practice with the procedures they perform in everyday clinical care. As this paper has argued, utilisation is shaped by a complex interaction between professional capability, organisational decision-making, funding arrangements and broader health system structures. Focusing exclusively on regulatory scope therefore provides only a partial explanation of how oral health therapists contribute to oral healthcare.

Viewing utilisation through a systems perspective also shifts the emphasis of workforce policy. Rather than asking whether oral health therapists should perform more procedures, a more meaningful question is whether the oral healthcare system enables each member of the dental team to contribute according to their education, competence and the needs of the population. Achieving this objective requires not only appropriate professional regulation, but also funding models, workplace practices and models of care that support effective collaboration across the dental workforce.

Ultimately, improving the utilisation of oral health therapists is not simply about expanding professional roles. It is about ensuring that professional capability is effectively translated into high-quality, accessible and prevention-oriented oral healthcare.

The central question, therefore, is not whether oral health therapists are capable of doing more, but whether the health system is capable of making better use of what they already know and are trained to do.