Abstract
Background: Brunei Darussalam is a Sultanate with a Malay Islamic monarchy. There are high levels of dental disease among its 406,200 population. The population’s oral health needs require an integrated blend of primary and specialist care, together with oral health promotion. Process and outcomes: This paper describes the planning and measures taken to address these needs. In accordance with an oral health agenda published and launched in 2008, focusing on access, health promotion and prevention, and the education and training of the dental workforce, the Brunei Darussalam Ministry of Health is seeking to improve oral health status and reduce the burden of oral disease. It also seeks to transform the country’s oral health services into a preventatively orientated, high-quality, seamless service underpinned by the concept of ‘teeth for life’. In the process of effecting this transition, the Brunei Darussalam Ministry of Health is developing a dental workforce fit for future purpose, with an emphasis on a modern approach to skill mix. An important element of this programme has been the development of a highly successful Brunei Darussalam Diploma in Dental Therapy and Dental Hygiene. Conclusion: It is concluded that the Brunei Darussalam oral health agenda and, in particular, the forward-looking programme of dental workforce development is a model for other countries facing similar oral health challenges.
Key words: Brunei Darussalam, dental workforce, oral health, strategic planning
INTRODUCTION
Brunei Darussalam
Brunei Darussalam is a sovereign state. It is a Sultanate with a Malay Islamic Monarchy. It is situated in South-east Asia on the North-eastern part of the island of Borneo, facing the South China Sea and surrounded by the Malaysian State of Sarawak. The capital is Bandar Seri Begawan.
The land area is 5765 sq. km (2226 sq. miles). It has an estimated population of 406,200 with an estimated population growth rate of 2.1% (2009). The population consists mainly of Malay (67%) and Chinese (15%) people with some Indian and other indigenous groups.
Brunei Darussalam is a welfare state in which health care and education are essentially provided free of charge to its citizens and permanent residents. The country’s main source of revenue is from natural resources of oil and gas. The 2009 estimate of gross domestic product (GDP) for Brunei Darussalam was US$18,000 per capita. The country’s economy is progressively diversifying into other non-petroleum based industries, transforming Brunei Darussalam into a newly industrialised country.
Levels of disease
Epidemiological surveys of oral health have revealed high levels of oral disease among the population of Brunei Darussalam, as detailed in Tables 1 and 2; children at 5 years of age had, on average, seven affected teeth and teenagers aged 13–15 years had a similar level of disease in their permanent dentition1. Dental caries remains one of the most common conditions in children and young people, and a willingness to address these high levels of disease has underpinned health policy. A further cross-sectional national oral health survey is planned in the near future. While it is hoped to identify improvements in the oral health status of the population, it is anticipated that the burden of dental diseases at all ages will still be relatively high, given the findings of a health screening programme for civil service employees in 2007–20082. These findings indicated that adults aged 18–24 years had the most decay present (59% of this age band)2., 3.. Adults aged 35–44 years had, on average, 9.9 decayed, missing and filled teeth, suggesting possible improvement on the statistics for this age group from the 1999 national survey [Diseased, Missing, Filled, Teeth (DMFT) = 14.4]3; however, the sample was relatively small and was representative of employees rather than the national population. Most importantly, even in this age group there was evidence that over half of the disease experience was represented by the ‘missing’ component, highlighting the role of extractions in disease management3. Only 9.7% of the adults surveyed had a healthy periodontium; calculus was present in 77.3% of participants and 27.2% of the dentate population were considered to require advanced periodontal treatment2. Late presentation for care was reported, with 68% reporting that they only attended for care when in pain3; this highlights the importance of having a workforce which can provide access to dental care at an early stage in the disease process, when conservative rather than surgical management can occur.
Table 1.
Prevalence of caries in Brunei Darussalam 1999
| Age (years) | dmft/DMFT 1999 | DMFT 2008 |
|---|---|---|
| 5 | 7.1 (11.3% caries free) | |
| 10–12 | 4.82 | |
| 13–15 | 7.24 | |
| 35–44 | 14.4 | 9.9 |
d/D, diseased; m/M, missing; f/F, filled primary (deciduous); t/T, permanent teeth.
Table 2.
