Oral Health – Briefing Paper

by | May 28, 2015 | Briefing Papers

TOPIC
“How are oral health services for Aboriginal people in rural and remote Australia helping to close the gap in life expectancy?”

About Poche Centres for Indigenous Health

The Poche Centre for Indigenous Health is an example of the power of partnership in achieving real change and genuinely contributing to closing the gap in life expectancy for Aboriginal people.
Established and funded by philanthropists Dr Greg Poche AO and Mrs Kay Van Norton Poche, Poche Centres seek to leverage the best of the best in Universities with communities and governments to seek solutions that address complex health problems faced by Aboriginal people.
Dr and Mrs Poche have gifted more than $50m to Aboriginal health in the past six years.
The Poche Centre at the University of Sydney draws upon a combination of Commonwealth, State and philanthropic funds and partners with other organisations to:

  • provide specialist health services for Aboriginal people;
  • build and support health education and career pathways for Aboriginal people;
  • develop opportunities for students and graduates to participate in Aboriginal health service delivery; and
  • develop and sustain collaborative evidence to practice Indigenous health research.

Poche Centres always work in partnership with communities and existing health and other services to promote sustainability and the likelihood of developing solutions that work.
The independence and flexibility of Poche Centres enables innovative solutions that are not limited by program boundaries, funding pathways, or state and territory borders.
University of Sydney Poche Centre’s three year Strategy, Healthy Kids, Healthy Teeth, Healthy Hearts is available at
http://sydney.edu.au/medicine/public-health/poche/about-us/strategy.php

Finding Common Ground – Background

Prior to the colonisation of Australia, the oral health of Indigenous people was better than that of non-Indigenous Australians.1 In the 1930s, poor oral health in Aboriginal people was recorded as an emerging problem when it was identified that the diet of Aboriginal people had been impacted by the dispossession of native lands for pastoral leases and the introduction of European foodstuffs such as tea, sugar and white flour. Children and young adults at this time were found to be almost entirely free from tooth decay, presumably because they were not involved in receiving European food in return for labour.2 This trend continued and as late as only 50 years ago, Aboriginal children were found to be largely cavity free. Today the story is very different and we see the oral health of rural and remote Aboriginal children and adults severely affected and factoring into the gap in life expectancy for a variety of reasons, including its contribution to chronic disease.

We now know the impacts of oral diseases can be far reaching. From a health point of view, oral diseases such as dental caries and periodontal disease can lead to severe pain and tooth loss and have been associated with heart disease, diabetes, stroke and pre-term low birth weight 3. The cost and time of treating major damage can be a barrier which
may lead to extractions rather than other treatments. This, however, can have other long-term consequences for patients affecting them economically and socially.
While fortunately both caries and periodontal disease are easily prevented and early stages of disease are curable, prevention is unfortunately far more difficult to achieve in rural and remote communities. The main difficulties are outlined below.

Current situation – what are the barriers to good oral health?

It has long been recognised that oral health is fundamental to overall health, wellbeing and quality of life. Healthy Mouths Health Lives, Australia’s first Oral Health Plan, developed in 2004 with a ten-year focus emphasised this. Ten years on; however, what is still commonly found in many rural and remote areas are expensive, poorly designed oral health services. This means the predominant treatment of emergency cases often requires people to travel significant distances or be treated in sometimes less optimal premises. Oral health services for Aboriginal people do not appear to be helping to close the gap in life expectancy.

Policy –
Oral health remains outside of general health despite the known benefits and cost savings prevention and early intervention of oral diseases can bring. Because of this, the majority of oral health services are provided privately, where services exist. Due to budgetary constraints most service providers, both private and public, operate on a business model. Although in the public sector decisions are not profit driven, tight budgets require strict regulation on what oral health care procedures are available to public patients, and under what circumstances. As a result, oral health services are often too costly for many Aboriginal people.

Workforce shortage –
Australia has been experiencing an increasing oral health workforce shortage, which is predicted to continue over at least the next decade. This is most acutely experienced in many areas of rural and remote Australia and is exacerbated by the pooling of dentists in capital cities.4

Cultural differences –
As in other areas of health, cultural differences can often stand in the way of good oral health provision. Most providers do not receive cultural competence training and lack access to Aboriginal Health Workers or other cultural brokers. Strict appointment times and inflexibility can lead to ‘failure to attend’ fees and missed appointments. Language and communication difficulties also arise for Indigenous Australians that have English as their second or third language. Aboriginal Controlled Community Health Services (ACCHSs) provide culturally appropriate, holistic health care, however not all ACCHSs are equipped to provide dental or oral health care or preventive education.

Geographic barriers –
Aboriginal Australians often need to travel long distances to see a dentist, sometimes over poor roads with vehicles in poor condition. Some do not have access to either public or private transportation. Mobile dental clinics operate in most states and territories; however some areas have abandoned these for centralised services in larger referral clinics.

Diet –
Fresh food in rural and remote communities can often be very expensive, much more so than in urban areas due to the transportation costs. In addition, many nutritious foods, such as reduced-fat milk, wholegrain bread, lean meat and a variety of fruit and vegetables are not always available or are expensive to purchase. Processed foods, high in sugars and simple carbohydrates are more economical and therefore more readily consumed contributing to poor general and oral health.

