Challenges for Brunei Darussalam
doi:10.1038/nindia.2017.26 Published online 17 March 2017
• Promote breastfeeding nationally.
• Reduce tobacco use.
• Disseminate guidelines on food and drinks served or sold in workplaces.
• Guide oral health promotion and prevention of common risk approach.
• Provide high quality, cost-effective and efficient oral health services.
Brunei Darussalam, located on the north coast of Borneo in Southeast Asia, ranks second highest on the Human Development Index among south-east Asian nations and 31st worldwide. The population of Brunei exceeds 400,000 and, as in many countries, it has experienced a demographic shift due to an increase in its aged population in the last few decades, and a move from rural dwelling. In 2015 the estimated life expectancy was 78.8 years, with nearly 75% of the Brunei population living in urban areas1.
In 2009, the Ministry of Health in Brunei Darussalam launched “Vision 2035 and Health Strategy”, a project aimed at identifying healthcare strategies, in order to achieve a comprehensive and sustainable healthcare system, a national healthy lifestyle and ensure effective health policies and regulations2.
In 2012, the Department of Dental Services, Ministry of Health, produced the Oral Health Agenda a five-year blueprint to promote oral health in Brunei Darussalam. The agenda included strategies to fulfil a mission to provide quality oral healthcare to citizens that is effective, equitable, affordable, accessible, safe and sustainable. Recently, the Oral Health Agenda was reviewed and efforts are being made to redesign services to align with the Ministry’s new strategic priorities3.
Dental care system in Brunei
Healthcare in Brunei, including oral healthcare, is heavily subsidised by the government. Despite this, only one third of the population use the dental services provided. The vast majority of the dental workforce (general dentists and specialists as well as complementary professionals) works in the public sector and provides services across the country. Facilities include four government hospitals and 18 government health centres/clinics, including maternal and child health clinics. Dental services in the private sector are available at two private institutions, as well as seven clinics. Additionally, flying dentist services cater to residents in areas inaccessible by land or water4. Dental services are provided to primary school children in most public and some private schools. Dental therapists provide these services in 45 static schools comprising dental clinics and in 59 schools where portable equipment are used. Transport and labour issues for portable equipment have hindered the running of the service resulting in only 30% primary schoolchildren being seen5.
Epidemiology of oral health in Brunei
The pattern of dental diseases in Brunei closely follows global trends. Dental caries, severe periodontitis and tooth loss constitute the major dental disease burden in the Brunei population. To meet needs and to promote oral health, efforts have been made on several fronts.
Dental Services conducted two National Oral Health Surveys in 1987 and 1999. These surveys showed that the percentage of 6- year old children that were free from caries increased from 3.0% to 11.3% and the mean number of decayed, missing and filled deciduous teeth (dmft) reduced from 9.5 to 7.1. However, no significant reduction in the mean number of decayed, missing and filled permanent teeth (DMFT) in the 12- year olds was observed6,7.
The 1999 survey showed that 35-44 year olds had a DMFT of 14.4 and only 1.7% of them were caries-free. Prevalence of periodontal pockets equal to or over 6mm was 20% and none was considered healthy in regarding periodontal disease according to the Community Periodontal Index (CPI index)7. Neither survey recorded the socioeconomic status or ethnicity of the participants.
The third National Oral Health Survey started in 2015 comprising two phases. In phase 1, a survey of a representative sample (n = 2,591) of 5-15 year old children was conducted. Dental caries, periodontal disease, fluorosis, dental trauma, malocclusion and oral mucosal lesions were investigated. Preliminary findings showed that 25.9% of children were caries-free at 5-6 years of age and their DMFT was 5.1. Overall, children whose parents had tertiary education had lower DMFT scores than children of parents with less education. This was also seen among 7-8 year old children. Nearly 50% of adolescents aged 12 and 13-15 years were caries-free and remarkable decreases in the severity of dental caries (DMFT) from 4.8 to 0.9 and from 7.4 to 1.6 were found in children aged 10-12 years of age and adolescents (13-15 years-old), respectively, with no significant differences across family income groups. A second phase, the adult survey will commence in September 2016 and will allow comparison with previous data8.
