The long reach: The oral health challenges of rural and remote dentistry

This article was first published in the ADA's News Bulletin, December 2022.

As one of the most urbanised countries in the world, Australia nevertheless enjoys mythologising its vast, stunningly diverse, rural and remote regions. Indeed, it is this vastness that perhaps causes 72% of our population to settle within major cities, largely along our coastlines; unlike more evenly populated places such as the United States or Europe, our famously described sunburned country and sweeping plains include swathes of land that are challenging to occupy on a sustainable level, to say the least. Other practical challenges facing our rural and remote- living 28% are documented by the federal government’s Australian Institute of Health and Welfare (AIHW), reporting in July this year on the rural and remote population’s access to quality primary healthcare services, and the health outcomes that come with that access.

The numbers are stark. Citing and translating figures from the Australian Bureau of Statistics (ABS), the AIHW reports that health risk factors climb noticeably in both males and females, the further away from a major city they reside. The eight risk factors taken into account by the ABS in these statistics can almost entirely be related directly or indirectly to oral health risk factors, such as daily smoking/tobacco use; daily sugary drink consumption; inadequate diet; high blood pressure; and alcohol consumption.

The rural and remote population have a higher mortality rate, including higher rates of potentially avoidable deaths, than major city dwellers. In especially striking statistics from the AIHW (2019), people living in ‘remote’ and ‘very remote’ areas were 24 times more likely to be hospitalised for domestic violence as those living in major cities. As the many ADA members who work on a volunteer basis with the various domestic violence-focused initiatives in our profession, such as Rebuilding Smiles and Healing Smiles, the lasting effects of domestic violence is commonly related to dental and oral health, from prosthodontic and oral-maxillofacial work to address injury and damage, to socio-economic factors that impact upon both preventive and ongoing care.
 

The practitioner shortage

Medicare data from 2020-21 allows us to compare non-hospital, non-referred attendances to GPs: compare 4.7% (‘remote’ population) and 3.4% (‘very remote’ population) per person, with 6.8% (‘major city’ and ‘inner regional’ populations) and 6.1% (‘outer regional’). Factors that create barriers for remote and very remote-based patients include low population density and sheer geographic distance, but limited infrastructure and the higher cost of delivering healthcare are both particularly significant ones.

When we focus on dental care delivery, again, the numbers tell the story. As of 2020, there were 56.7 dentists (clinical full-time equivalent rate [FTE]) employed in major cities. By comparison (see Figure 1) outer regional areas had 34.6 dentists FTE; remote areas had less than half, with 26.6 equivalent dentists; very remote areas, just 18.8 dentists FTE. The National Rural Health Alliance (NRHA) is one organisation tackling these issues head on, advocating especially for policies which encourage the full range of health professionals to consider a rural career. It produces a range of resources and fact sheets to give a clear and unambiguous snapshot of issues such as healthcare professional distribution. According to the NRHA, Rural communities need an additional 21,357 FTE of healthcare personnel to match major cities on a per-population basis.

“In light of the multiple factors influencing the oral health status of people living in rural, regional and remote Australia, integrated efforts that address workforce issues alongside the social determinants of oral disease and risk factors for oral disease and chronic disease are required,” says Margaret Deerain, Director of Policy & Strategy Development at the NRHA. “Initiatives that facilitate improved access to dental services should be developed and fully funded.

“There are several factors that expose people, particularly those living in remote and very remote areas, to risk of poor oral health. These include: longer travel times, limited transport options to services, higher likelihood to smoke and drink alcohol at risky levels, taking illicit drugs and reduced access to fluoridated drinking water. The increased cost of healthy food and oral hygiene products for people living in rural areas is also associated with poorer oral health outcomes. The link between chronic disease and oral health status makes oral health a priority health issue, particularly for rural and remote Australians who already face compound challenges in accessing oral healthcare.”
 

The Royal Flying Doctor Service

There are a number of organisations that provide healthcare services to the rural and remote populace in Australia, and surely there is none more famous than the RFDS. However, there are many more practitioners than simply ‘doctors’, of course, and there are more modes of transport than flying.

In fact Dr Lyn Mayne, Rural and Remote Dental Manager and Senior Clinician for the RFDS’s South Eastern Section, tells us that their dental van service manages to provide extensive coverage partially across three states.

“The dental van rotates through more remote areas, providing access to dental care for patients who would otherwise have to travel long distances or would otherwise not receive dental care,” she says. “The van covers our network from both Broken Hill and Dubbo, extending into some communities in South Australia and Queensland, but mainly in NSW.

“As the dental van has full sterilisation facilities and x-ray unit, a full range of treatment is possible.”

The dental van enables the RFDS to visit schools and provide screening and treatment, as well as oral health education. Treatments services include extractions, restorations, root canal treatments as well as ‘check and cleans’. “We also provide toothbrushing programs in schools, Mums and Bubs, and aged care programs where residential facilities exist,” says Dr Mayne. “Our trainee Indigenous dental assistants are key personnel in providing community-based care, and provide a local point of contact for locals, and enable us to have a better understanding of Community’s needs.”

Considering the thin spread of healthcare professionals across more remote areas, complex or multidisciplinary cases can present challenges in terms of timing and personnel, but because the RFDS employs a range of practitioners across the spectrum of healthcare provision, there are opportunities to solve problems in-house – but not always.

