ORIG INAL ART ICLE

Dental workforce development as part of the oral healthagenda for Brunei Darussalam

Nairn H. F. Wilson1, Z. Abidin Shamshir2, Sylviana Moris2, Mabel Slater1, Ei Chuen Kok2,Stephen M. Dunne1, Samsiah H. M. Said2, James M. K. Lee2 and Jennifer E. Gallagher1

1King’s College London Dental Institute at Guy’s, King’s College and St Thomas’ Hospitals, London, UK; 2Department of Dental Services,Ministry of Health, Bandar Seri Begawan, Brunei Darussalam.

Background: Brunei Darussalam is a Sultanate with a Malay Islamic monarchy. There are high levels of dental diseaseamong its 406,200 population. The population’s oral health needs require an integrated blend of primary and specialistcare, together with oral health promotion. Process and outcomes: This paper describes the planning and measures takento address these needs. In accordance with an oral health agenda published and launched in 2008, focusing on access,health promotion and prevention, and the education and training of the dental workforce, the Brunei Darussalam Minis-try of Health is seeking to improve oral health status and reduce the burden of oral disease. It also seeks to transform thecountry’s oral health services into a preventatively orientated, high-quality, seamless service underpinned by the conceptof ‘teeth for life’. In the process of effecting this transition, the Brunei Darussalam Ministry of Health is developing a den-tal workforce fit for future purpose, with an emphasis on a modern approach to skill mix. An important element of thisprogramme has been the development of a highly successful Brunei Darussalam Diploma in Dental Therapy and DentalHygiene. Conclusion: It is concluded that the Brunei Darussalam oral health agenda and, in particular, the forward-look-ing programme of dental workforce development is a model for other countries facing similar oral health challenges.

Key words: Brunei Darussalam, dental workforce, oral health, strategic planning

INTRODUCTION

Brunei Darussalam

Brunei Darussalam is a sovereign state. It is a Sultan-ate with a Malay Islamic Monarchy. It is situated inSouth-east Asia on the North-eastern part of theisland of Borneo, facing the South China Sea and sur-rounded by the Malaysian State of Sarawak. The capi-tal is Bandar Seri Begawan.The land area is 5765 sq. km (2226 sq. miles). It

has an estimated population of 406,200 with an esti-mated population growth rate of 2.1% (2009). Thepopulation consists mainly of Malay (67%) and Chi-nese (15%) people with some Indian and other indige-nous groups.Brunei Darussalam is a welfare state in which

health care and education are essentially provided freeof charge to its citizens and permanent residents. Thecountry’s main source of revenue is from naturalresources of oil and gas. The 2009 estimate of grossdomestic product (GDP) for Brunei Darussalam was

US$18,000 per capita. The country’s economy is pro-gressively diversifying into other non-petroleum basedindustries, transforming Brunei Darussalam into anewly industrialised country.

Levels of disease

Epidemiological surveys of oral health have revealedhigh levels of oral disease among the population ofBrunei Darussalam, as detailed in Tables 1 and 2;children at 5 years of age had, on average, sevenaffected teeth and teenagers aged 13–15 years had asimilar level of disease in their permanent dentition1.Dental caries remains one of the most common condi-tions in children and young people, and a willingnessto address these high levels of disease has underpinnedhealth policy. A further cross-sectional national oralhealth survey is planned in the near future. While it ishoped to identify improvements in the oral health sta-tus of the population, it is anticipated that the burdenof dental diseases at all ages will still be relativelyhigh, given the findings of a health screening