Prevalence of periodontal disease in Brunei Darussalam 1999
| Age (years) | Bleeding gums (%) | Calculus (%) |
|---|---|---|
| 12 | 76.4 | 86.4 |
| 18 | 75.7 | 87.0 |
| 35–44 | 43.4 | 85.7 |
In addition to high levels of dental disease, there is significant need for specialist oral healthcare. For example, 32% of 10- to 15-year-olds surveyed in 1999 were considered to require orthodontic treatment. This compares well with the UK where the latest survey of children’s oral health suggested that 35% had a great or very great need for orthodontic treatment4. The level of demand outstripped services back in 1999 as the waiting list at the time was 3–5 years. As detailed below, Brunei Darussalam now has six specialist orthodontists, with a further individual in training. The waiting list for treatment remains long (2.5 years in 2008), albeit reduced.
The demand for primary dental care is mainly for public oral healthcare services, which provide oral healthcare to around 15% of the country’s population per year. There were around 126,000 public service attendances for oral healthcare in 2010. Of these, 91.4% were treated by primary care professionals (35.4% by primary care dentists and 56.1% by dental therapists and hygienists who serve children aged 16 years and under). Only 8.6% of the attendances in that year were for specialised oral health care.
Oral health awareness and diet
The typical Bruneian diet includes large amounts of refined sugars. Sugar consumption in Brunei Darussalam is moderately high for the region and was estimated at 29.7 in 2005.5 From observation and feedback, it is apparent that oral hygiene practices among the general population are far from ideal and oral health awareness is relatively low. Even though the self-administered questionnaire for civil service employees in 2007–20082 indicated that 93% of the respondents claimed that they brushed their teeth two or more times each day, this is not reflected by levels of caries in the population, or by periodontal health status.
Furthermore, levels of smoking in the population remain relatively high. From a sample of 358 subjects included the integrated health screening programme for civil service employees2, it was found that 11.8% (n = 66) of the participants were smokers, 11% (n = 61) were past smokers and 41.5% (n = 231) were non-smokers. These findings are despite wide-ranging measures to encourage cessation of smoking within Brunei Darussalam.
Fluoride
The public water supplies in Brunei Darussalam are mostly fluoridated, with about 99% of the population being provided with fluoridated water. The Ministry of Health recommends that the level of fluoride in the water be kept within the optimal concentration of between 0.5 and 0.7 ppm. Collaborative efforts are ongoing between the Ministry of Health, the Department of Water Services and the Ministry of Development to maintain the level of fluoride in public water at this optimal level.
Oral hygiene aids
Toothpaste, toothbrushes and other oral hygiene aids are widely available commercially. While data are not available in respect of the purchase and use of oral hygiene aids, it is understood that oral hygiene techniques and practices are, in common with many countries around the world6, very variable amongst the population.
Funding and infrastructure
In 2008, the Department of Dental Services was allocated nearly 4.0% of the national healthcare budget. Efforts are continuously being made to attract additional funding to further develop the provision and quality of the oral health services. As in any healthcare system, however, the need for developments in oral healthcare provision has to be balanced against the need to develop other core healthcare services, while being mindful of cost benefits and quality of life issues.
Transitioning to preventively orientated care
In common with many oral healthcare services around the world7, the oral healthcare services in Brunei Darussalam face challenges in changing from a service primarily based on clinical interventions to meet pressing treatment needs among, in particular, patients with high levels of disease and, as is typically the case, low levels of dental motivation to a preventatively orientated, minimal interventive approach, supported by patient engagement and ownership of the need to improve oral health. The high cost of clinical interventions necessary to address the large burden of oral diseases limits the resources available to effect transition to oral healthcare orientated towards prevention of oral disease and the promotion of the concept of teeth for life. To effect this transition in a timely manner, rather than waiting for a generational change in attitudes and behaviour, there would be a need for an interim increase in funding over a number of years.
Oral health agenda
In 2008, the Department of Dental Services, Ministry of Health in Brunei Darussalam published and launched an ambitious and comprehensive oral health agenda entitled ‘PEARL 2012.8. The main aim of this agenda was ‘to improve the health and well-being of the Brunei population by improving the oral health status and reducing the burden of oral diseases’. More specific aims are to help the residents of Brunei Darussalam to:
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Retain as many as possible of their teeth throughout their lives.
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Have good oral health as part of their general good health and wellbeing.
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Have access to appropriate information and an affordable, safe and sustainable, seamless, fully integrated, high-quality oral health service.
The agenda has three main themes: accessibility; promotion and prevention; and education and training.
