For more than 20 years, Dr Estie Kruger has been trying to find out how to improve the oral health of our most vulnerable patients. By Samantha Trenoweth
It’s a 20-degree, sunshiny, mid-winter morning in Perth and Dr Estie Kruger has her sights set on the garden. She doesn’t get a lot of time for it these days, with her research and teaching commitments at the University of Western Australia, but she loves to “potter in the garden—put something in and see if it grows”. And warm, dry winter mornings like these remind her of South Africa, where she grew up.
It was while she was studying dentistry at Stellenbosch University in Cape Town that she first became aware of the deep-seated injustices in the world around her, and that awareness set the course of her career.
Dr Kruger was a child of the 1960s, which was, she explains, “right smack bang in the middle of apartheid”. The political balance began to shift during her university years. “By the time I finished my post-graduate degree, Nelson Mandela was the president—that’s how quickly things changed—and I began to realise what was going on in the world. With that came a sense of social justice and I became aware of just how unfair the world can be.”
That sense has remained with her through more than 20 years, working across three countries (Australia, South Africa and New Zealand) in dental public health. In recent years, Dr Kruger has been investigating issues of equity and access to dental treatment, particularly for people who live in rural and remote communities. We think of ourselves in Australia as a classless society but her work—particularly with remote Indigenous communities—has led her to believe we’re far from it.
“Large parts of the Australian population are marginalised,” she explains. “I think poverty is not as visible here as it is in some other countries, but it exists. Most people are not aware of the conditions in the poorer Aboriginal communities in rural Australia. I think, if they went out there, most Australians would be surprised.”
Dr Kruger (with her colleagues, Drs Kate Dyson and Marc Tennant) has spent years researching strategies to improve access to dentistry in the most remote parts of the country. One of the many difficulties they’ve identified is that dentists, by and large, don’t want to work there.
“It’s an Australia-wide problem,” she explains. “Services are largely concentrated in cities because private practice is a business, it’s economically driven, and people have to establish their businesses where the market is.”
Those dentists who are interested in working in regional Australia are largely those who grew up there, and there are not nearly enough of them.
Treatment plan
Drs Kruger, Dyson and Tennant have, however, identified some practical remedies. They cite recent collaborative programs between the University of Western Australia and Aboriginal health services that have yielded very positive results. Close cooperation with health services in local communities has been one key to the project’s success. Another has been including student participation programs, because students who work in remote communities during their degree are much more likely to return to practice there after graduation. Incorporating research capabilities, workforce development activities and experienced mentoring for new participants have also helped to increase project sustainability, as has adopting a fly-in/fly-out approach.
When managed skilfully and sensitively, Dr Kruger believes that working in remote communities can be as valuable for the dentists who travel there as for the patients they treat.
“It was our experience,” the team reported, “that rural and remote Aboriginal health services approach health care in quite different ways from public (and private) dental services. This offers great learning opportunities for dental service providers with a willingness to examine their established views about oral health care provision.” And the primary lesson, says Dr Kruger, was that “a good service is one that the community wants, rather than one that dental service providers consider appropriate.”
Hiding in plain sight
Poor oral health is not restricted to people living in outback Australia. “Even in cities,” Dr Kruger points out, “there are a great many people who really struggle to make ends meet, and often they are older people, which is a worry.”
Dr Kruger is genuinely concerned about the ability of dental services to meet the needs of an ageing population. “In years to come,” she says, “we’re going to have quite a large older population. Older people are not all walking around with dentures any more—they retain their teeth—and someone will have to look after their dental health. That’s one of the issues that I worry about, and I think it’s a time bomb because the population is ageing so rapidly.”
People in aged-care facilities have particular vulnerabilities and she would like to see some dental health training for their carers—just the fundamentals that explain the importance of oral health and of a basic dental care routine (simple brushing and flossing).
She laments that “dental health is not taken seriously enough. Sometimes I think it’s our own fault, as dentists,” she muses, “because we’ve tended to work in isolation. So, dental health is seen on one side and general health on the other when, in reality, the mouth is part of the body—it’s not an isolated thing—and we should see it in the same way we see any other aspect of our health.”
It bothers her that “dental issues are not generally considered critical or life threatening”, when they can be both. She has seen dental problems prevent people—particularly children and older people—from eating properly and, “when their diet is compromised, they become malnourished. So dental health is crucial.”
Another group whose dental needs, Dr Kruger believes, often go unmet, are those who fall into the gap between rich and poor.
“The situation remains,” she says, “that part of the population can afford to access dentistry because they have health insurance or they have incomes high enough that they can visit a private dentist. There is another group who have health care cards and therefore access to public dental services. However, I think, there is a large part of the population that falls somewhere in the middle—not quite rich enough for private insurance, not quite poor enough for public health—and they are the people who don’t have easy access to dentistry because it’s not covered by Medicare.”
There are, she says, no simple solutions that will deliver access to everyone—certainly, none that dentists can implement overnight.
“It’s a complicated issue,” she explains. “There are many determinants of dental health, including social determinants, and there are changes to be made that it might not always be possible for dentists to influence. I’m talking about housing and economics and all sorts of policies like that. But I think access to primary dental care services is an important factor. As a society, we can work towards that. I think a more equitable access to primary dental care services is something we could change.”
Meeting the future
One of the most exciting aspects of Dr Kruger’s work is her role as coordinator of the Masters of Dental Public Health Program at the University of WA.
“Every year, we have between five and 10 post-graduate students and they are all international. A lot of them are sponsored students, so they’ve been sent by their governments. We’ve also had some AusAID students, who come from poorer countries. These overseas students go back and make a real difference to dental health in the countries they’ve come from.
“This year, I have one student from Kenya and another from Uganda. As you can imagine, they have huge problems in public dentistry where they come from. They have large, very poor populations and dental services are not always well planned there.
“So, with this course, I’m trying to provide them with an advanced set of skills and knowledge that they can use in their home countries. We keep in touch and it’s good to see what they can do with those new skills when they go back home. I find that quite satisfying, I must say.”
Dr Kruger is also excited about the potential for using new media platforms to increase access to dental knowledge and diagnosis.
“The world is changing and dentistry needs to change with it,” she says. “We notice, with undergraduate students nowadays, that this is an important part of their world. So, if we can use that, then we must. One of our students is doing research on e-dental health, and using the technology in remote areas for diagnosis and screening of certain dental diseases. The potential here is immense.”
Teaching and studying dentistry have changed enormously since Dr Kruger’s own university days, and not for a minute has she felt threatened by change. Quite the opposite.
“Back when I first went to university in South Africa, there was a limit to the number of female dentistry students they took in. There was a quota! Can you believe it?” She laughs warmly. “It’s not like that anymore. Nowadays, if I look at our own undergrad students, there might even be more females than males. So changes like these have been very positive. I welcome them.”
