1. International Dental Journal 2013; 63: 49–55
ORIGINAL ARTICLE
doi: 10.1111/idj.12005
Dental workforce development as part of the oral health
agenda 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
1
King’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 disease
among its 406,200 population. The population’s oral health needs require an integrated blend of primary and specialist
care, together with oral health promotion. Process and outcomes: This paper describes the planning and measures taken
to 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 the
country’s oral health services into a preventatively orientated, high-quality, seamless service underpinned by the concept
of ‘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 this
programme has been the development of a highly successful Brunei Darussalam Diploma in Dental Therapy and Dental
Hygiene. 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
US$18,000 per capita. The country’s economy is pro-
INTRODUCTION
gressively diversifying into other non-petroleum based
industries, transforming Brunei Darussalam into a
Brunei Darussalam
newly industrialised country.
Brunei Darussalam is a sovereign state. It is a Sultan-
ate with a Malay Islamic Monarchy. It is situated in
Levels of disease
South-east Asia on the North-eastern part of the
island of Borneo, facing the South China Sea and sur- Epidemiological surveys of oral health have revealed
rounded by the Malaysian State of Sarawak. The capi- high levels of oral disease among the population of
tal is Bandar Seri Begawan. Brunei Darussalam, as detailed in Tables 1 and 2;
The land area is 5765 sq. km (2226 sq. miles). It children at 5 years of age had, on average, seven
has an estimated population of 406,200 with an esti- affected teeth and teenagers aged 13–15 years had a
mated population growth rate of 2.1% (2009). The similar level of disease in their permanent dentition1.
population consists mainly of Malay (67%) and Chi- Dental caries remains one of the most common condi-
nese (15%) people with some Indian and other indige- tions in children and young people, and a willingness
nous groups. to address these high levels of disease has underpinned
Brunei Darussalam is a welfare state in which health policy. A further cross-sectional national oral
health care and education are essentially provided free health survey is planned in the near future. While it is
of charge to its citizens and permanent residents. The hoped to identify improvements in the oral health sta-
country’s main source of revenue is from natural tus of the population, it is anticipated that the burden
resources of oil and gas. The 2009 estimate of gross of dental diseases at all ages will still be relatively
domestic product (GDP) for Brunei Darussalam was high, given the findings of a health screening
© 2013 FDI World Dental Federation 49

2. Wilson et al.
Table 1 Prevalence of caries in Brunei Darussalam The demand for primary dental care is mainly for
1999 public oral healthcare services, which provide oral
healthcare to around 15% of the country’s population
Age (years) dmft/DMFT 1999 DMFT 2008
per year. There were around 126,000 public service
5 7.1 (11.3% caries free) attendances for oral healthcare in 2010. Of these,
10–12 4.82
13–15 7.24
91.4% were treated by primary care professionals
35–44 14.4 9.9 (35.4% by primary care dentists and 56.1% by dental
therapists and hygienists who serve children aged
d/D, diseased; m/M, missing; f/F, filled primary (deciduous); t/T,
permanent teeth. 16 years and under). Only 8.6% of the attendances in
that year were for specialised oral health care.
Table 2 Prevalence of periodontal disease in Brunei
Darussalam 1999 Oral health awareness and diet
Age (years) Bleeding gums (%) Calculus (%) The typical Bruneian diet includes large amounts of
12 76.4 86.4 refined sugars. Sugar consumption in Brunei Darussa-
18 75.7 87.0 lam is moderately high for the region and was esti-
35–44 43.4 85.7 mated at 29.7 in 2005.5 From observation and
feedback, it is apparent that oral hygiene practices
among the general population are far from ideal and
programme for civil service employees in 2007–20082. oral health awareness is relatively low. Even though
These findings indicated that adults aged 18–24 years the self-administered questionnaire for civil service
had the most decay present (59% of this age band)2,3. employees in 2007–20082 indicated that 93% of the
Adults aged 35–44 years had, on average, 9.9 respondents claimed that they brushed their teeth two
decayed, missing and filled teeth, suggesting possible or more times each day, this is not reflected by levels
improvement on the statistics for this age group from of caries in the population, or by periodontal health
the 1999 national survey [Diseased, Missing, Filled, status.
