Remote Indigenous Oral Health a view from the APY Lands AHCSA IT & Public Health Workshop 25 July 2008

1. Remote Indigenous Oral Healtha view from the APY LandsAHCSA IT & Public Health Workshop 25 July 2008 Dr Simon Wooley BDS, MPHC

3. Remote Indigenous Oral Healtha view from the APY Lands Outline Acknowledgement: Drs Sandra Meihubers & Colin Endean Introduction Oral health and General health relationship Indigenous Oral health status NHC Dental program goal Challenges and achievements: the NHC dental program Conclusion: Key challenges & opportunities for ACCHS oral health programs

4. Introduction • Speaker’s background • Focus on remote Indigenous oral health service delivery challenges and achievements on the APY Lands • Challenges common to ACCHS oral health programs?

5. Oral health and General health relationship • “a part of the body, not a body part” ( the late Puggy Hunter) • You cannot be healthy without oral health (US Dept of Human Services, 2000, Oral health in America: A Report of the Surgeon General) • Oral health is important in its own right- oral function and freedom from pain is a reasonable aspiration for all people (Spencer and Harford, Inequality in oral health in Australia, 2007) • Oral health is integral to general health

6. Causal pathway for a number of systemic diseases & conditions • Aspirational pneumonia • Preterm low birth weight • Cardiovascular diseases • Stroke • Oral cancer • Severe dental infection potentially rapidly fatal A medical emergency, not ‘just’ a dental problem 2003 RAH dental inpatient study, 17% Aboriginal. 8% (of total) had diabetes, 1 admission a week, 40% in ICU ( ‘Severe Odontogenic infections’ UluibauIC, JaunayT & Goss AN ADJ 2005)

7. Oral disease may exacerbate underlying general disease or conditions (‘medically necessary dental care’) • Diabetes • Rheumatic heart disease/infective endocarditis risk • Bisphosphonate therapy • Immunosuppression eg dialysis/ transplant • Head and neck cancer

8. Common risk factors for oral and medical conditions (and a point of intervention) Smoking • gum disease/decay/xerostomia (dry mouth) • oral cancer • cardiovascular/lung disease • ‘Quit’ brief intervention Poor Diet&Nutrition • dental decay, gum disease • obesity • diabetes • heart disease • **Scurvy/vit C deficiency & periodontal (gum) disease Alcohol • Dental caries, enamel erosion • oral cancer • liver disease.

9. Indigenous Oral health Status Child status • Rural Indigenous 4-10 year old children have approximately twice the deciduous (baby tooth) decay experience compared to rural non Indigenous children • Permanent (adult tooth) decay experience among 6-14 yearold rural Indigenous children is almost twice that of rural non-Indigenous children • Fewer rural Indigenous children are decay free compared to rural non Indigenous counterparts • Untreated decay higher in rural Indigenous children compared to their non Indigenous counterparts • Rural location is associated with poorer oral health among Indigenous and non Indigenous children (JamiesonLM, ArmfieldJM, Roberts-ThomsonKF, The role of location in Indigenous and non-Indigenous child oral health J Public Health Dent 2006;66(2):123-30)

10. Indigenous Oral health Status Adult status • Indigenous adults have worse oral health than non Indigenous adults • Higher prevalence of severe periodontal (gum) disease. (higher rates of Smoking and poorly controlled diabetes are major risk factors for periodontal disease and are likely contributors) (note approx 35% of all tooth loss is due to gum disease) • Similar total decay experience of Indigenous and non Indigenous adults, however Indigenous adults have more extractions and untreated decay, and fewer fillings (DS Brennan, KF Roberts-Thomson, AJ Spencer, Oral Health of Indigenous adult public dental patients in Australioa, ADJ 2007;52(4): 322-328)

11. Oral Health Status on the AP Lands • Many communities with naturally high fluoride levels, average 1.5ppm, up to 2.5ppm • Increasing child caries experience 4-6 year olds, twice state average (2005) • Increasing tooth loss among adults associated with diabetes prevalence • Completely edentulous (no teeth) prevalence increasing in association with diabetes • (Endean C, Roberts Thomson KF, Wooley S, Anangu Oral health-the status of the Indigenous population of the Anangu PitjantjatjaraLands, AJRural Health, 2004, 12, 99-103)

12. NHC Dental Program Goal “To enable Anangu on the Anangu Pitjantjatjara Yankunytjatjara (APY) lands in South Australia to achieve oral and general health improvement through the delivery of an accessible, appropriate and effective oral health program.”

