An assessment of strategies to control dental caries in Aboriginal children living in rural and remote communities in New South Wales, Australia

Dental caries is a serious problem for Australian Aboriginal children [1]. For example, Aboriginal children living in New South Wales (NSW) experience on average 2.64 decayed, missing or filled teeth (dmft/DMFT) due to dental caries. This is near double the dmft/DMFT rate of 1.54, experienced by non-Aboriginal children in NSW [2]. When left untreated, dental caries can cause severe pain, and negatively impact a child’s quality of life, ability to concentrate at school, and capacity to eat, speak and socialize without embarrassment [3].

Improving the oral health of Aboriginal children is a priority in the Oral Health 2020: A Strategic Framework for Dental Health in NSW [4], and the NSW Aboriginal Oral Health Plan [5]. It is essential that strategies aimed at improving the oral health of Aboriginal children are sustainable, supported by the local Aboriginal community and culturally competent [6].

Culturally competent health promotion programs for Aboriginal people should be developed in consultation with Aboriginal communities and designed to meet the needs of specific communities [5]. Additionally, they should be culturally and linguistically appropriate, evidence-based, sustainable, implemented in collaboration with communities and evaluated [7]. In rural and remote communities, programs that solely rely on the input from dental professionals are often not sustainable given the general shortage of qualified professionals [4]. Therefore, prevention programs that can be delivered by the local Aboriginal community are likely to be more sustainable and suitable for the needs of that population.

In 2013, Aboriginal Elders in Central Northern NSW, identified three Aboriginal communities that had extremely limited access to dental services and needed preventive oral health care programs. Subsequently, the Poche Centre for Indigenous Health and the Centre for Oral Health Strategy were invited into these communities to work in partnership with the local Aboriginal community to introduce sustainable dental services and preventive oral health care programs for Aboriginal people in the region [8] In 2014, a community-led oral health service was established, which provides comprehensive dental treatment for Aboriginal people in Central Northern NSW. The service operates using clinicians who have relocated to the region and local Aboriginal people who have been trained and employed as dental assistants. Portable dental equipment is used to provide dental treatment to Aboriginal children and adults from schools and local community health centres. The local Aboriginal community still however, maintained the need for preventive oral health care programs to be implemented alongside dental treatment provided in schools and community health centres.

In response to the community’s request for preventive oral health care programs, a three-stage plan based on the Precede-Proceed model of health program planning was used to develop a sustainable, community-led preventive oral health program (Fig. 1).

The Precede-Proceed model was used as it is a popular planning tool for population health programs [9]. It consists of a series of phases to assist researchers plan, design, implement and evaluate health programs. The first set of phases (PRECEDE) includes planned assessments to inform the design of the health program. The second set of phases (PROCEED) involves implementing a health program based on information learnt from the PRECEDE phases [10].

Guided by the Precede-Proceed model, Stage 1 included an epidemiological assessment of all Aboriginal children aged 5–12 years enrolled in local schools as well as an educational and ecological assessment of the community to determine predisposing risk factors and reinforcing and enabling factors to inform a targeted oral health program. The number of decayed, missing and filled teeth were recorded as well as baseline oral health knowledge and oral hygiene practices of children, parents/guardians, school staff and health workers.

The baseline data collected as part of Stage 1 data provided valuable planning information. The majority of children (87.5%) had untreated dental caries. The mean number of decayed primary teeth (dt) was 4.1 and the mean number of decayed permanent teeth (DT) was 0.7, indicating a clear need for dental treatment and education to prevent dental disease [11].

Based on the risk factors identified, the following oral health promotion strategies for Aboriginal children living in Central Northern NSW were developed, namely: increasing fluoride use through daily toothbrushing; ensuring safe and refreshing tap water is accessible to encourage the consumption of water rather sugar sweetened beverages; providing culturally competent oral health and nutrition education; and providing training programs to build capacity of the local Aboriginal community and existing health workforce to ensure oral health promotion is led and supported by the community.

The results of Stage 1 and proposed oral health promotion strategies were presented in a leaflet and also verbally reported back to the local Aboriginal people at an open community forum (locally known as a community ‘yarn up’) which is held to discuss local issues and events. The ‘yarn up’ included local Aboriginal Elders, teachers and school principals from the three local schools and representatives from the Poche Centre for Indigenous Health. The strategies were well-received at the ‘yarn up’ and members verbally agreed to the development of an oral health promotion program to be implemented in each of the schools in the three communities; which was later formalised in writing. This led to Stage 2 and thus the ‘implementation phase’ of the Precede-Proceed model.

The four components are based on existing programs which have shown to be effective in other Aboriginal communities [6, 12], and utilising high quality systematic reviews [13]. This study protocol describes the components of the proposed school-based program and evaluation protocol to determine the feasibility, efficiency and effectiveness of the strategies to control dental caries in Aboriginal children living in rural and remote communities in NSW.

