doi:10.1038/nindia.2017.31 Published online 11 April 2017
• Integration of population oral and general health promotion with anti-smoking & anti-betel quid chewing, newborn & infant oral health.
• Population oral health promotion to include salt fluoridation, affordable toothbrushes & toothpaste, school-based dental health education, dental screening & fissure sealant programme.
• Personal dental treatment care to focus on oral urgent treatment, atraumatic restorative treatment, routine dental care.
• Health workers should be trained in dental and oral cancer screening, oral health promotion, fluoride applications, glass ionomer sealants.
• Government monitoring of oral healthcare workers’ numbers, size, composition and mix to ensure most appropriate work-force.
The culture of Papua New Guinea (PNG) is complex. Many different cultural groups exist, and over 800 languages are spoken1. Most (87%) people live in villages and access to healthcare is often difficult. The adult literacy rate at 58%2 making dissemination of health information difficult.
The people of PNG are generally in poor health. Life expectancy at birth is 54 years and one child in 13 will die before the age of five. Preventable and treatable diseases, including malaria, pneumonia, diarrhoea, tuberculosis, HIV, and neonatal sepsis, are the most frequent causes of death. There is an increasing incidence of antibiotic resistant tuberculosis and HIV/ tuberculosis co-infections. The level of violence against women is among the highest in the world. The PNG National Health Plan 2011-20202 paints a grim picture for the next two decades of healthcare due to a rapidly increasing population, a rapid rise in communicable diseases, and low per capita expenditure on healthcare.
Oral health issues in PNG
Oral health is low on the scale of priorities and not even mentioned in the National Health Plan2. Although no epidemiological oral health surveys have been undertaken in PNG, anecdotal evidence suggests tooth decay is a problem, especially in children, and gum disease continues to be a major cause of tooth loss. There are high levels of trauma requiring complex oral surgery and an increasing number of patients with HIV-AIDS presenting with serious oral health issues. Oral cancer is the most common cancer in PNG2 due to smoking and the chewing of betel quid, made of areca nut, part of the Piper betel plant, and slaked lime3, 4, 5 or ‘buai’, as it is known locally, is a deeply entrenched practice.
A major component of the PNG policy approach has been to follow the biomedical model where care is delivered by health professionals, which leads to treatment growing more complex, healthcare costs spiralling6, and a lack of disease prevention. The biomedical approach has seen an increase in dentist numbers. While the need for dental care is great, the government has cannot afford to employ all the graduating dentists. This has seen a boom in private practice targeted at people who can afford dental care. At the same time, PNG has a falling number of dental therapists (who treat children: At the time of writing there were approximately 35), and only 20 technicians to make dentures. Specialists are desperately needed, especially oral surgeons, of which there is only one in the whole country. There is also an urgent need for dental chairside assistant /dental orderly training.
Much of the ageing dental equipment needs urgent replacement. The dental school at the University of Papua New Guinea has ten dental chairs, eight of which are largely functional, though the suction doesn’t work on some of the chairs and the some won’t recline. Equipment maintenance is an ongoing problem. Next to the dental school clinic is the 12-chair PNG General Hospital Dental Clinic, but that has been closed down because the equipment is not fit for purpose. The reading resources and textbooks in the University of PNG Medical Library are outdated and in short supply, and there is little access to online resources.
It is not all doom and gloom. In all the areas of dental speciality and with the need for dental chairside assistant /dental orderly training, PNG is investigating associations with Australian dental schools. John McIntyre, a past dean of the School of dentistry at the University of Adelaide, who has been visiting and supporting PNG dentistry for more than 40 years, has arranged for dental chairs to be shipped from the Adelaide Dental Hospital for use by potential private sector dentists. It is hoped that a trickle-down effect for low income residents will be achieved through government subsidies for private treatment. The PNG hospital dental equipment is being replaced. Undergraduate and graduate dental students are being encouraged to undertake research and they have developed some innovative projects. The Australian Dental Association recently offered the University of PNG Dental School student access to its online resources. In the area of health promotion, Rose Putupai, a PNG dentist and Fulbright Scholar who is undertaking a masters in public health in the United States, has arranged ‘No Betel Nut Chewing Days’ and Dental Public Health Awareness Campaigns. The government has imposed a total ban on the sale of betel quid in Port Moresby, Lae and Mt Hagen.
So where to from here?
The answers for PNG’s oral health problems must be generated locally, in particular from the dental professionals who understand the local cultures, norms and oral health problems in PNG. These comments are suggestions for consideration.