14. Challenges and achievements: the Nganampa Health Council Dental Program Challenges Sociocultural & Environmental • Poverty • Communication • Autonomy • Social mobility • Diet • Oral hygiene and fluoride exposure Management • Geography • Workforce • Resourcing and funding

15. Challenges: Sociocultural & Environmental Poverty Cost of living “healthy food basket” unaffordable high fuel costs, $2.00 + per litre Ability to store, prepare and cook food (Table with permission P Pholeros) “healthy choices easy choices”?

16. Challenges: Sociocultural & Environmental Communication • English as 2nd, 3rd or 4th language • Aboriginal Health Worker/Aboriginal Education Worker Role.

17. Challenges: Sociocultural & Environmental • Autonomy • Children’s independence • Community stores, health vs profit • Schools and health curriculum

18. Challenges: Sociocultural & Environmental Social mobility • Social and ceremonial activity • Patterns of school attendance.

19. Challenges: Sociocultural & Environmental Diet • Increasing reliance on store bought food • UPK (1987) - average sugar consumption 66 tsp per day • Recent store turnover - 50% cool (sweet fizzy) drinks, hi cigarette sales

20. Challenges: Sociocultural & Environmental Oral hygiene and fluoride exposure • Patterns of oral health practices at home • Decreasing fluoride exposure

21. Challenges: Management Geography Remote communities, desert extremes of weather and terrain • Staff isolation, professional support • Equipment & materials wear and tear.

22. Challenges: Management Workforce • Recruitment and retention of dental staff • AHW role development Resourcing and funding • No uniform funding nationally or statewide for ACCHS oral health programs • Additional costs of remote services

23. Achievements • Community acceptance and accessibility • Health promotion strategies • Mininimal Intervention Dentistry • Responsive Management • Systematic Data Collection • Program sustainability and continuity of care

24. Achievements Acceptance and Accessibility • Primary health care philosophy and approach • Community ownership • Trust • Mobile dental clinic • Twice yearly community visits, annual child exam. • Client transport support

25. Achievements Health Promotion Strategies • Oral health promotion in schools • Established tooth brushing programs • Oral health education provision and support for teachers • Fluoride varnish strategy for at risk children • Mai Wiru (“Healthy Food”) policy genesis.

26. Achievements Minimal Intervention Dentistry • Prevention and early intervention focus • Atraumatic Approach (AgF, ART, SMART), LA not required - needle phobia common • Fissure sealants and topical F, oral hygiene and diet consultation

27. Achievements Responsive Management • Oral health advisor role • Flexible locum strategies • Mobile program • Dentistry in Remote Aboriginal Communities

28. Achievements Systematic Data Collection • OMR methodology • Robust simplicity • ARCPOH relationship • Program planning and evaluation • Communicare role

29. Achievements Program Sustainability and Continuity of Care • Program inception 1986 • Staff retention • Continuity of care • Nganampa Health Council - “our health service”.

30. Conclusion: Key challenges & opportunities for ACCHS oral health programs • Aboriginal Oral Health Advisory Group, and its potential to ‘..address the lack of Aboriginal dental services across SA’ (Draft Terms of reference 2008) • Workforce • Resourcing & funding • Data collection

31. Workforce • Recruitment and retention of clinical staff a national issue • Flexible and creative management & locum strategies • AHW role development • Other Aboriginal oral health service models such as coordination with existing public & private sector dental services where feasible and appropriate include: • Aboriginal Dental Scheme (eligible patient access to private sector, administered on behalf of AHCSA by SADS) • SADS/AHS Aboriginal Liason Program in progress in CNAHS region (AHS/CHS/AHW/GP referral to selected ‘priority access’ SADS Clinics, diabetes camps) • Contracted service delivery with public provider eg Pika Wiya with SADS • Coober Pedy model ( in progress) • Other eg Tullawon

32. Resourcing & Funding • Historical federal & state under-resourcing of public sector oral health programs • No uniformity of funding for ACCHS oral health programs • Potential additional funding opportunities as of July 2008 include • Teen Dental Plan • up to $150 Annually for all 12-17 yo in family tax benefit part A, Youth Allowance or Abstudy • $490m nationally over 5yrs • Medicare funded exam and preventive package, voucher direct to those eligible • Option of public sector as well as private • Commonwealth Dental Health Scheme $290 m next 3 yr • $8.4 m per yr SA, $1m annual Aboriginal oral health (via SADS) • Dept of Health and Aging

33. Data collection • National uniform data set required (National Oral Health Plan 2004-2013) • Improve the knowledge and understanding of patterns of disease experience nationally and locally • Community needs assessment • Assist adequate and appropriate resourcing & funding • Program planning, monitoring and evaluation

34. Palya!