The aim of the program is to improve the oral health of Aboriginal children by promoting daily toothbrushing using fluoride toothpaste, increasing oral health knowledge and encouraging the consumption of water to reduce the reliance on sugar-sweetened beverages.

Stage 3 will pilot the proposed program for 12 months in three schools in Central Northern NSW that enroll a high proportion of Aboriginal children. The process evaluation to be undertaken at the completion of the pilot, is based on the Precede-Proceed model for process evaluation (Phase 6) and will determine the program’s feasibility, efficiency, effectiveness and overall satisfaction of the participating communities.

Dental caries is recognised as a preventable disease [15], however, Aboriginal children continue to experience higher levels of dental caries than their non-Aboriginal peers [2]. ‘Closing the gap’ in Aboriginal oral health has been identified as a State and National priority [5, 16]. Developing and implementing evidence based and sustainable oral health promotion programs has been identified as an important strategy to ‘Close the gap’ [5, 17]. The shortages of dental professionals in rural and remote communities only reinforces the need for programs to be developed that can be delivered by the local community.

The proposed program includes four evidence-based strategies which have been well documented in international literature to prevent and reduce dental caries. While some of these strategies have been implemented and evaluated in Australian Aboriginal communities [6], Aboriginal children continue to experience near double the rate of dental caries than non-Aboriginal children. Therefore, research into the effective implementation of these strategies that can control dental caries in Aboriginal communities (such as this study) is still needed.

The incorporation of fluoride into preventive oral health care programs is fundamental to ensuring programs are effective. Children who brush their teeth with fluoride toothpaste at least once daily are less likely to develop dental caries. This program proposes daily in-school toothbrushing using fluoride toothpaste for primary school students in Kindergarten to Year 6 which is to be supervised by a classroom teacher and/or Oral Health Aide. School toothbrushing programs often face staffing barriers and problems with infection control [6]. This program proposes two unique points of difference to overcome these barriers. Local Aboriginal Oral Health Aides will assist teachers supervise toothbrushing and teachers and Oral Health Aides will be offered a NSW TAFE skillset in Infection Control and First Aid to ensure they can supervise toothbrushing competently and mitigate infection control issues.

The utilisation of a local Aboriginal Oral Health Aide to supervise toothbrushing is based on the COHI in Canada which uses ‘COHI Aides’. The ‘COHI Aides’ are Indigenous people who have been specifically trained as oral health professionals, providing dental screenings, oral health education and apply fluoride varnish to improve the oral health of Indigenous children in Canada [14]. Aboriginal Oral Health Aides in time may become a recognised role for Aboriginal people in communities with limited access to oral health services to support the local implementation of community oral health promotion. The role of an Aboriginal Oral Health Aide could potentially include supporting local implementation of oral health promotion programs, delivering dental health education and applying fluoride varnish, similar to the role of ‘COHI Aides’ in Canada.

Additionally, this program includes a strategic approach to the distribution of free toothpaste and toothbrushes for home use every 3 months to all school students and parent/guardians. This aims to increase accessibility to oral hygiene implements in Aboriginal communities and encourage the social norm of toothbrushing at home.

Preventive oral health programs for Aboriginal children are more likely to be effective if they include dental health education for the wider community [6, 18]. Therefore, this program will provide three-monthly dental health education sessions for students in schools and parents/guardians at local community health centres. The dental health education delivered through this program aims to improve the oral health literacy of Aboriginal children and adults and encourage the uptake of oral hygiene implements which are to be distributed. -. The program proposes that dental health education is delivered by an Oral Health Therapist, accompanied by a local Aboriginal dental assistant to ensure the cultural competence of information given.

The frequent consumption of sugar-sweetened beverages, is associated with increased risk of developing dental caries [19].This program facilitates the installation of refrigerated and filtered water fountains in schools to ensure access to cold and filtered water at schools and reduce reliance on sugar-sweetened beverages. A structured water bottle program component which will be supervised by teachers aims to encourage the consumption of water, rather than sugar-sweetened beverages.

Genuine collaboration has been undertaken with the local Aboriginal community to ensure that these evidence-based strategies are implemented culturally competently, can be led and implemented locally and are sustainable. Oral health promotion in Aboriginal communities is often unsuccessful or ends prematurely due to unsustainable sources of funding or relying on only one individual in the community [6]. This program provides schools and communities the opportunity to work together to implement a suite of evidence-based strategies which are known to prevent and reduce dental caries in an innovative way in Aboriginal communities. This study protocol describes the implementation of four evidence based strategies in schools to improve the oral health of Aboriginal children in Central Northern NSW and may provide insight into the effective implementation of sustainable oral health promotion to reduce dental caries in Aboriginal children in NSW and Australia.These strategies include daily in-school toothbrushing, distribution of free fluoride toothpaste and toothbrushes, a school water bottle program and in-school and community dental health education.