Teeth (DMFT) = 14.4]3; however, the sample was rel- Furthermore, levels of smoking in the population
atively small and was representative of employees remain relatively high. From a sample of 358 subjects
rather than the national population. Most impor- included the integrated health screening programme
tantly, even in this age group there was evidence that for civil service employees2, it was found that 11.8%
over half of the disease experience was represented by (n = 66) of the participants were smokers, 11%
the ‘missing’ component, highlighting the role of (n = 61) were past smokers and 41.5% (n = 231)
extractions in disease management3. Only 9.7% of were non-smokers. These findings are despite wide-
the adults surveyed had a healthy periodontium; cal- ranging measures to encourage cessation of smoking
culus was present in 77.3% of participants and within Brunei Darussalam.
27.2% of the dentate population were considered to
require advanced periodontal treatment2. Late presen-
Fluoride
tation for care was reported, with 68% reporting that
they only attended for care when in pain3; this high- The public water supplies in Brunei Darussalam are
lights the importance of having a workforce which mostly fluoridated, with about 99% of the population
can provide access to dental care at an early stage in being provided with fluoridated water. The Ministry
the disease process, when conservative rather than of Health recommends that the level of fluoride in the
surgical management can occur. water be kept within the optimal concentration of
In addition to high levels of dental disease, there is between 0.5 and 0.7 ppm. Collaborative efforts are
significant need for specialist oral healthcare. For ongoing between the Ministry of Health, the Depart-
example, 32% of 10- to 15-year-olds surveyed in ment of Water Services and the Ministry of Develop-
1999 were considered to require orthodontic treat- ment to maintain the level of fluoride in public water
ment. This compares well with the UK where the lat- at this optimal level.
est survey of children’s oral health suggested that
35% had a great or very great need for orthodontic
Oral hygiene aids
treatment4. The level of demand outstripped services
back in 1999 as the waiting list at the time was Toothpaste, toothbrushes and other oral hygiene aids
3–5 years. As detailed below, Brunei Darussalam now are widely available commercially. While data are not
has six specialist orthodontists, with a further individ- available in respect of the purchase and use of oral
ual in training. The waiting list for treatment remains hygiene aids, it is understood that oral hygiene
long (2.5 years in 2008), albeit reduced. techniques and practices are, in common with many
50 © 2013 FDI World Dental Federation

3. Dental workforce for Brunei Darussalam
countries around the world6, very variable amongst The agenda has three main themes: accessibility;
the population. 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 education
Funding and infrastructure
and training theme of the agenda and to highlight the
In 2008, the Department of Dental Services was allo- ways in which these steps may be viewed as an exem-
cated nearly 4.0% of the national healthcare budget. plar by neighbouring and other countries worldwide
Efforts are continuously being made to attract addi- that have oral health challenges similar to those iden-
tional funding to further develop the provision and tified in Brunei Darussalam.
quality of the oral health services. As in any healthcare
system, however, the need for developments in oral Dental education and training
healthcare provision has to be balanced against the
need to develop other core healthcare services, while The main aim of the education and training theme of
being mindful of cost benefits and quality of life issues. the oral health agenda in Brunei Darussalam is ‘to
achieve a sufficient and appropriately skilled work-
force and to increase the oral health services work-
Transitioning to preventively orientated care force diversity, capacity, flexibility and expertise,
including the utilisation of PCDs’ [PCDs-professionals
In common with many oral healthcare services around complementary to dentistry is a term coined in the
the world7, the oral healthcare services in Brunei Dar- UK to include all members of the dental team other
ussalam face challenges in changing from a service pri- than dentists and administrative staff and which has
marily based on clinical interventions to meet pressing now changed to dental care professionals (DCPs)].
treatment needs among, in particular, patients with
high levels of disease and, as is typically the case, low
levels of dental motivation to a preventatively orien- Dentists
tated, minimal interventive approach, supported by In 2010, Brunei Darussalam had a total of 93 dentists
patient engagement and ownership of the need to (Table 3), including the dentists in the public services,
improve oral health. The high cost of clinical interven- armed forces, general dental practitioners and those
tions necessary to address the large burden of oral working in private organisations and hospital, giving
diseases limits the resources available to effect transi- a dentist to population ratio of 1:4046. Seventy of the
tion to oral healthcare orientated towards prevention 93 dentists were public services dentists of whom only
of oral disease and the promotion of the concept 60 were in active service; the others (n = 23) under-
of teeth for life. To effect this transition in a timely went in-service postgraduate training. Only 31 den-
manner, rather than waiting for a generational change tists were principally engaged in the delivery of
in attitudes and behaviour, there would be a need primary oral health care, giving a public service pri-
for an interim increase in funding over a number of mary care dentist to population ratio of 1:12,137.
