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2013 vol. 37 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 47 2013 The Authors. ANZJPH 2013 Public Health Association o Australia

The importance o outreach clinical

placements as an integral component

o undergraduate dental programs has

gained recognition over the past 20 years.1-5

Many dental programs in Australia have

provided students with clinical experience

outside the university dental clinic itsel.1,2,6-9A

recent report rom the Association or Dental

Education in Europe (ADEE) special interest

group (SIG) on outreach training summarised

the diversity, benets and alternative models

o such experiences.4 The SIG has met at three

ADEE annual meetings since 2006 to discuss

the various outreach training models across

the world. They stated that: Access to these

resources provides demonstrated benets to

students condence, competence, extended

team-working and proessionalism through an

increase in the quantity and variety o clinical

experience.While this enhanced clinical

experience is important, the other benets

o an outreach program, such as exposure

to a particular type o working environment,

appreciation o the ethical responsibilities o

a dental proessional or the oral health o

the community as a whole, understanding

not only the principles o public health

dentistry but also their implementation

and appreciation o the responsibilities and

requirements o the practice environment, are

equally important.4

The geographic maldistribution o

the dental workorce in Australia is well

documented.10,11 Between 2003 and 2006, the

number o practising dentists increased only

in major cities (by 11%).11 Inner regional,

outer regional and remote/very remote

areas decreased by 5.9%, 4.3% and 4.4%

respectively. More than 80% o dentists

work in the private sector.11 Due to this

maldistribution, access is dicult or people

living in rural and remote areas.12,13 In these

communities, the indirect costs o travel and

the impact on amily lie are urther important

barriers to accessing dental care.14Student

clinical placement programs in regional and

rural settings could play a role in encouraging

students to consider a proessional career

outside the major cities.7,15,16

There is consensus that the burden o

dental conditions is higher in rural and remote

locations, especially among Indigenous

people.17-20 A recent report o the dental caries

status o Indigenous children in Australia

showed that those in rural and/or remote

areas have a much higher mean number o

decayed, missing and lled deciduous teeth

(dmt). For example, Indigenous children in

rural and/or remote areas (dmt ~4 in 6-year

old children) had a higher mean compared

to non-Indigenous children in metropolitan

(dmt ~1.5) and rural settings (dmt ~1.8),

Dental care provision by students on

a remote rural clinical placement

Ratilal Lalloo

Rural, Remote & Indigenous Oral Health, School o Dentistry and Oral Health and

Population and Social Health Research Programme, Grifth University, Queensland

Jane L. Evans

School o Dentistry and Oral Health and Population and Social Health Research

Programme, Grifth University, Queensland

Newell W. Johnson

Dental Researchand Population and Social Health Research Programme, Grifth

University, Queensland

Submitted: December 2011 Revision requested: April 2012 Accepted: September 2012

Correspondence to: Pro R. Lalloo, Colgate Chair: Rural, Remote & Indigenous Oral Health,DOH, Gold Coast campus, Grifth University, QLD, 4222; e-mail: [email protected]

Abstract

Background:In 2009, the School

o Dentistry and Oral Health, Grifth

University, commenced a clinical

placement in a remote rural and

Indigenous community in Australia. This

paper analyses the type o treatment

services provided rom 2009 to 2011 by

year, type o patient and age o patient.

Methods:All treatment data provided were

captured electronically using the AustralianDental Association (ADA) treatment

codes. Audited reports were analysed

and services categorised into six broad

treatment types: consultation, diagnostic,

preventive, periodontics, oral surgery and

restorative services.

Results:The bulk o dental care episodes

provided over the three-year period were

or clinical examinations, restorative and

oral surgery services. Preventive and

periodontic services generally comprised

less than 10% o the care provided.Over time ewer clinical examinations

were conducted and restorative dentistry

increased in the second and third years o

the placement. There were no signifcant

dierences in the types o care provided to

public and private patients.

Conclusion:Clinical placement o

fnal-year dental students in remote rural

settings has helped address a largely

unmet dental need in these regions.

Implications:Dental student clinical

placement is eective in providing careto communities in a remote rural setting.

Student placements are, however, only

able to deliver dental care in ew remote

rural communities, and thereore will

make a negligible impact on the level o

untreated dental disease in the short term.

It is hoped that the experience will lead

to more graduates serving some o their

proessional lives in remote communities.

Key words: clinical placement, dental care,

remote, rural, students

Aust NZ J Public Health. 2013; 37:47-51

doi: 10.1111/1753-6405.12009

Article Population Inequality


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48 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2013 vol. 37 no. 1 2013 The Authors. ANZJPH 2013 Public Health Association o Australia

as well as Indigenous metropolitan children (dmt ~2.6).21 The

situation is the same in the permanent dentition o older children.

The National Survey o Adult Oral Health showed that 57% o

Indigenous adults had untreated coronal dental caries, compared

with 25% o non-Indigenous adults.22 The mean number o decayed

teeth among Indigenous adults (>15 years o age) was 2.7 compared

to 0.8 among non-Indigenous adults. Indigenous adults were,

however, under-represented in this survey, and the ndings need to

be interpreted with caution.