The purpose of the present paper is to describe and discuss the steps taken to date to realise the education and training theme of the agenda and to highlight the ways in which these steps may be viewed as an exemplar by neighbouring and other countries worldwide that have oral health challenges similar to those identified in Brunei Darussalam.
Dental education and training
The main aim of the education and training theme of the oral health agenda in Brunei Darussalam is ‘to achieve a sufficient and appropriately skilled workforce and to increase the oral health services workforce diversity, capacity, flexibility and expertise, including the utilisation of PCDs’ [PCDs-professionals complementary to dentistry is a term coined in the UK to include all members of the dental team other than dentists and administrative staff and which has now changed to dental care professionals (DCPs)].
Dentists
In 2010, Brunei Darussalam had a total of 93 dentists (Table 3), including the dentists in the public services, armed forces, general dental practitioners and those working in private organisations and hospital, giving a dentist to population ratio of 1:4046. Seventy of the 93 dentists were public services dentists of whom only 60 were in active service; the others (n = 23) underwent in-service postgraduate training. Only 31 dentists were principally engaged in the delivery of primary oral health care, giving a public service primary care dentist to population ratio of 1:12,137.
Table 3.
Demographics of dentists practising in Brunei Darussalam (2010)
| Nationality | Gender | Age (years) |
|---|---|---|
| Bruneian 41 (59%) | Female 50 (71%) | < 35, n = 39 (56%) |
| Other 29 (41%) | Male 20 (29%) | 35–44, n = 18 (26%) |
| 45–54, n = 8 (11%) | ||
| < 55, n = 5 (7%) |
A further 10 individuals, presently undergraduates in the UK and Australasia will join the dental workforce in Brunei Darussalam by 2013, but this increase may, at least in part, be offset by losses through retirements or other causes.
While the outcome of the planned dental workforce development review must be awaited, it is anticipated that the number of dentists in training will need to be increased, even if plans are made to further develop the dental team approach (see below), with dentists as the leader of teams of dental care professionals and associated administrative staff.
Regarding the future training of dentists, this could mirror arrangements in medical training in Brunei Darussalam, whereby graduates of either the Bachelor of Biological Sciences or the Bachelor of Health Science degrees of the University of Brunei Darussalam may enter graduate entry programmes overseas, to return to Brunei Darussalam under the terms and conditions of professional training schemes.
Specialist practitioners
The number and specialty distribution of specialist practitioners in Brunei Darussalam, including specialist practitioners in the armed forces, is detailed in Table 4. Many of these specialist practitioners are under 35 years of age. Having 21, and in due course a further five members of the total dentist workforce of 70 individuals trained to the specialty level, is commendable. This is greater than the level of specialists in the UK and the USA where 10% and 20% of the dental profession are trained to specialist level9 respectively, but takes into account that more routine primary dental care may be provided by DCPs. However, there is need for coverage of all dental specialties so that comprehensive continuing professional development and clinical support are provided for all dentists within the country. It is notable that Brunei Darussalam has no specialists in dental public health and special care (needs) dentistry, let alone oral medicine or oral pathology – services that are provided by oral maxillofacial surgeons as medical specialists and general pathologists, respectively.
Table 4.
Numbers and specialty distribution of specialist dental practitioners in Brunei Darussalam (2010)
| Specialty | Number of practitioners | Number in training |
|---|---|---|
| Orthodontics | 6 | 1 |
| Paediatric dentistry | 5 | 1 |
| Oral surgery | 4 | 1 |
| Prosthodontics | 3 | – |
| Endodontics | 2 | 1 |
| Periodontics | 2 | – |
| Restorative dentistry | 1 | 1 |
Workforce priorities
While it may appear that the priority is to use available resources to train more general dental practitioners, it is anticipated that the planned dental workforce review may recommend succession planning in the dental specialties, together with the introduction of specialists in dental public health and special care dentistry as an important early action. Investment in developing specialist dental public health expertise to actively inform health policy and planning could result in better oral health for the population and ensure that resources are used to promote health and well-being and not just to treat disease. Areas for action include: addressing the diet, in conjunction with public health professionals, as part of a common risk factor approach to promoting health and preventing disease10., 11.; implementing the strong global evidence base for prevention as a core pillar of primary care provision; and building the monitoring of oral health and dental service provision into routine data collection (in electronic format) to inform future planning and provision of care – the application of health informatics.
