Health Research Article

Introduction: Oral disease causes pain and disfigurement, has a negative influence on quality of life, and is linked to poor nutrition, diabetes, and cardiovascular disease. Aboriginal and Torres Strait Islander peoples in regional and remote areas are Australia’s most vulnerable group when it comes to the burden of oral disease. Australia’s Oral Health Policy Environment is underpinned by the National Oral Health Plan 2015–2024. The foundational goals are to improve Oral Health Promotion, Accessible Oral Health Services and Systems alignment and integration.  Method: This literature review aims to explore the current evidence and policy environment that addresses the public health issue of oral health in Aboriginal and Torres Strait Islander populations in rural and remote tropical Australia. Results: Indigenous Australians face further disadvantage due to limited health services and workforces, particularly dental services. Extensive travel may be needed to access services and the existence of multiple competing social and health issues faced by the communities further compounds these effects There are multiple public health initiatives and a variety of dental care models in place across rural and remote Indigenous communities in Northern Australia, though in each unique community setting, consultation is needed to determine the strategies as a best fit for the community. Conclusion: Community-based consultation can inform future oral health strategies in Tropical Australia. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Indigenous people living in remote communities where determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

 

Oral disease causes pain and disfigurement, has a negative influence on quality of life, and is linked to poor nutrition, diabetes, and cardiovascular disease (Tynan et al., 2020).

There are greater experiences of poor oral health, with high rates of dental caries, periodontitis, oral cancer, and human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) in Aboriginal and Torres-Strait Islander people when compared with non-Indigenous Australians (Bachlani, 2022).

 

The Oral Health Monitoring Group identified Australia’s priority populations as people who are socially disadvantaged or on low incomes, Aboriginal and Torres Strait Islander people, people living in regional and remote areas and people with additional and/or specialised health care needs (Oral Health Monitoring Group, 2015).  Many Aboriginal and Torres Strait Islander people living in Northern Australia are categorised in each of these high-risk priority areas, making them Australia’s most vulnerable group when it comes to the burden of oral disease. Aborignal and Torres Strait Islander people also access oral healthcare differently (Bachlani, 2022).

 

Australia’s Oral Health Policy Environment is underpinned by the National Oral Health Plan 2015–2024. The foundational goals are to improve Oral Health Promotion, Accessible Oral Health Services and Systems alignment and integration (Oral Health Monitoring Group, 2015).

 

This literature review aims to explore the current evidence and policy environment that addresses the public health issue of Oral health in Aboriginal and Torres Strait Islander populations in rural and remote tropical Australia.

 

From this point this paper will respectfully use the term ‘Indigenous’ when referring to Aboriginal and Torres Strait Islander people, for the purpose of conciseness, however the author acknowledges that these terms are not interchangeable.

 

A literature search was conducted using Scopus database.

Inclusion criteria: Articles which were Australian, related to oral health in Indigenous populations in Northern Australia since 2014 were included.

 

The search yielded 32 articles; the abstracts were screened for relevance. Articles published outside Australia, or relevant only to on-tropical climates were excluded from the review.

 

Oral health, and health more generally is impacted by the social and economic environment in which individuals live. There are numerous social and environmental impacts that contribute to the poorer oral health outcomes for Indigenous Australians in remote Tropical Australia.

 

Indigenous communities experience a higher prevalence of social concerns, including a higher level of psychosocial risk factors; lower socioeconomic status; lower social capital; and a higher prevalence of lifestyle risk factors (Tynan et al., 2020). In rural and remote communities, Indigenous Australians face further disadvantage due to limited health services and workforces, particularly dental services. Extensive travel may be needed to access services and the existence of multiple competing social and health issues faced by the communities further compounds these effects. Factors such as cost of oral hygiene products, access to quality food, and poor transport availability provide further challenges in these rural and remote contexts (Tynan et al., 2022). Research shows that system-level barriers to accessing and engaging with oral health services and prevention influence how rural Indigenous communities manage oral health and seek treatment (Tynan et al., 2022).

 

Individual health behaviours also impact oral health. Infrequent toothbrushing among Indigenous communities can be attributed to issues around affordability, accessibility, and awareness around the importance of oral health. The high costs of toothbrushes and toothpaste along with overcrowded housing and not having a safe place to store a toothbrush are some of the more pertinent barriers that have been previously reported (Dimitropoulos et al., 2019).

 

These determinant factors often inhibit Indigenous people making optimum health choices to prevent oral disease and access services for treatment. Factors included cost of services, limited education about oral health, intense advertising of sugary drinks and discrimination from service providers. Yet the literature indicates individuals, rather than structural factors, are held responsible and blamed for the poor state of their oral health.