years. A further 10 individuals, presently undergraduates
in the UK and Australasia will join the dental work-
force in Brunei Darussalam by 2013, but this increase
Oral health agenda may, at least in part, be offset by losses through
In 2008, the Department of Dental Services, Ministry retirements or other causes.
of Health in Brunei Darussalam published and While the outcome of the planned dental workforce
launched an ambitious and comprehensive oral health development review must be awaited, it is anticipated
agenda entitled ‘PEARL 2012.8. The main aim of this that the number of dentists in training will need to be
agenda was ‘to improve the health and well-being of increased, even if plans are made to further develop
the Brunei population by improving the oral health the dental team approach (see below), with dentists as
status and reducing the burden of oral diseases’. More the leader of teams of dental care professionals and
specific aims are to help the residents of Brunei Dar- associated administrative staff.
ussalam to: Table 3 Demographics of dentists practising in Brunei
• Retain as many as possible of their teeth through- Darussalam (2010)
out their lives.
• Have good oral health as part of their general good Nationality Gender Age (years)
health and wellbeing. Bruneian 41 (59%) Female 50 (71%) < 35, n = 39 (56%)
• Have access to appropriate information and an Other 29 (41%) Male 20 (29%) 35–44, n = 18 (26%)
affordable, safe and sustainable, seamless, fully 45–54, n = 8 (11%)
< 55, n = 5 (7%)
integrated, high-quality oral health service.
© 2013 FDI World Dental Federation 51

4. Wilson et al.
Regarding the future training of dentists, this could health expertise to actively inform health policy and
mirror arrangements in medical training in Brunei planning could result in better oral health for the pop-
Darussalam, whereby graduates of either the Bachelor ulation and ensure that resources are used to promote
of Biological Sciences or the Bachelor of Health Sci- health and well-being and not just to treat disease.
ence degrees of the University of Brunei Darussalam Areas for action include: addressing the diet, in con-
may enter graduate entry programmes overseas, to junction with public health professionals, as part of a
return to Brunei Darussalam under the terms and con- common risk factor approach to promoting health
ditions of professional training schemes. and preventing disease10,11; implementing the strong
global evidence base for prevention as a core pillar of
primary care provision; and building the monitoring
Specialist practitioners
of oral health and dental service provision into rou-
The number and specialty distribution of specialist tine data collection (in electronic format) to inform
practitioners in Brunei Darussalam, including special- future planning and provision of care – the applica-
ist practitioners in the armed forces, is detailed in tion of health informatics.
Table 4. Many of these specialist practitioners are
under 35 years of age. Having 21, and in due course
Dental therapists and dental hygienists
a further five members of the total dentist workforce
of 70 individuals trained to the specialty level, is com- In 2007, the Brunei Darussalam Ministry of Health
mendable. This is greater than the level of specialists signed a memorandum of understanding with King’s
in the UK and the USA where 10% and 20% of the College London Dental Institute, where many of the
dental profession are trained to specialist level9 Brunei Darussalam specialist practitioners were
respectively, but takes into account that more routine trained, to underpin arrangements for a collaboration
primary dental care may be provided by DCPs. How- to develop a Brunei Darussalam Diploma in Dental
ever, there is need for coverage of all dental specialties Therapy and Dental Hygiene provided by the Brunei
so that comprehensive continuing professional devel- Darussalam Ministry of Health National Dental Cen-
opment and clinical support are provided for all den- tre. This innovative, highly successful programme,
tists within the country. It is notable that Brunei which has given Brunei Darussalam a degree of inde-
Darussalam has no specialists in dental public health pendence in dental workforce development, has to
and special care (needs) dentistry, let alone oral medi- date produced 14 dental therapy/hygienists. Six of the
cine or oral pathology – services that are provided by serving dental nurses (New Zealand type) have gone
oral maxillofacial surgeons as medical specialists and on to become tutor dental therapy/hygienists, subse-
general pathologists, respectively. quent to a 1-year programme of training at King’s
College London Dental Institute. The development of
mid-level dental providers is becoming an important
Workforce priorities
part of healthcare development across the world12–14.
