6 October 2011

Paediatric Dentistry in the Central Australia and the Top End

The release of the Little Children are Sacred report early in 2007 prompted the Howard Government to initiate the Northern Territory National Emergency Response. A component of Phase 1 of the Australian Government Intervention (AGI) was health checks on all indigenous children throughout the Territory. It became clear following the start of the health checks that many of the children who had been assessed had extensive dental caries. During Phase 1 of the AGI over 9,000 children were assessed, 40% of whom required referral for follow-up oral health care (DoHA, 2008). It was estimated that 10% of these children would require completion of their dental treatment under general anaesthesia. The Commonwealth Chief Medical Officer, Dr John Howarth, called a meeting in September 2007, with representatives from NT Health, Aboriginal Medical Services Alliance Northern Territory (AMSANT), the Royal Australasian College of Dental Surgeons (A/Prof Angus Cameron), the University of Adelaide (Dr Kay Roberts-Thompson) and the ADA (Dr Bruce Simmons and Dr Denise Salvestro) to devise an emergency response. The meeting resolved to establish professional outreach teams to tackle the huge problems of indigenous oral health throughout the Territory.

NT Health led Phase 2 of the Intervention or Helping Hands project and in May 2008, the first specialist intervention team from the Department of Paediatric Dentistry at Westmead Hospital in Sydney visited Alice Springs Hospital to treat indigenous children under general anaesthesia. The project brought together the team from Westmead, the NT Helping Hands Dental Project Team headed by Julie Hornibrook, the local Dental services at Flynn Drive in Alice Springs headed by Dr Meg Simmons, Community Health Centre Managers, Remote Health staff, Congress (Aboriginal Medical Service) and the staff at Alice Springs Hospital.

The team of 10 from Westmead included a specialist paediatric anaesthetist, a fellow in anaesthetics, 3 anaesthetic/theatre nurses, 2 dental assistants, 2 paediatric dental specialists and a registrar. The model for access to care was to bring children in for surgery from the town camps in Alice Springs and the outlying communities, usually by bus. All the children had preoperative anaesthetic and dental checks prior to surgery the following day. The team was able to treat 40 indigenous children under GA, coming from town camps in Alice Springs and remote communities in Central Australia as far as 1000km away. This was an enormous logistical exercise using the existing services from Flynn Drive working with the local communities.

Following the success of this trip, four other teams have provided treatment under GA for the most severely affected indigenous children. In July, a team from the John James Foundation in Canberra, with paediatric dental specialists, Dr Peter Wong and Dr Fiona Bell (both former staff from Westmead) visited Katherine over 2 weeks. The Westmead team returned to Alice Springs in August and has recently completed a week of operating in Nhulunbuy in the far north east of Arnhem Land where 35 children were flown in from many outlying communities including Galiwin'ku on Elcho Island and Groote Eylandt.

The Westmead team has now been involved in 10 trips to the NT to Alice Springs, Tennant Creek and Gove and over 600 of the most urgent children have been treated under anaesthesia over the last 3.5 years. This figure excludes all those children not requiring theatre, who have been managed by other dental outreach teams visiting throughout the Top End and Central Australia as part of the project.

The enormity of the problems facing indigenous children in remote communities cannot be underestimated. Our inability to be able to manage these children in all but an emergency response highlights again the failure to provide an adequate and sustainable public oral health system. Most Australians have the luxury of first world facilities and access to care. It remains the responsibility of Government to adequately fund oral health care for those in most need in our society. Long-term recruitment to rural and remote public sector positions will always be difficult, but it is inconceivable that two dentists could service most of Central Australia (1.35 million km2) or that one dental therapist could provide adequate care for all children in East Arnhem Land. Unfortunately, the present shortage of dentists and dental auxiliaries in Australia, the high personal cost of dental education, the huge differential between private and or public sector (and academic) remuneration, the enormity of the amount of disease that is present and the tyranny of distance mean that the disparity in oral health for these communities will persist. The structure of the current workforce is simply not a sustainable model for the long-term delivery of oral health to these remote communities. While the Helping Hands and Closing the Gap programs have relied on an intermittent or transitory workforce, this may prove to be a viable adjunct to existing services. Nonetheless, these visits have demonstrated how cooperation across the different jurisdictions can bring about a significant improvement in outcomes for so many disadvantaged children. There is obviously much more work to complete.

While the message remains that dental caries is a preventable disease, the problems for indigenous children are similar to those facing all children in remote communities throughout Australia and revolve around an appropriate diet and access to dental care. It is clear that much of the caries is secondary to developmental defects of enamel that also relate to issues of maternal, perinatal and early infant health. Early childhood caries (bottle or nursing caries) is a significant issue but clinicians working in these areas also need to be cognisant of the cultural and social conditions under which these children live. Clean water, housing, education, good oral hygiene practices, limiting the consumption of carbonated soft-drinks and moreover, access to regular and sustainable oral health care programs are essential if these children are to maintain their teeth.

In the meantime, oral health has been identified as a priority area following the Emergency Response and there is a great deal of goodwill to achieve something important in improving the health of indigenous children for the long-term. These visits have been a huge effort building on existing services from all over the Territory and the long-standing relationships with local communities established over years of service and understanding about the value of dental services to these children and their families.

Angus Cameron

Clinical Associate Professor and Head

Paediatric Dentistry, Westmead Hospital

The comments are those of the author alone and do not reflect the policy of the Northern Territory Department of Health and Families nor the Sydney West Area Health Service.