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doi: 10.1111/idj.12005

programme for civil service employees in 2007–20082.These findings indicated that adults aged 18–24 yearshad the most decay present (59% of this age band)2,3.Adults aged 35–44 years had, on average, 9.9decayed, missing and filled teeth, suggesting possibleimprovement on the statistics for this age group fromthe 1999 national survey [Diseased, Missing, Filled,Teeth (DMFT) = 14.4]3; however, the sample was rel-atively small and was representative of employeesrather than the national population. Most impor-tantly, even in this age group there was evidence thatover half of the disease experience was represented bythe ‘missing’ component, highlighting the role ofextractions in disease management3. Only 9.7% ofthe adults surveyed had a healthy periodontium; cal-culus was present in 77.3% of participants and27.2% of the dentate population were considered torequire advanced periodontal treatment2. Late presen-tation for care was reported, with 68% reporting thatthey only attended for care when in pain3; this high-lights the importance of having a workforce whichcan provide access to dental care at an early stage inthe disease process, when conservative rather thansurgical management can occur.In addition to high levels of dental disease, there is

significant need for specialist oral healthcare. Forexample, 32% of 10- to 15-year-olds surveyed in1999 were considered to require orthodontic treat-ment. This compares well with the UK where the lat-est survey of children’s oral health suggested that35% had a great or very great need for orthodontictreatment4. The level of demand outstripped servicesback in 1999 as the waiting list at the time was3–5 years. As detailed below, Brunei Darussalam nowhas six specialist orthodontists, with a further individ-ual in training. The waiting list for treatment remainslong (2.5 years in 2008), albeit reduced.

The demand for primary dental care is mainly forpublic oral healthcare services, which provide oralhealthcare to around 15% of the country’s populationper year. There were around 126,000 public serviceattendances for oral healthcare in 2010. Of these,91.4% were treated by primary care professionals(35.4% by primary care dentists and 56.1% by dentaltherapists and hygienists who serve children aged16 years and under). Only 8.6% of the attendances inthat year were for specialised oral health care.

Oral health awareness and diet

The typical Bruneian diet includes large amounts ofrefined sugars. Sugar consumption in Brunei Darussa-lam is moderately high for the region and was esti-mated at 29.7 in 2005.5 From observation andfeedback, it is apparent that oral hygiene practicesamong the general population are far from ideal andoral health awareness is relatively low. Even thoughthe self-administered questionnaire for civil serviceemployees in 2007–20082 indicated that 93% of therespondents claimed that they brushed their teeth twoor more times each day, this is not reflected by levelsof caries in the population, or by periodontal healthstatus.Furthermore, levels of smoking in the population

remain relatively high. From a sample of 358 subjectsincluded the integrated health screening programmefor civil service employees2, it was found that 11.8%(n = 66) of the participants were smokers, 11%(n = 61) were past smokers and 41.5% (n = 231)were non-smokers. These findings are despite wide-ranging measures to encourage cessation of smokingwithin Brunei Darussalam.

Fluoride

The public water supplies in Brunei Darussalam aremostly fluoridated, with about 99% of the populationbeing provided with fluoridated water. The Ministryof Health recommends that the level of fluoride in thewater be kept within the optimal concentration ofbetween 0.5 and 0.7 ppm. Collaborative efforts areongoing between the Ministry of Health, the Depart-ment of Water Services and the Ministry of Develop-ment to maintain the level of fluoride in public waterat this optimal level.

Oral hygiene aids

Toothpaste, toothbrushes and other oral hygiene aidsare widely available commercially. While data are notavailable in respect of the purchase and use of oralhygiene aids, it is understood that oral hygienetechniques and practices are, in common with many

Table 1 Prevalence of caries in Brunei Darussalam1999

Age (years) dmft/DMFT 1999 DMFT 2008

5 7.1 (11.3% caries free)10–12 4.8213–15 7.2435–44 14.4 9.9

d/D, diseased; m/M, missing; f/F, filled primary (deciduous); t/T,permanent teeth.

Table 2 Prevalence of periodontal disease in BruneiDarussalam 1999

Age (years) Bleeding gums (%) Calculus (%)

12 76.4 86.418 75.7 87.035–44 43.4 85.7

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countries around the world6, very variable amongstthe population.