While it may appear that the priority is to use avail- While controversial in certain countries, the develop-
able resources to train more general dental practitio- ment of the dental team offers many important advan-
ners, it is anticipated that the planned dental tages, in particular, when, as in Brunei Darussalam,
workforce review may recommend succession plan- mid-level providers can meet many of the dental needs.
ning in the dental specialties, together with the intro- Concurrently, the development of the specialist dental
duction of specialists in dental public health and workforce should, as in Brunei Darussalam, anticipate
special care dentistry as an important early action. changing needs for specialist services, notably among
Investment in developing specialist dental public the ageing population.15
Arrangements are in hand to recruit and train fur-
ther cohorts of dental therapy and dental hygiene stu-
Table 4 Numbers and specialty distribution of spe- dents in Brunei Darussalam and to establish a
cialist dental practitioners in Brunei Darussalam conversion course to allow existing dental nurses (see
(2010) below) to receive top-up training to qualify as dental
therapists/hygienists. This will further enhance the
Specialty Number of practitioners Number in training
competence of the dental team and its flexibility to
Orthodontics 6 1 work across the dental service.
Paediatric dentistry 5 1
Oral surgery 4 1
Prosthodontics 3 – School dental nurses
Endodontics 2 1
Periodontics 2 – School dental nurses in Brunei Darussalam are qualified
Restorative dentistry 1 1
to provide primary dental care to children, working
52 © 2013 FDI World Dental Federation

5. Dental workforce for Brunei Darussalam
predominantly in school-based clinics. In 2010 there
Workforce goals
were 74 dental nurses engaged in clinical practice in
Brunei Darussalam, with the training of these members Concurrent with plans to develop a new National
of the dental team having been provided largely in Dental Centre, supported by a network of district
Malaysia and to a lesser extent in Singapore 20– dental clinics, the goal for dental workforce develop-
35 years ago. Many of these dental nurses have one or ment in Brunei Darussalam is to create a dental team
more post-qualification certificates or diplomas, with of appropriate size and composition, according to
two having obtained BScs (one in Oral Health and the World Health Organization (WHO) workforce tar-
other in Health Service Management). As a result of gets, with the expertise, capacity, flexibility and skill
having established the Brunei Darussalam Diploma in mix to provide modern, preventatively orientated oral
Dental Therapy and Dental Hygiene, Brunei Darussa- health care, sufficient to realise the national Oral
lam is no longer sending trainees to be trained as dental Health Agenda8. A further goal is to support contin-
nurses in Malaysia or Singapore. uing professional development for the dental work-
force, sufficient to maintain knowledge and
understanding and to keep the entire workforce
Dental surgery assistants
abreast of developments in clinical practice. The latter
Dental surgery assistants play a vital role in ensuring is viewed as essential to drive continuous quality
the delivery of quality care by dentists, therapists and improvement in the national provision of oral health
hygienists by enhancing their productivity in well- care. It is acknowledged that considerable investment
developed systems. Dental surgery assistants (DSAs) will be required to realise the dental workforce and
in Brunei Darussalam support dentists, dental thera- associated goals, but the benefits of fulfilling the Min-
pists, dental hygienists and dental nurses in the provi- istry of Health’s vision for 2015 are considered to jus-
sion of dental services. In 2010 there were a total of tify the commitment of the necessary resources16. In
93 DSAs in Brunei Darussalam, comprising two Chief addition to the immediate plans for a new oral health
DSAs, 13 Senior DSAs, 25 qualified DSAs and 53 trai- survey and a programme of workforce modelling to
nee DSAs. Before 2002, DSA training for Brunei Dar- ensure that there are robust longer-term plans in
ussalam was provided in Malaysia. Subsequent to place, decisions will be required in respect of the
establishing a training programme locally in 2002, the wider dental team to include, for example, clinical
Ministry of Health introduced a Certificate in Dental dental technicians and orthodontic therapists. In tak-
Surgery Assisting in 2003. This programme, as indi- ing forward this agenda, initial deliberations would
cated above, presently provides training for 53 train- suggest that the most pressing need could be consid-
ees. ered to be the training of specialists in dental public
health. These specialists will be critical in driving and
monitoring progress in the nation’s oral health
Dental laboratory staff
agenda.