Dental therapists and dental hygienists
In 2007, the Brunei Darussalam Ministry of Health signed a memorandum of understanding with King’s College London Dental Institute, where many of the Brunei Darussalam specialist practitioners were trained, to underpin arrangements for a collaboration to develop a Brunei Darussalam Diploma in Dental Therapy and Dental Hygiene provided by the Brunei Darussalam Ministry of Health National Dental Centre. This innovative, highly successful programme, which has given Brunei Darussalam a degree of independence in dental workforce development, has to date produced 14 dental therapy/hygienists. Six of the serving dental nurses (New Zealand type) have gone on to become tutor dental therapy/hygienists, subsequent to a 1-year programme of training at King’s College London Dental Institute. The development of mid-level dental providers is becoming an important part of healthcare development across the world12., 13., 14.. While controversial in certain countries, the development of the dental team offers many important advantages, in particular, when, as in Brunei Darussalam, mid-level providers can meet many of the dental needs. Concurrently, the development of the specialist dental workforce should, as in Brunei Darussalam, anticipate changing needs for specialist services, notably among the ageing population.15
Arrangements are in hand to recruit and train further cohorts of dental therapy and dental hygiene students in Brunei Darussalam and to establish a conversion course to allow existing dental nurses (see below) to receive top-up training to qualify as dental therapists/hygienists. This will further enhance the competence of the dental team and its flexibility to work across the dental service.
School dental nurses
School dental nurses in Brunei Darussalam are qualified to provide primary dental care to children, working predominantly in school-based clinics. In 2010 there were 74 dental nurses engaged in clinical practice in Brunei Darussalam, with the training of these members of the dental team having been provided largely in Malaysia and to a lesser extent in Singapore 20–35 years ago. Many of these dental nurses have one or more post-qualification certificates or diplomas, with two having obtained BScs (one in Oral Health and the other in Health Service Management). As a result of having established the Brunei Darussalam Diploma in Dental Therapy and Dental Hygiene, Brunei Darussalam is no longer sending trainees to be trained as dental nurses in Malaysia or Singapore.
Dental surgery assistants
Dental surgery assistants play a vital role in ensuring the delivery of quality care by dentists, therapists and hygienists by enhancing their productivity in well-developed systems. Dental surgery assistants (DSAs) in Brunei Darussalam support dentists, dental therapists, dental hygienists and dental nurses in the provision of dental services. In 2010 there were a total of 93 DSAs in Brunei Darussalam, comprising two Chief DSAs, 13 Senior DSAs, 25 qualified DSAs and 53 trainee DSAs. Before 2002, DSA training for Brunei Darussalam was provided in Malaysia. Subsequent to establishing a training programme locally in 2002, the Ministry of Health introduced a Certificate in Dental Surgery Assisting in 2003. This programme, as indicated above, presently provides training for 53 trainees.
Dental laboratory staff
In 2010, Brunei Darussalam had a total of 38 dental laboratory staff, including 19 technicians, seven technologists, nine trainee technicians and six possible future trainees. The dental technologists completed three-year BSc degrees in dental technology, while the technicians hold a diploma in dental technology obtained in Malaysia. Consideration may, at some time in the future, be given to establishing a Brunei Darussalam Diploma in Dental Technology in collaboration with King’s College London Dental Institute.
Administrative and support staff
The delivery of dental services by the Ministry of Health in Brunei Darussalam is supported by a total of 45 administrative and support staff, ranging from a Chief Executive Officer (CEO) and hospital administrator to 12 reception staff and 14 attendants who serve as clinical assistants and ‘runners’ in major dental clinics.
Workforce goals
Concurrent with plans to develop a new National Dental Centre, supported by a network of district dental clinics, the goal for dental workforce development in Brunei Darussalam is to create a dental team of appropriate size and composition, according to World Health Organization (WHO) workforce targets, with the expertise, capacity, flexibility and skill mix to provide modern, preventatively orientated oral health care, sufficient to realise the national Oral Health Agenda8. A further goal is to support continuing professional development for the dental workforce, sufficient to maintain knowledge and understanding and to keep the entire workforce abreast of developments in clinical practice. The latter is viewed as essential to drive continuous quality improvement in the national provision of oral health care. It is acknowledged that considerable investment will be required to realise the dental workforce and associated goals, but the benefits of fulfilling the Ministry of Health’s vision for 2015 are considered to justify the commitment of the necessary resources16. In addition to the immediate plans for a new oral health survey and a programme of workforce modelling to ensure that there are robust longer-term plans in place, decisions will be required in respect of the wider dental team to include, for example, clinical dental technicians and orthodontic therapists. In taking forward this agenda, initial deliberations would suggest that the most pressing need could be considered to be the training of specialists in dental public health. These specialists will be critical in driving and monitoring progress in the nation’s oral health agenda.