Funding and infrastructure

In 2008, the Department of Dental Services was allo-cated nearly 4.0% of the national healthcare budget.Efforts are continuously being made to attract addi-tional funding to further develop the provision andquality of the oral health services. As in any healthcaresystem, however, the need for developments in oralhealthcare provision has to be balanced against theneed to develop other core healthcare services, whilebeing mindful of cost benefits and quality of life issues.

Transitioning to preventively orientated care

In common with many oral healthcare services aroundthe world7, the oral healthcare services in Brunei Dar-ussalam face challenges in changing from a service pri-marily based on clinical interventions to meet pressingtreatment needs among, in particular, patients withhigh levels of disease and, as is typically the case, lowlevels of dental motivation to a preventatively orien-tated, minimal interventive approach, supported bypatient engagement and ownership of the need toimprove oral health. The high cost of clinical interven-tions necessary to address the large burden of oraldiseases limits the resources available to effect transi-tion to oral healthcare orientated towards preventionof oral disease and the promotion of the conceptof teeth for life. To effect this transition in a timelymanner, rather than waiting for a generational changein attitudes and behaviour, there would be a needfor an interim increase in funding over a number ofyears.

Oral health agenda

In 2008, the Department of Dental Services, Ministryof Health in Brunei Darussalam published andlaunched an ambitious and comprehensive oral healthagenda entitled ‘PEARL 2012.8. The main aim of thisagenda was ‘to improve the health and well-being ofthe Brunei population by improving the oral healthstatus and reducing the burden of oral diseases’. Morespecific aims are to help the residents of Brunei Dar-ussalam to:

• Retain as many as possible of their teeth through-out their lives.

• Have good oral health as part of their general goodhealth and wellbeing.

• Have access to appropriate information and anaffordable, safe and sustainable, seamless, fullyintegrated, high-quality oral health service.

The agenda has three main themes: accessibility;promotion and prevention; and education and training.The purpose of the present paper is to describe and

discuss the steps taken to date to realise the educationand training theme of the agenda and to highlight theways in which these steps may be viewed as an exem-plar by neighbouring and other countries worldwidethat have oral health challenges similar to those iden-tified in Brunei Darussalam.

Dental education and training

The main aim of the education and training theme ofthe oral health agenda in Brunei Darussalam is ‘toachieve a sufficient and appropriately skilled work-force and to increase the oral health services work-force diversity, capacity, flexibility and expertise,including the utilisation of PCDs’ [PCDs-professionalscomplementary to dentistry is a term coined in theUK to include all members of the dental team otherthan dentists and administrative staff and which hasnow changed to dental care professionals (DCPs)].

Dentists

In 2010, Brunei Darussalam had a total of 93 dentists(Table 3), including the dentists in the public services,armed forces, general dental practitioners and thoseworking in private organisations and hospital, givinga dentist to population ratio of 1:4046. Seventy of the93 dentists were public services dentists of whom only60 were in active service; the others (n = 23) under-went in-service postgraduate training. Only 31 den-tists were principally engaged in the delivery ofprimary oral health care, giving a public service pri-mary care dentist to population ratio of 1:12,137.A further 10 individuals, presently undergraduates

in the UK and Australasia will join the dental work-force in Brunei Darussalam by 2013, but this increasemay, at least in part, be offset by losses throughretirements or other causes.While the outcome of the planned dental workforce

development review must be awaited, it is anticipatedthat the number of dentists in training will need to beincreased, even if plans are made to further developthe dental team approach (see below), with dentists asthe leader of teams of dental care professionals andassociated administrative staff.

Table 3 Demographics of dentists practising in BruneiDarussalam (2010)

Nationality Gender Age (years)

Bruneian 41 (59%) Female 50 (71%) < 35, n = 39 (56%)Other 29 (41%) Male 20 (29%) 35–44, n = 18 (26%)

45–54, n = 8 (11%)< 55, n = 5 (7%)

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Regarding the future training of dentists, this couldmirror arrangements in medical training in BruneiDarussalam, whereby graduates of either the Bachelorof Biological Sciences or the Bachelor of Health Sci-ence degrees of the University of Brunei Darussalammay enter graduate entry programmes overseas, toreturn to Brunei Darussalam under the terms and con-ditions of professional training schemes.