The School o Dentistry and Oral Health at Grith University

started a remote rural clinical placement or nal-year dental

students in February 2009.23 The dental training acility is in

Brewarrina, north-west New South Wales (NSW). Brewarrina is

a remote rural town, about 850 km rom the Grith University

dental school, which is in the City o the Gold Coast, south-east

Queensland (see Figure 1). The population o the town o Brewarrina

is approximately 1,500; with 60 to 70% identiying themselves as

o Indigenous origin. The population o the wider Brewarrina Shireis a urther 500, in an area o about 20,000 km2. The nearest large

town is Dubbo, 374 km away, and the nearest other small towns

are about 100 km away. No dental services had been available

in Brewarrina or many years prior to the commencement o this

initiative in 2009. The clinic has our dental surgeries. In the rst

three years o the project which we report here, 166 (o the 174

= 95%) nal (th) year dental students have spent a three-week

rotation in Brewarrina. Students are generally rotated in groups o

eight. Student accommodation and travel (a 12-hour road journey)

are provided. Stang at the clinic includes a supervising dentist,

a dental assistant and a receptionist. The clinic provides health

promotion, prevention and basic dental services to the community

o the town and surrounding areas. The students experience a setting

that would be unique or most, and we hope this placement will make

them appreciate the general and oral health burden experienced by

rural, remote and Indigenous communities, as well as the risk actors

they conront on a daily basis.

One o the central aims o the clinic placement is to provide

an accessible dental service to the community o Brewarrina and

surrounding towns. This paper analyses the types o treatment

services provided to patients rom the clinics inception in early 2009

to late 2011. The types o services provided are urther explored by

year, type o patient (public versus private) and the age o patients.

Methods

At the university dental clinic in the Gold Coast, all patient

records, including the treatment services provided, are captured

electronically, using the Titanium patient management system

o Spark Dental Technology. The same system was installed in

Brewarrina and is linked to the main server. Australian Dental

Association (ADA) treatment codes are used to capture data on the

treatment services provided (www.ada.org.au). A nance ocer

in the Planning and Financial Services (PFS) unit o the university

audits all treatment data entered onto the system at regular intervals.

The audited reports or 2009 to 2011 were summarised into

six broad treatment types: consultations/clinical examinations,

diagnostic services (mainly radiographs), preventive services,

periodontics, oral surgery (largely tooth extractions) and restorative

dentistry. The treatment services provided across the three-year

study period were compared by year and type o patient (public/

private). All children younger than 19 years o age are considered

public patients, as treatment is provided at no cost. Adult patients on

health care concession cards are also entitled to care at no charge.

Other adult patients are charged a ee-per-item o service and are

considered private patients. The total number o patients treated,

occasions o services (appointments) and age distribution, were also

analysed by patient type and year. The chi-square was applied or

comparing treatment types provided to public and private patients,with ap-value 18 years o age) who

attended the clinic, by patient type, shows that across all three years

about two-thirds o private patients were older than 40 years o age.

In the rst year o the clinic, 46% o the adult public patients were

older than 40 years o age. In 2010 this increased to 58%, with a

slight decrease to 54% in 2011.

Gold Coast to Brewarrina - 845km

Brewarrrina to Dubbo - 374km

Figure 1: Map of south-east Queensland and northern

New South Wales (Source: Google Maps).

Lalloo, Evans and Johnson Article


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Population Inequality Dental students on remote rural placement

In the rst year o the clinic (2009), almost one-third (29%) o

all treatment codes were or consultations/examinations (Table

2). This decreased to 9% and 16% in the second and third years,

respectively. Over the study period, restorative dentistry was by ar

the most common type o treatment provided, increasing rom 30%

o codes in 2009 to almost hal (49%) in 2010 and 35% in 2011.

Preventive dentistry and treatment o the periodontium comprised

generally less than 10% o the codes entered. The dierences in the

types o treatment provided to public and private patients were not

statistically signicant across all three years (2009:p=0.844; 2010:

p=0.738 and 2011:p=0.708). Private patients received slightly more

diagnostic type services, while public patients received slightly more

oral surgery (extraction) treatment services (Table 2).

O the 583 treatment services provided to children (


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50 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2013 vol. 37 no. 1 2013 The Authors. ANZJPH 2013 Public Health Association o Australia

Aboriginal) oral surgery services were less common and restorative

services were more common. In both settings prosthetics services

comprised a very small component o the dental service provision.

An analysis o service provision by students in outreach clinic

placements in the United Kingdom (UK), Canada and the United

States (US) showed that clinical examinations (patient assessments),

restorative and extraction services were the most common types o

dental care provided.5,25-27

There were minor dierences in the treatment services provided

to public and private patients. Public patients received more tooth

extractions, perhaps due to lower socioeconomic groups suering

more severe levels o dental disease, having more limited access to

care and the patients themselves having lower expectations.24,28-31

An analysis o treatment services provided to Indigenous peoplewas dicult as there are sensitivities in obtaining this inormation

on an individual basis, and we are not condent that the Indigenous

status data or 2009 (our rst year in the community) were accurate.

