Why is the gap widening

Indigenous Australians suffer from far worse oral health outcomes than non-Indigenous Australians. At the core of the issue are difficulties with access, culturally appropriate treatment and preventive health; and the solutions are complex. By Sue Nelson

There are various ways for the dental profession to improve Aboriginal children’s teeth.

There are various ways for the dental profession to improve Aboriginal children’s teeth.

It might be surprising to learn that the dental health gap between Aboriginal and non-Aboriginal Australians is a relatively recent problem. In fact, 30 to 40 years ago, the gap existed in reverse—Aboriginal Australians actually had better oral health than the general Australian population.

“There has really been quite a rapid decline in oral health for the Aboriginal population,” says Associate Professor Lisa Jamieson, who leads the Indigenous Oral Health Unit at the University of Adelaide. “There are a lot of different contributors to poor oral health, but if we just consider dental decay, the main culprit is sugar.”

In Aboriginal communities in recent years there has been increased access to sugar-filled carbonated soft drinks, while components of a healthy diet such as fresh fruit and vegetables aren’t always available. Similarly, the availability and affordability of fluoride toothpastes and toothbrushes can be limited in these locations.

By contrast, for a long time in the mainstream Australian population, dental disease was widespread. “It used to be considered the norm for people to have missing teeth or a lot of decay,” A/Prof Jamieson says. “There has been a lot of improvement in the oral health of the general Australian population, either through fluoride in the water or fluoride in toothpaste or the general increase in oral hygiene, and that improvement in oral health has occurred at the same time as the decreased oral health in the Aboriginal population—they’ve crossed over, if you like.”

Declining economic, social and general health indicators all act to compound the problem of poor Indigenous oral health. “Oral diseases are often considered social deprivation diseases,” says A/Prof Jamieson. “Periodontal or gum disease has links with other systemic conditions such as diabetes, cardiovascular disease, chronic kidney disease and even obesity. It’s fair to say that for this condition, the disease process itself is going to be influenced by the general health status of the person.”

Regular attendance at the dentist is one of the key components of preventive dental health—but the worse a dental health issue becomes, the more reluctance can build to pay a visit, and the greater the likelihood of a poor outcome. “We certainly know that most Aboriginal patients go to the dentist for a problem rather than for a check-up,” says A/Prof Jamieson. “In the general population, about 50 per cent would attend for a check-up every year or every other year, but that proportion is much less in the Aboriginal population.”

“You’re invading a fairly personal part of the body. You’re right on top of them, and there was a sense of being so close to someone that they didn’t know, who they didn’t feel comfortable with.” – A/Prof Lisa Jamieson, University of Adelaide

In her work, A/Prof Jamieson has attempted to understand why there is this reluctance to attend the dentist. Is it a question of competing priorities and problems, which trump a regular dental check-up, or is it a lack of availability of dentists to provide care?

The issue of access is complex. “While a third of the Australian Aboriginal population live in remote areas, the remainder live in regional areas or cities. But even those who live in the cities and regions—where there is arguably better access to dental care—don’t visit the dentist very often,” A/Prof Jamieson says. “There are many good services available. Many Aboriginal-controlled health organisations provide dental care which is free or means tested, and there are plenty of private dentists who do pro-bono work as well, but still we’re seeing the evidence that if you had a dentist available on every corner, they still wouldn’t be accessed by the Aboriginal population, so there’s something else going on as well.”

A/Prof Jamieson was one of the authors of a study that conducted focus groups with Aboriginal Australians living in a regional location to find out what prevented them from seeing a dentist more regularly. A lot of it was to do with shame—the respondents said they felt embarrassed about the state of their teeth. They felt that often the dental environments were very clinical, very clean and white and stark, and very efficient. They worried that if they attended with their relatives and were late, they might not be received in a friendly way, which would affect their desire to return.

Many Aboriginal patients are intimidated by dental practices as they are stark, white and clinical.

Many Aboriginal patients are intimidated by dental practices as they are stark, white and clinical.

Cultural factors to do with contact, space and intimacy also play a part. “As a dentist you’re invading a fairly personal part of the body. You’re right in there, right on top of them almost, and that was certainly the feedback we got from the focus groups that we ran, there was a sense of being so close to someone that they didn’t know, who they didn’t feel comfortable with.” But the researchers also found that when they asked whether more Aboriginal dentists would make respondents feel more comfortable, the results were mixed. While some said they felt they would be less embarrassed and ashamed, some said it would be even worse because of close community links—they might know each other or be related somehow, and they didn’t want these Aboriginal dentists to know the state of their dental health.

The answer seems to be education, including increased preventive health measures. Regular visits to the dentist may help to remove the embarrassment. Many Aboriginal Australians regularly see their GP, which removes some of the reticence they might have about seeing a clinician. “It’s important for health professionals to work more closely together—for example, so that GPs are able to feel comfortable about looking inside the mouth as part of the general health check,” A/Prof Jamieson says. “This will probably mean that people will become accustomed to having their teeth looked at regularly rather than attending a one-off appointment to have their teeth pulled out when they’re in pain—to become more comfortable with the medical and dental environment generally.”

The problem of poor Indigenous health certainly requires more Aboriginal people in dentistry, but the mainstream dental profession can help in some ways. Filling the Gap is a dental volunteer organisation that deploys dentists to work in remote and regional Aboriginal communities for Aboriginal-controlled health services. The service identifies the often-desperate need in these communities and supplies willing dentists to help meet the need. “Dentists can only understand the very different circumstances for dentally degraded Aboriginal communities compared to suburban dentistry through paid locum or volunteer work,” says board secretary and retired dentist Dr Ivor Epstein.

The service implements an exit strategy to leave the community once a service is up and running, enabling community members to employ their own dentist. “We go where there is no dental service,” says Dr Epstein. “We demonstrate a need in the community and the statistics we deliver are used to justify the need for funding from government agencies—we effectively create opportunities for dentists.”

Most or all of the diseases faced by Aboriginal communities are preventable—they just require the help and willpower of the greater Australian community. Collaboration between the health professions and other agencies is crucial. “Aboriginal people who are higher on the income scale don’t have as much dental disease,” A/Prof Jamieson says. “In some ways it’s not an Aboriginal issue; it’s an issue of being poor.”

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