Specialist practitioners

The number and specialty distribution of specialistpractitioners in Brunei Darussalam, including special-ist practitioners in the armed forces, is detailed inTable 4. Many of these specialist practitioners areunder 35 years of age. Having 21, and in due coursea further five members of the total dentist workforceof 70 individuals trained to the specialty level, is com-mendable. This is greater than the level of specialistsin the UK and the USA where 10% and 20% of thedental profession are trained to specialist level9

respectively, but takes into account that more routineprimary dental care may be provided by DCPs. How-ever, there is need for coverage of all dental specialtiesso that comprehensive continuing professional devel-opment and clinical support are provided for all den-tists within the country. It is notable that BruneiDarussalam has no specialists in dental public healthand special care (needs) dentistry, let alone oral medi-cine or oral pathology – services that are provided byoral maxillofacial surgeons as medical specialists andgeneral pathologists, respectively.

Workforce priorities

While it may appear that the priority is to use avail-able resources to train more general dental practitio-ners, it is anticipated that the planned dentalworkforce review may recommend succession plan-ning in the dental specialties, together with the intro-duction of specialists in dental public health andspecial care dentistry as an important early action.Investment in developing specialist dental public

health expertise to actively inform health policy andplanning could result in better oral health for the pop-ulation and ensure that resources are used to promotehealth and well-being and not just to treat disease.Areas for action include: addressing the diet, in con-junction with public health professionals, as part of acommon risk factor approach to promoting healthand preventing disease10,11; implementing the strongglobal evidence base for prevention as a core pillar ofprimary care provision; and building the monitoringof oral health and dental service provision into rou-tine data collection (in electronic format) to informfuture planning and provision of care – the applica-tion of health informatics.

Dental therapists and dental hygienists

In 2007, the Brunei Darussalam Ministry of Healthsigned a memorandum of understanding with King’sCollege London Dental Institute, where many of theBrunei Darussalam specialist practitioners weretrained, to underpin arrangements for a collaborationto develop a Brunei Darussalam Diploma in DentalTherapy and Dental Hygiene provided by the BruneiDarussalam Ministry of Health National Dental Cen-tre. This innovative, highly successful programme,which has given Brunei Darussalam a degree of inde-pendence in dental workforce development, has todate produced 14 dental therapy/hygienists. Six of theserving dental nurses (New Zealand type) have goneon to become tutor dental therapy/hygienists, subse-quent to a 1-year programme of training at King’sCollege London Dental Institute. The development ofmid-level dental providers is becoming an importantpart of healthcare development across the world12–14.While controversial in certain countries, the develop-ment of the dental team offers many important advan-tages, in particular, when, as in Brunei Darussalam,mid-level providers can meet many of the dental needs.Concurrently, the development of the specialist dentalworkforce should, as in Brunei Darussalam, anticipatechanging needs for specialist services, notably amongthe ageing population.15

Arrangements are in hand to recruit and train fur-ther cohorts of dental therapy and dental hygiene stu-dents in Brunei Darussalam and to establish aconversion course to allow existing dental nurses (seebelow) to receive top-up training to qualify as dentaltherapists/hygienists. This will further enhance thecompetence of the dental team and its flexibility towork across the dental service.

School dental nurses

School dental nurses in Brunei Darussalam are qualifiedto provide primary dental care to children, working

Table 4 Numbers and specialty distribution of spe-cialist dental practitioners in Brunei Darussalam(2010)

Specialty Number of practitioners Number in training

Orthodontics 6 1Paediatric dentistry 5 1Oral surgery 4 1Prosthodontics 3 –Endodontics 2 1Periodontics 2 –Restorative dentistry 1 1

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predominantly in school-based clinics. In 2010 therewere 74 dental nurses engaged in clinical practice inBrunei Darussalam, with the training of these membersof the dental team having been provided largely inMalaysia and to a lesser extent in Singapore 20–35 years ago. Many of these dental nurses have one ormore post-qualification certificates or diplomas, withtwo having obtained BScs (one in Oral Health and theother in Health Service Management). As a result ofhaving established the Brunei Darussalam Diploma inDental Therapy and Dental Hygiene, Brunei Darussa-lam is no longer sending trainees to be trained as dentalnurses in Malaysia or Singapore.