As the dental school was closed for 20 years prior to 2005, there is no middle generation of dentists, and the few senior dental practitioners in PNG are reaching retirement age. This means the younger generation will have to step up.
Other than low fluoride exposure, the potential causes of poor oral health; poor hygiene, poor diet, lack of access of healthcare, smoking and betel quid chewing, are the same as causes of poor general health. In Timor Leste, a 2002 report7 suggested integrating oral and general health promotion and that it should include anti-smoking and anti-betel quid chewing, pre- and post-natal and infant oral health measure. Specifically public oral health promotion, salt fluoridation, affordable toothbrushes and toothpaste, school-based dental health education and a screening and fissure sealant program were recommended. It is not feasible to fluoridate the water supplies across PNG because the landscape is diverse with many hilly areas and isolated villages. Papua New Guineans should not be encouraged to eat more salt, but the salt they do eat should be fluoridated. Personal dentistry should include oral urgent treatment, atraumatic restorative treatment, where demineralized and insensitive outer carious dentin are removed with hand instruments, as part of a school-based dental care program and routine dental care should be part of personal treatment within a primary healthcare service. These recommendations are similar to that found in other reports8, 9, 10 and would be suitable for PNG.
Midwives, general nurses, health promotion teachers and health workers in dental and oral cancer screening could be trained in oral health promotion and fluoride applications including the tooth decay arresting agent silver diamine fluoride11 and glass ionomer sealants. If necessary, they should have a referral pathway for further professional dental treatment. Research would be needed after an oral cancer screening programme was implemented to evaluate its effectiveness. Similarly, the production of oral cancer pamphlets for health workers that show early-stage oral cancer and the referral pathway for health staff for people would help tackle oral cancer when it is treatable.
The PNG government should monitor dental workforce size and composition. Student dentists are used to seeing patients for a problem rather than for a check-up and this has led to a focus on the patient’s symptoms, when they should also be looking for ways to improve longer-term health and oral health outcomes.
They could consider improving the dental equipment, instruments and materials; using portable dental chairs and equipment for outreach services; buying uniform and reliable brands of dental equipment, instruments and materials in all surgeries so that they are easy to maintain; training workers how to perform basic repairs on dental equipment as part of their undergraduate programmes; teaching some local electricians more advanced dental equipment repair.
There is a long way to go to improve oral health in PNG. Let’s hope the Papua New Guineans find a way forward.
1Associate Professor, Centre for Rural Health, University of Tasmania, Hobart, Tasmania; Australian Research Centre for Population Oral Health, Adelaide, Australia; APHCRI Centre for Research Excellent in Primary Oral Healthcare; (email@example.com); 2Professor, University of Papua New Guinea, Port Moresby, Papua New Guinea (firstname.lastname@example.org), (email@example.com).
1. Ethologue: Languages of the World. http://www.ethnologue.com/country/PG/languages. Accessed 3 September 2016
2. Government of Papua New Guinea National Health Plan 2011–2020 Volume 1: Policies and Strategies. June 2010. http://www.wpro.who.int/countries/png/PNGNHP_Part1.pdf Accessed 14 December 2015
3. IARC. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. IARC Monogr. Eval. Carcinog. Risks Hum. 85 (2004)
4. Parkin, D. M. International variation. Oncogene 23, 6329–6340 (2004)
5. Thomas, S. J. et al. Betel quid not containing tobacco and oral cancer: A report on a case–control study in Papua New Guinea and a meta-analysis of current evidence. Int. J. Cancer. 120, 1318–1323 (2007)
6. Pine, C. M. Introduction, principles and practice of public health. Community oral health. Oxford. Reed International & Professional Publishing Ltd. 1-10 (1997)
7. Roberts-Thomson, K. F. Australia-East Timor National Oral Health project. AusAid (2002)
8. Northern Territory Government. Northern Territory Oral Health Promotion Plan 2011-2015. http://www.health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/59/85.pdf&siteID=1&str_title=Oral Accessed 14 December 2015
9. World Health Organization (WHO) framework - social determinants, entry-points and interventions to address oral health inequalities. whqlibdoc.who.int/publications/2010/9789241563970_eng.pdf. Accessed 14 December 2015
10. Oral Health Monitoring Group. Australian National Oral Health Plan 2015-2024 (2015) www.nds.org.au/asset/view_document/979323603 Accessed 14 December 2015
11. Rosenblatt. A. et al. Sodium Diamine Fluoride: A caries ‘’silver-fluoride bullet’’. J. Dent. Res. 88, 116-125 (2009)