In 2010, Brunei Darussalam had a total of 38 dental
laboratory staff, including 19 technicians, seven tech-
DISCUSSION
nologists, nine trainee technicians and six possible
future trainees. The dental technologists completed Addressing the oral health of a nation, irrespective of
three-year BSc degrees in dental technology, while size, requires strong political action, wide participa-
the technicians hold a diploma in dental technology tion, buy-in and sustained effort and investment. As
obtained in Malaysia. Consideration may, at some set out in the WHO resolution WHA.60.177, action
time in the future, be given to establishing a Brunei plans for the promotion of oral health and integrated
Darussalam Diploma in Dental Technology in disease prevention comprise various elements, includ-
collaboration with King’s College London Dental ing workforce planning for oral health and scaling up
Institute. the capacity to produce oral health personnel. The
Ministry of Health in Brunei Darussalam is rising to
this challenge as part of its Oral Health Agenda8.
Administrative and support staff
Such action, which may in due course result in Brunei
The delivery of dental services by the Ministry of Darussalam becoming a regional centre of excellence
Health in Brunei Darussalam is supported by a total for dental education, is an exemplar to countries else-
of 45 administrative and support staff, ranging from a where in the world that face oral health problems
Chief Executive Officer (CEO) and hospital adminis- similar to those that exist in Brunei Darussalam.
trator to 12 reception staff and 14 attendants who In countries in which there are substantial unmet
serve as clinical assistants and ‘runners’ in major health needs, often together with health inequalities,
dental clinics. oral health, other than acute dental care, may not be
© 2013 FDI World Dental Federation 53

6. Wilson et al.
viewed as a funding priority. However, with the lam is to be commended for wishing to improve oral
growing body of evidence of associations between var- health and, in turn, general health and well-being
ious forms of chronic systemic disease and poor oral through effective, equitable, affordable, accessible, safe
health6, let alone the impact of oral health on general and sustainable oral healthcare by a dental team trained
wellbeing, in particular in older patients,15 the philos- to international standards.
ophy of Together Towards a Healthy Nation adopted The 2008–2012 oral health agenda in Brunei Dar-
by the Ministry of Health in Brunei Darussalam17 is a ussalam,8 and, in particular, its programme of dental
very progressive in national healthcare policy. Fur- workforce development and associated investment is
thermore, it is laudable that oral health promotion in considered to be a model for other countries facing
Brunei Darussalam is an integral element of a major similar oral health issues.
strategic goal to promote healthy living through
modified lifestyles, as emphasised in the Brunei
Acknowledgements
Darussalam, Ministry of Health, Promotion Blueprint
2011–201517. We thank the current Minister of Health Brunei Dar-
Given the lead time necessary to develop a dental ussalam (Yang Berhormat, Pehin Orang Kaya Johan
workforce fit for future purpose in the provision of Pahlawan Dato Seri Setia Awang Haji Adanan bin
preventatively orientated, minimally interventive oral Begawan Pehin SiRaja Khatib Dato Seri Setia Haji
healthcare, dental workforce strategies of the type Mohd Yusof) and former Minister of Health Brunei
being implemented in Brunei Darussalam require sus- Darussalam (Yang Berhormat Pehin Orang Kaya
tained support and funding over extended periods. Indera Pahlawan Dato Seri Setia Awang Hj Suyoi bin
From inception to the time of realising major goals, Haji Osman).
at least 5 years – and possibly more – may elapse.
Success in dental workforce development may there-
Competing Interests
fore rely heavily on stable domestic affairs, with rele-
vant policy being carried forward through different Professor Wilson and Miss Slater from King’s College
Ministers and ministerial teams when organisational London Dental Institute were engaged in the work-
change occurs, as has happened since the national force development reported in this paper through an
Oral Health Agenda and strategy16. Under these cir- agreement between King’s College London and the
cumstances, the previous Minister of Health is to be Ministry of Health Brunei Darussalam. Drs Shamshir,
congratulated for having established the strategy, and Moris, Kok, Said and Lee are employees of the Minis-
his successor, the present Minister of Health also try of Health, Brunei Darussalam.
deserves praise for not only sustaining the programme
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