Dental surgery assistants

Dental surgery assistants play a vital role in ensuringthe delivery of quality care by dentists, therapists andhygienists by enhancing their productivity in well-developed systems. Dental surgery assistants (DSAs)in Brunei Darussalam support dentists, dental thera-pists, dental hygienists and dental nurses in the provi-sion of dental services. In 2010 there were a total of93 DSAs in Brunei Darussalam, comprising two ChiefDSAs, 13 Senior DSAs, 25 qualified DSAs and 53 trai-nee DSAs. Before 2002, DSA training for Brunei Dar-ussalam was provided in Malaysia. Subsequent toestablishing a training programme locally in 2002, theMinistry of Health introduced a Certificate in DentalSurgery Assisting in 2003. This programme, as indi-cated above, presently provides training for 53 train-ees.

Dental laboratory staff

In 2010, Brunei Darussalam had a total of 38 dentallaboratory staff, including 19 technicians, seven tech-nologists, nine trainee technicians and six possiblefuture trainees. The dental technologists completedthree-year BSc degrees in dental technology, whilethe technicians hold a diploma in dental technologyobtained in Malaysia. Consideration may, at sometime in the future, be given to establishing a BruneiDarussalam Diploma in Dental Technology incollaboration with King’s College London DentalInstitute.

Administrative and support staff

The delivery of dental services by the Ministry ofHealth in Brunei Darussalam is supported by a totalof 45 administrative and support staff, ranging from aChief Executive Officer (CEO) and hospital adminis-trator to 12 reception staff and 14 attendants whoserve as clinical assistants and ‘runners’ in majordental clinics.

Workforce goals

Concurrent with plans to develop a new NationalDental Centre, supported by a network of districtdental clinics, the goal for dental workforce develop-ment in Brunei Darussalam is to create a dental teamof appropriate size and composition, according toWorld Health Organization (WHO) workforce tar-gets, with the expertise, capacity, flexibility and skillmix to provide modern, preventatively orientated oralhealth care, sufficient to realise the national OralHealth Agenda8. A further goal is to support contin-uing professional development for the dental work-force, sufficient to maintain knowledge andunderstanding and to keep the entire workforceabreast of developments in clinical practice. The latteris viewed as essential to drive continuous qualityimprovement in the national provision of oral healthcare. It is acknowledged that considerable investmentwill be required to realise the dental workforce andassociated goals, but the benefits of fulfilling the Min-istry of Health’s vision for 2015 are considered to jus-tify the commitment of the necessary resources16. Inaddition to the immediate plans for a new oral healthsurvey and a programme of workforce modelling toensure that there are robust longer-term plans inplace, decisions will be required in respect of thewider dental team to include, for example, clinicaldental technicians and orthodontic therapists. In tak-ing forward this agenda, initial deliberations wouldsuggest that the most pressing need could be consid-ered to be the training of specialists in dental publichealth. These specialists will be critical in driving andmonitoring progress in the nation’s oral healthagenda.

DISCUSSION

Addressing the oral health of a nation, irrespective ofsize, requires strong political action, wide participa-tion, buy-in and sustained effort and investment. Asset out in the WHO resolution WHA.60.177, actionplans for the promotion of oral health and integrateddisease prevention comprise various elements, includ-ing workforce planning for oral health and scaling upthe capacity to produce oral health personnel. TheMinistry of Health in Brunei Darussalam is rising tothis challenge as part of its Oral Health Agenda8.Such action, which may in due course result in BruneiDarussalam becoming a regional centre of excellencefor dental education, is an exemplar to countries else-where in the world that face oral health problemssimilar to those that exist in Brunei Darussalam.In countries in which there are substantial unmet

health needs, often together with health inequalities,oral health, other than acute dental care, may not be