 

The current neoliberal climate focuses on individual responsibility for health and wellbeing often ignoring the social context. To avoid the mouth becoming an ongoing site for structural inequality, critically reviewing oral health policies and practices for whether they promote or compromise Indigenous Australians’ oral health is a step towards accountability-related oral health outcomes.

 

There are multiple public health initiatives and a variety of dental care models in place across rural and remote Indigenous communities in Northern Australia.

Water fluoridation is one of the key national strategies to prevent dental caries in Australia.

Fluoride reduces demineralisation, making teeth more resistant to decay, and enhances remineralisation. Fluoride also slows the activity of bacteria that cause decay and combines with enamel on the tooth surface to make it stronger and better able to resist decay (National Health and Medical Research Council, 2017). Regional and remote indigenous communities in Australia’s North have varying levels of fluoridation, and lower access than the population more widely (Stormon and Lalloo, 2020). The cost of implementing such programs means there is low feasibility in small, remote communities for water fluoridation. There is also lack of community support in some areas. Since 2012 the decision and cost of water fluoridation has been transferred to local councils. Some regional and remote local councils have elected to remove water fluoridation due to the ongoing cost and lack of perceived benefit to the council. Understandably small regional and remote councils might feel the cost burden of supporting water fluoridation, but evidence indicates regional/remote Australia populations experience a higher burden of dental disease (Stormon and Lalloo, 2020).  

 

Access to oral health services and education is limited in remote Indigenous communities. Many communities access dental services in a fly-in, fly-out (FIFO) model. Studies show this model tends to be more focused on complex clinical care, with less capacity for preventative care models. Community based oral health services are better situation to provide more regular preventative care, though the feasibility of such services is limited in smaller and more remote communities (Gwynne et al., 2021). The short periods of time spent in communities by FIFO and volunteer oral health teams, combined with desire to deliver maximum productivity may present a disconnect from actual community needs. There are ethical considerations needed to encourage providers to continuously question, consult and strive towards improving services in consultation with local community leaders, rather than simply providing more of the same (Patel et al., 2023). 

 

In-school tooth brushing is another widely adopted public health approach. As an integral part of remote communities, the school is perceived as being more than just a place for education but also as an inclusive site facilitating efficient screening and health promotion. Remote schools can be valued as being critical in implementing positive oral health behaviours such as daily toothbrushing, thereby laying down the foundation for optimal health into the future. The concept of a health promoting school is endorsed by the World Health Organisation have and authors have advocated for this concept of oral health promotion activities to be embedded within the framework of schools (Walker et al., 2023)

 

The above public health interventions are in place in varying capacities in Tropical Australia. While the strategies highlighted in the “Healthy mouths, Healthy lives” National plan are evidence-based and should be the priority, their feasibility and effectiveness will be unique and specific to the individual settings in which they are implemented. Remote Indigenous health in Australia is by no means a one-size fits all scenario. In any given town or community, local consultation and decision making is the key-ingredient to an effective oral health program or intervention (Walker et al, 2023).

 

Effective programs should be delivered with the support of Indigenous Health Practitioners and Health Workers trained in oral healthcare promotion activities; the representation of such positions regularly in the community being shown to increase the level of relatability and trust (Walker et al., 2023).

Walker et al’s (2023) study also highlights that consultation between rural oral healthcare services and rural Indigenous communities will not occur without planning, will and funding. Community consultation should be seen as an essential role of rural oral health services, with a focus on preventative care not just the provision of individual clinical oral health care to individual patients, measuring performance solely by the number of occasions of clinical service. It should be recognised by oral healthcare services that an individual, one-off consultation with a community is unlikely to bring about significant change. There is therefore a need to plan for regular consultation while recognising financial cost including time and other resources of both communities and of healthcare services in an ongoing consultation process.

 

Policy makers and health providers committed to providing care that is non-discriminatory, non-judgemental, and respectful of Indigenous people and their lived experience is important if attendance at dental services is to increase and health outcomes improve. Without this commitment, inequalities are set to continue (Durey et al., 2016).