There are also complex issues attached to interpretation o any such

analysis. We were thereore more condent analysing the treatment

data by public and private patient status.

At the rural clinical placement no prosthetic and endodontic

services were provided. No prosthetic laboratory was available in

Brewarrina and provision o dentures was not considered a priority

when the scheme began. It was considered clinically prudent not to

provide an endodontic service because o the lack o continuity oservice through the year. There were concerns that emergency care

was not easily accessible to deal with complications, with the nearest

dentist more than 100 km away and not continuously available.

Over time, there was an increase in younger patients attending

the clinic. This may suggest a greater awareness o the service

availability and increased awareness o the importance o oral health

ollowing visits to schools. There were also many private patients

(assumed to be o higher socioeconomic status) who accessed the

clinic or care, but this uptake has decreased slightly over time.

Public patients were initially slower to take up the opportunity

or care in Brewarrina, but this has changed over time. The initial

slower uptake by the local community may be due the structure and

operations o the clinic, which is largely based on the usual public

sector system o specic appointments. All the students in the three

cohorts were non-Indigenous, the medium o communication was

exclusively English, and students may have been unable to explain

complex dental jargon in a way that was easily understandable to

the community.32 The clinic also only provided basic primary oral

health care, which may not have been considered appropriate by

the community, and patients may not have received the care they

requested. The clinic, however, was not punitive on patients who

ailed to attend and patients were allowed to bring people to their

appointments to support them.

Based on student eedback obtained by an online survey, more

than 80% elt they had enhanced their clinical operative skills in a

primary care environment by virtue o this experience. Randomised

controlled trials in Sheeld (UK) suggest that the students who

experienced both the dental school clinic training and an outreach

clinical placement were more conident in tackling clinical

situations, compared to students who trained only at the dental

school clinic.33Students who had outreach experiences scored higher

on capturing the social history o their patients and or developing

an appropriate treatment plan.34 A ollow-up study o graduates at a

dental school in Wales reported that they elt the outreach teaching

program played an important role in their proessional development

and subsequent clinical careers.35

While it is important that the types o care provided is monitored,

especially to assess a shit towards oral health maintenance and

preventive services, it is as important to evaluate the broader

impact o the clinical placement. An accurate recording o activities

beyond the scope o the treatment codes, such as health promotion

activities and screenings conducted outside the clinic, needs tobe implemented. An analysis o attendance and non-attendance

(ailed to attend and cancelled appointment) patterns needs to be

monitored, and data rom 2011 show that 888 patients made a total

o 1,862 appointments. The percentage o ailed to attend (FTA) was

17.3% and cancelled appointment was 20.4%. Hal o patients only

attended a single appointment in 2011. Almost one-th o public

patient appointments were FTA (18%) compared to 11% among

private patients. It will be important to investigate the ollow-up and

completion o care o patients accessing the dental clinic. In-depth

group interviews with community and service organisations are

currently being conducted by the Health Co-ordinator in the localshire council to inorm the on-going improvement o the clinical

placement. These interviews ocus on issues related to oral health

in remote rural communities and how best to address these, taking

into account the cultural values o the local community. A service

user survey is also currently being conducted.

In summary, this clinical placement o nal-year dental students

in a remote, rural and Indigenous setting in Australia has made an

important contribution in addressing a largely unmet dental need

in the communities in the town and the surrounding region. In the

rst three years o the placement, the bulk o the care provided was

o a restorative and surgical (extractions) nature, but this should

change as more o the urgent dental needs are met. There is a need

to prioritise health promotion and oral health preventive initiatives,

Figure 3: Percentage distribution of treatment services

provided to adults, by year.

50

40

45

35

30

25

20

15

105

0

2009 2010 2011

Consultations

Periodontics

Diagnostic

Oral Surgery

Prevention

Restorations

Lalloo, Evans and Johnson Article


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such as oral health promotion and opportunistic dental screenings

at schools (already commenced) and chair-side health education.

This community has beneted rom an easily accessible dental

service, avoiding long-distance travel to the nearest service and the

associated costs. The students have beneted in that they believe they

have enhanced their clinical competence and condence. However,

student placements will only be able to deliver dental care in a ew

remote rural communities currently without access to care; this will

make a negligible impact on the level o untreated dental disease

and ultimately on the prevention o these conditions in these many

communities. The issue o oral health in remote rural, and especially

Indigenous communities, as well as in a more general sense, needs a

holistic, common risk-actor approach36 and the social determinants

o health must be addressed.37-39

Acknowledgements

This placement is primarily in partnership with the Brewarrina

Shire Council, based on a Service Level Agreement. The Shire

Council has a separate agreement with the NSW Greater Western

Area Health Service to support the dental clinic. The clinical

placement is unded by the Commonwealth Grant or Dental

Training Expanding Rural Placements Program (DTERP).

Further unding to build capacity was also provided by the Rio Tinto

Aboriginal Fund. The project leader at Grith University or this

project is the Chair or Rural, Remote & Indigenous Oral Health.

This chair is sponsored by Colgate Oral Care, Australia.

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Population Inequality Dental students on remote rural placement

dental care provision

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