“The dental team works closely with the RFDS primary health teams, including GP services and mental health and drug and alcohol to provide a holistic approach to patient care,” says Dr Mayne, “but some more complex procedures such as surgical removal of impacted wisdom teeth, crown and bridge work, and dentures are referred to either the Area Health Service or private dentists.

“Our team of dentists, oral health therapists and dental assistants monitor, order and stock both the dental van and outreach clinics. Radiology services such as OPG are referred to the nearest possible location. Unfortunately, this can delay treatments, and patients may have to travel long distances to access these services.”
 

All Access CQU Oral Health Outreach Project

In Queensland, one project has won funding from the Australian Dental Health Foundation and Mars Wrigley Foundation’s Healthier Smiles Community Service Grants program and is putting the money to instant good use.

The $11,000 grant has enabled a mobile dental program to deliver dental services to at-risk cohorts in non- traditional settings outside of the dental clinic in Central Queensland, headed by Central Queensland University (CQU)’s Bachelor of Oral Health course, Associate Professor Carol Tran. An ‘all in one’ 8.6kg dental kit has been developed to help 20 CQU final- year dental students bring care into the community.

“Up until now, a small team of oral health practitioners and third year students have attended the outreach clinic to complete free dental screenings with limited resources – no dental chair, suction, triplex or handpieces,” said A/Prof. Tran when the grant was announced. “With this new grant and equipment, we will be able to offer residents fillings, cleans and check-ups without the need for the residents to leave their facilities.”

As part of the program, CQU is set up now to support adult clients of the Lives Lived Well Rockhampton Residential Rehabilitation Centre’s Binbi Yadubay ‘Healthy Beginnings’, a new live-in program for people struggling with alcohol and other drug use.

“The rehab centre is across the road from our clinic, technically, literally across the highway,” says A/Prof. Tran, “and we’ve been lucky enough to establish a good relationship with them. Initially, we were only screening the clients and referring them back to our oral health clinic to get treatment done, but because some of the clients might not want to leave the facility, we decided it would be better if we could actually provide the services to them directly. So that was the idea. To actually do treatment chairside in a facility that’s not a dental clinic – that’s very unique.”

The students have shown real eagerness to help out, even planning to come and volunteer their time out of term time over these summer holidays. The success of the project has also led to Carol and her colleagues planning to partner with Queensland Health, to offer this service to aged care and even childcare centres. Considering the wait to access a dental appointment in Rockhampton is currently quoted by A/Prof. Tran as 15 months, it is clearly addressing a gap in service.

“We’ve also provided oral health education to the clients, tailored to what they need, and a lot of the clients have told us this is the first time they’ve had this tailored advice. For example, there is a lot of untreated gum disease, and we can help with both treatment and preventive care. With the portable dental unit, our screening is for free and our treatment is significantly discounted.”
 

The pain of the wait

During the worst of the pandemic, access to healthcare even in the cities was reduced; in rural and remote areas, the very long waits were quite literally excruciating – and this is a real issue being addressed by these organisations now.

“Unfortunately, post-COVID the most common presentation is pain, swelling and broken restorations,” says Dr Mayne of the RFDS’s dental service. “The dental team continued to function during COVID lockdown, and while this provided some pain relief, this has also increased the need for follow-up treatment. Our dental team are increasingly dealing with patients who are frustrated and in pain, and this is distressing for them, as they try and meet patients’ expectations and needs.”

Over in the CQU All-Access project, it’s a similar story. “Normally these patients will wait until the pain is excruciating!” says A/Prof. Tran. “There’s a lot of neglect that has been going on. They’ll wait until a toothache occurs, then they’ll present either to the public dental clinic or to a private dental clinic to just get that treatment done to address their pain – and that’s it. They won’t go beyond having a look at the rest of the mouth to see what else can be treated. Quite a lot of the clients here have untreated disease and we can actually address that now, in a safe environment.”
 

Flipping the script

Despite the challenges, the opportunities to think more flexibly and provide solutions in an agile and sometimes unexpected way create a great deal of satisfaction. Simply put, unusual locations present unusual problems that require an out-of-the-box approach.

“We bring the whole unit to the actual facility,” says A/Prof. Tran. “One of the comments from Queensland Health when they do go out to aged care facilities, or when they do need to bring clients to their dental clinic, is that transport is often the barrier to actually getting appropriate dental care. We flip that model around now. We’ll actually go out to the client of the facility and their setting and provide treatment where we can.

“I think this is potentially the future in terms of really engaging with the community, flipping the model of care. Instead of waiting for people to come to our dental clinic to get treatment done, we’re actually going out to them to create community awareness, and to create engagement within the community as well.”

“Providing rural and remote oral health care is the most rewarding, frustrating, yet positive experience,” agrees Dr Mayne. “The ability to think outside the box to provide solutions to problems, the logistical challenges, the constant demand, the relief on the patients’ faces, the teamwork required to provide the best care possible, all contribute to the overall job satisfaction of working as part of the RFDSSE Section dental team. All members of our dental team work together to provide the best patient-centred care possible.”
 

Ready to play your part?

- Dental professionals considering a career with the Royal Flying Doctor Service South East Section can register their interest or request more details by emailing careers@rfdsse.org.au or, for nationwide information, visiting flyingdoctor.org.au

- For more information on volunteering with the programs run by the Australian Dental Health Foundation, or on the Healthier Smiles Community Service Grants, visit adhf.org.au