 

Besides introducing oral health services and passive (water fluoridation) interventions in remote areas of Northern Australia, it is critical to address social determinants to reduce the burden of poor oral health. Strategies to reduce sugar consumption and increase nutrition are essential. Service providers should focus on contextualizing nutrition education whenever possible in relation to the traditional food supply, and framing it within information regarding food origin, its history, cultural practice, processes of production, distribution, and preparation. This has a greater relevance for Indigenous peoples than the Western reductionist approach of teaching about food in relation to nutrients and disease (Brimblecombe et al., 2014). It is incumbent upon dental researchers, dental providers, and policymakers to advocate for public health interventions to address the upstream social determinants of health that have the most impact on the oral and general health. (Lalloo et al., 2021)

 

Community-based consultation may better inform future oral health strategies in Tropical Australia. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Indigenous people living in remote communities where macro-level determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

Bachlani, A. (2022). Exploring the relationships between periodontitis, high-risk oral human papillomavirus and social factors and their impact on oral health status in Indigenous South Australians (Doctoral dissertation).

 

Brimblecombe J, Maypilama E, Colles S, et al. Factors Influencing Food Choice in an Australian Aboriginal Community. Qualitative Health Research. 2014;24(3):387-400. doi:10.1177/1049732314521901

 

Dimitropoulos, Y., Holden, A., & Sohn, W. (2019). In-school toothbrushing programs in Aboriginal communities in New South Wales, Australia: A thematic analysis of teachers’ perspectives. Community Dental Health, 36, 106-110.

 

Durey, A., Bessarab, D., & Slack-Smith, L. (2016). The mouth as a site of structural inequalities; the experience of Aboriginal Australians. Community Dent Health, 33(2), 161-3.

 

Gwynne K, Poppe K, McCowen D, Dimitropoulos Y, Rambaldini B, Skinner J, Blinkhorn A.  A scope of practice comparison of two models of public oral health services for Aboriginal people living in rural and remote communities. Rural and Remote Health 2021; 21: 5821. https://doi.org/10.22605/RRH5821

 

Kularatna, S., Lalloo, R., Kroon, J., Tadakamadla, S. K., Scuffham, P. A., & Johnson, N. W. (2020). Demonstration of high value care to improve oral health of a remote Indigenous community in Australia. Health and Quality of Life Outcomes, 18(1), 1-10.

 

Lalloo R, Tadakamadla SK, Kroon J, Jamieson LM, Ware RS, Johnson NW (2021) Carious lesions in permanent dentitions are reduced in remote Indigenous Australian children taking part in a non-randomised preventive trial. PLoS ONE 16(1): e0244927. https://doi.org/10.1371/journal.pone.0244927

 

National Health and Medical Research Council. (2017). Water fluoridation and human health in Australia: questions and answers.

 

Oral Health Monitoring Group. Australia’s National Oral Health Plan 2015–2024. Canberra: COAG Health Council, 2015.

 

Patel, J., Durey, A., Naoum, S., Kruger, E., & Slack‐Smith, L. (2022). Oral health education and prevention strategies among remote Aboriginal communities: a qualitative study. Australian Dental Journal, 67(1), 83–93. https://doi.org/10.1111/adj.12890

 

Shield JM, Kearns TM, Garŋgulkpuy J, Walpulay L, Gundjirryirr R, Bundhala L, Djarpanbuluwuy V, Andrews RM, Judd J. Cross-Cultural, Aboriginal Language, Discovery Education for Health Literacy and Informed Consent in a Remote Aboriginal Community in the Northern Territory, Australia. Tropical Medicine and Infectious Disease. 2018; 3(1):15. https://doi.org/10.3390/tropicalmed3010015

 

Skinner, J., Dimitropoulos, Y., Masoe, A., Yaacoub, A., Byun, R., Rambaldini, B., ... & Gwynne, K. (2020). Aboriginal dental assistants can safely apply fluoride varnish in regional, rural and remote primary schools in New South Wales, Australia. Australian Journal of Rural Health, 28(5), 500-505.

 

Stormon, N., & Lalloo, R. (2020). Monitoring the extent of water fluoridation coverage in Australia. Health Promotion Journal of Australia, 31(2), 169–171. https://search.informit.org/doi/10.3316/ielapa.180404446348344

 

Tynan, A., Walker, D., Tucker, T. et al. Factors influencing the perceived importance of oral health within a rural Aboriginal and Torres Strait Islander community in Australia. BMC Public Health 20, 514 (2020). https://doi.org/10.1186/s12889-020-08673-x

 

Tynan, A., Walker, D., Tucker, T., Fisher, B., & Fisher, T. (2022). Managing oral health care and prevention: The experience of Aboriginal and Torres Strait Islanders living in a rural community in Queensland, Australia. Australian Journal of Rural Health, 30(2), 228-237.

 

Walker, D., Tynan, A., Tucker, T., Fisher, B., & Fisher, T. (2022). Engaging with a rural Aboriginal community to identify strategies to improve oral health within their community: a qualitative study. Australian Journal of Primary Health.