DISCUSSION
Addressing the oral health of a nation, irrespective of size, requires strong political action, wide participation, buy-in and sustained effort and investment. As set out in the WHO resolution WHA.60.177, action plans for the promotion of oral health and integrated disease prevention comprise various elements, including workforce planning for oral health and scaling up the capacity to produce oral health personnel. The Ministry of Health in Brunei Darussalam is rising to this challenge as part of its Oral Health Agenda8. Such action, which may in due course result in Brunei Darussalam becoming a regional centre of excellence for dental education, is an exemplar to countries elsewhere in the world that face oral health problems similar to those that exist in Brunei Darussalam.
In countries in which there are substantial unmet health needs, often together with health inequalities, oral health, other than acute dental care, may not be viewed as a funding priority. However, with the growing body of evidence of associations between various forms of chronic systemic disease and poor oral health6, let alone the impact of oral health on general wellbeing, in particular in older patients,15 the philosophy of Together Towards a Healthy Nation adopted by the Ministry of Health in Brunei Darussalam17 is a very progressive in national healthcare policy. Furthermore, it is laudable that oral health promotion in Brunei Darussalam is an integral element of a major strategic goal to promote healthy living through modified lifestyles, as emphasised in the Brunei Darussalam, Ministry of Health, Promotion Blueprint 2011–201517.
Given the lead time necessary to develop a dental workforce fit for future purpose in the provision of preventatively orientated, minimally interventive oral healthcare, dental workforce strategies of the type being implemented in Brunei Darussalam require sustained support and funding over extended periods. From inception to the time of realising major goals, at least 5 years – and possibly more – may elapse. Success in dental workforce development may therefore rely heavily on stable domestic affairs, with relevant policy being carried forward through different Ministers and ministerial teams when organisational change occurs, as has happened since the national Oral Health Agenda and strategy16. Under these circumstances, the previous Minister of Health is to be congratulated for having established the strategy, and his successor, the present Minister of Health also deserves praise for not only sustaining the programme but planning to expand it to include, as a next phase, the development of a new National Dental Centre. This is linked with the possibility of concurrent arrangements for the training of dentists, involving international collaborative working between King’s College London and the University of Brunei Darussalam. Furthermore, the present Minister of Health has highlighted the need to focus on ‘modifiable risk behaviours such as diet, nutrition, tobacco use and personal (oral) hygiene’, with the dental workforce shifting away from a ‘treatment only mentality’ which is viewed as expensive and mostly ineffective. The vision for the future includes the promotion of health and the prevention and early detection of oral diseases at both population-wide and individual healthcare intervention levels, with the appropriate use of state-of-the-art methodologies.
Brunei Darussalam is to be commended for the adoption of its bold Oral Health Agenda, underpinning and supporting the philosophy of the national strategy Together Towards a Healthy Nation17. As discussed in the present publication, investment in dental workforce development is critical to the success of an action plan to improve the oral health of a nation. Brunei Darussalam is to be commended for wishing to improve oral health and, in turn, general health and well-being through effective, equitable, affordable, accessible, safe and sustainable oral healthcare by a dental team trained to international standards.
The 2008–2012 oral health agenda in Brunei Darussalam,8 and, in particular, its programme of dental workforce development and associated investment is considered to be a model for other countries facing similar oral health issues.
Acknowledgements
We thank the current Minister of Health Brunei Darussalam (Yang Berhormat, Pehin Orang Kaya Johan Pahlawan Dato Seri Setia Awang Haji Adanan bin Begawan Pehin SiRaja Khatib Dato Seri Setia Haji Mohd Yusof) and former Minister of Health Brunei Darussalam (Yang Berhormat Pehin Orang Kaya Indera Pahlawan Dato Seri Setia Awang Hj Suyoi bin Haji Osman).
Competing Interests
Professor Wilson and Miss Slater from King’s College London Dental Institute were engaged in the workforce development reported in this paper through an agreement between King’s College London and the Ministry of Health Brunei Darussalam. Drs Shamshir, Moris, Kok, Said and Lee are employees of the Ministry of Health, Brunei Darussalam.
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