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viewed as a funding priority. However, with thegrowing body of evidence of associations between var-ious forms of chronic systemic disease and poor oralhealth6, let alone the impact of oral health on generalwellbeing, in particular in older patients,15 the philos-ophy of Together Towards a Healthy Nation adoptedby the Ministry of Health in Brunei Darussalam17 is avery progressive in national healthcare policy. Fur-thermore, it is laudable that oral health promotion inBrunei Darussalam is an integral element of a majorstrategic goal to promote healthy living throughmodified lifestyles, as emphasised in the BruneiDarussalam, Ministry of Health, Promotion Blueprint2011–201517.Given the lead time necessary to develop a dental

workforce fit for future purpose in the provision ofpreventatively orientated, minimally interventive oralhealthcare, dental workforce strategies of the typebeing implemented in Brunei Darussalam require sus-tained support and funding over extended periods.From inception to the time of realising major goals,at least 5 years – and possibly more – may elapse.Success in dental workforce development may there-fore rely heavily on stable domestic affairs, with rele-vant policy being carried forward through differentMinisters and ministerial teams when organisationalchange occurs, as has happened since the nationalOral Health Agenda and strategy16. Under these cir-cumstances, the previous Minister of Health is to becongratulated for having established the strategy, andhis successor, the present Minister of Health alsodeserves praise for not only sustaining the programmebut planning to expand it to include, as a next phase,the development of a new National Dental Centre.This is linked with the possibility of concurrentarrangements for the training of dentists, involvinginternational collaborative working between King’sCollege London and the University of Brunei Darussa-lam. Furthermore, the present Minister of Health hashighlighted the need to focus on ‘modifiable riskbehaviours such as diet, nutrition, tobacco use andpersonal (oral) hygiene’, with the dental workforceshifting away from a ‘treatment only mentality’ whichis viewed as expensive and mostly ineffective. Thevision for the future includes the promotion of healthand the prevention and early detection of oral diseasesat both population-wide and individual healthcareintervention levels, with the appropriate use of state-of-the-art methodologies.Brunei Darussalam is to be commended for the adop-

tion of its bold Oral Health Agenda, underpinning andsupporting the philosophy of the national strategyTogether Towards a Healthy Nation17. As discussed inthe present publication, investment in dental workforcedevelopment is critical to the success of an action planto improve the oral health of a nation. Brunei Darussa-

lam is to be commended for wishing to improve oralhealth and, in turn, general health and well-beingthrough effective, equitable, affordable, accessible, safeand sustainable oral healthcare by a dental team trainedto international standards.The 2008–2012 oral health agenda in Brunei Dar-

ussalam,8 and, in particular, its programme of dentalworkforce development and associated investment isconsidered to be a model for other countries facingsimilar oral health issues.

Acknowledgements

We thank the current Minister of Health Brunei Dar-ussalam (Yang Berhormat, Pehin Orang Kaya JohanPahlawan Dato Seri Setia Awang Haji Adanan binBegawan Pehin SiRaja Khatib Dato Seri Setia HajiMohd Yusof) and former Minister of Health BruneiDarussalam (Yang Berhormat Pehin Orang KayaIndera Pahlawan Dato Seri Setia Awang Hj Suyoi binHaji Osman).

Competing Interests

Professor Wilson and Miss Slater from King’s CollegeLondon Dental Institute were engaged in the work-force development reported in this paper through anagreement between King’s College London and theMinistry of Health Brunei Darussalam. Drs Shamshir,Moris, Kok, Said and Lee are employees of the Minis-try of Health, Brunei Darussalam.

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Correspondence to:Professor Nairn Wilson,Professor of Dentistry,

King’s College London Dental Institute,Central Office, Floor 18,

Guy’s Tower Wing,Guy’s Hospital,

London SE1 9RT, UKEmail: nairn.wilson@kcl.ac.uk

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