Water fluoridation –
Many rural and remote communities do not have access to fluoridated water, an extremely cost effective way of reducing caries.

Living conditions –
Substandard living conditions are associated with poor oral health and disease and many Aboriginal Australians live in housing conditions that do not meet basic standards for shelter, do not have safe drinking water or adequate sewerage provisions and are overcrowded. If toothbrushes are thought not to be safe for use, such as in an overcrowded house or when unguarded at schools, decreased use can result, leading to increased levels of poor oral health.5

Oral hygiene –
Statistics show that Aboriginal Australians are less likely to use toothbrushes and fluoridated toothpaste at recommended levels.6 There also appears to be less awareness about the benefits of good oral care. Poor availability of toothbrushes, toothpaste and floss may also limit recommended oral hygiene.

Other risk factors –
A number of other conditions/health risk factors have been found to contribute to higher levels of oral disease in Aboriginal people. In Aboriginal children, high rates of enamel hypoplasia (weak enamel) occur. This can be due to a congenital condition, premature birth, infections during childhood, malnutrition and low birthweight.
The high rate of smoking among Aboriginal adults is also a significant risk factor in oral infections as is diabetes, which has been found to be more common in Aboriginal people.

What are the issues and opportunities for the future?

Against these significant barriers to oral health, new approaches to service provision for rural and remote Aboriginal communities have emerged. The University of Western Australia has witnessed the success of a model, implemented approximately ten years ago, that is based on a collaborative partnership between the Aboriginal health sector, universities, non-government organisations and volunteer groups.7

Over the past year, the Poche Centre for Indigenous Health at The University of Sydney has also seen promising signs that comprehensive oral health services can be delivered to Aboriginal people in remote communities when a model is established that harnesses the skills, motivation and resources of communities, governments and philanthropy in a sustainable way. The Poche Centre works with elders, ACCHSs, schools, community health services, new graduates, senior clinicians and academics to deliver high quality services in existing community facilities using fixed and portable equipment.

The Northern Territory has introduced a program that enables non-dental personnel to apply fluoride varnish in particular circumstances. NSW and WA are looking at establishing approaches to fluoride varnish for communities without fluoridated water.

In light of the well-known barriers to oral health and lessons to be gleaned from emerging solutions, it appears that there is a real opportunity for a step-change to take place in the way oral health is delivered in rural and remote Aboriginal communities.

First and foremost, with the barriers to good oral health crossing into a range of other health related issues, a holistic approach to health that includes oral health needs to be established.

Applying a community capacity/community development approach to improving Aboriginal oral health is likely to have a more sustained, affordable and effective outcome.
Building capacity within communities would have a marked effect on providing regular and timely access to dental care and effective promotion of oral health. A sustainable workforce comprising more Aboriginal dentists and oral health therapists and dental assistants is fundamental in this regard. Aboriginal people must be part of shaping oral health oral health and the oral health professions in the future.

Questions to assist the discussion on the day

1. What are the main barriers when accessing oral health care in rural and remote communities?
2. How can these barriers be addressed sustainably?
3. How do we know what existing capacity, services and infrastructure there is to be built upon?
4. Whose responsibility is oral health?
5. How do we encourage mainstream health services to embrace oral health as part of their work?
6. How can we effectively promote oral hygiene to prevent disease and encourage regular check ups to intervene early if
necessary?
7. How can preventive treatments such fluoride varnish be applied effectively and sustainably in remote areas?
8. What is the role and benefit of a population health approach to dental health and hygiene and whose responsibility is it undertake this?
9. How can we promote a healthier diet?
10. What roles can we play in influencing the availability and affordability of healthy food in rural and remote Australia?
11. How can we make oral health service affordable and accessible for all?
12. What is the role of technology in improving the current situation?
13. Integrating research, service and education is the long-term solution. How can this be done?

References

1. Williams S, Jamieson L, MacRae A, Gray C (2011) Review of Indigenous oral health. Australian Indigenous HealthInfoNet. p. 3
Available at: http://www.healthinfonet.ecu.edu.au/oral_review [accessed 28/10/14]
2. Campbell TD, (1936) Observations on the teeth of Australian Aborigines. Australian Journal of Dentistry, Vol. 40, p. 292.
3. Williams S, Jamieson L, MacRae A, Gray C, op, cit., p. 2.
4. Dyson K, Kruger E, Tennant M (2014) A Decade of experience evolving dental services in partnership with rural remote
Aboriginal communities. Australian Dental Journal; 59, p. 187. 5 Williams S, Jamieson L, MacRae A, Gray C, op. cit., p. 14.
6. Ibid. p. 15.
7. Dyson K, Kruger E, Tennant M, op. cit., pp: 187-192.

Details of the Key Thinkers’ Forum

Date: 11 July 2014
Time: 9:00am
Venue: Charles Darwin University (Room TBA)
Chair: Dr Tom Calma AO

Further Information

At the conclusion of each forum a paper will be produced which summarises the issues raised
and makes comment or presents an opinion about the topic discussed. This will then be published as a ‘Poche Opinion paper’. Poche Opinions will be a tool to contribute to knowledge and to draw the wider community into the key debates and issues in Aboriginal health.
For further information, please contact:
poche.admin@sydney.edu.au
(02) 9114 0776
facebook.com/pochecentre

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