Challenges for oral health promotion in Brunei
Almost three-quarters of the population has been supplied with fluoridated water since 1987 and from 2000, community water fluoridation was made available nationwide. Fluoride levels have been monitored regularly and the optimum level has been consistently achieved only over the past few years9.
Expectant mothers are referred from the Maternal and Child Health (MCH) clinic and priority is given to them to reduce their waiting times at the dental clinic. Constant effort is required to monitor and ensure that processes for referrals to dental clinics are being made. Oral health awareness and education are emphasised during these visits and again during the Toddler Fluoride Rolling Toothpaste programme where children under 5 years are seen twice a year for oral health counselling and prevention measures10.
Mothers are encouraged to breastfeed their babies up to the age of 2, a challenging message for parents as bottle feeding is a deep-seated practice in Brunei11.
The Daily Fluoridated Tooth brushing (DFTB) programme provides students with toothbrushes and fluoridated toothpaste to brush their teeth daily at school. Uptake of this programme is low because of poor buy-in by the school teachers who give priority to other school programmes over tooth brushing during school hours10.
School Canteen Guidelines and Heath Promoting School Initiatives provide guidance on promoting a healthy environment for living and studying, including healthy eating at schools. Despite the guidelines, sweetened food and drinks are still readily available in some school eateries5.
Children and young adults with special needs are screened and necessary intervention taken by the Paediatric Dental Services including treatment under general anaesthetic12.
A Dental Hygiene and Therapy training programme, provided in conjunction with King’s College London, UK, has been completed by 44 dental hygienists and therapists12.
A ‘Mukim Sihat’ (Healthy Sub-district) programme aims to empower the village councils to carry out health-related activities. Health screenings including dental examinations are also provided for villagers10.
An activity Centre for the Elderly: aims to increase the awareness of the elderly population on healthy lifestyle through structured physical activities. Regular oral health examinations and demonstrations on care of dentures and stages of dentures construction are provided for attendees of the centre10.
Regular lectures aim to increase public awareness of good oral health. These are often carried out during career carnivals, at schools, in programmes to promote healthy villages, community events, health conferences and road shows.
1Director, Dental Practice Education and Research Unit, Associate Professor, Australian Research Centre for Population Oral Health, Adelaide Dental School, Adelaide, Australia(email@example.com); 2Medical Superintendent, Dental Services, Ministry of Health, Brunei Darussalam (firstname.lastname@example.org); 3Dentist, Oral Health Promotion, Dental Services, Ministry of Health, Brunei Darussalam (email@example.com); 4Adjunct Professor, Australian Research Centre for Population Oral Health, Adelaide Dental School, Adelaide, Australia (firstname.lastname@example.org)
1. United Nations Development Programme (UNDP) Human Development Report Work for Human Development, New York (2015)
2. Vision 2035: Together towards a healthy nation. Brunei (2009)
3. A review of the oral health agenda 2008-2012. Ministry of Health, Brunei Darussalam (2012)
4. Oral Health Information Booklet, Ministry of Health, Brunei Darussalam (2015)
5. School of Dental Services, Department of Dental Services, Ministry of Health, Brunei Darussalam (2015)
6. National Oral Health Survey, Ministry of Health, Brunei Darussalam (1987)
7. National Oral Health Survey, Ministry of Health, Brunei Darussalam (1999)
8. Roberts-Thomson KF, Peres KG, Haag DG. Brunei Darussalam Oral Health Survey preliminary report (2016)
9. Monthly chemical test reports from Department of Water Services, Ministry of Development and Department of Scientific Services, Ministry of Health, Brunei Darussalam, 2012-2016
10. Oral Health Promotion Unit, Department of Dental Services, Ministry of Health, Brunei Darussalam (2016)
11. National Breastfeeding Policy, Ministry of Health, Brunei Darussalam (2014)
12. Department of Dental Services, Ministry of Health, Brunei Darussalam (2016)