Abstract
Oral disease is the most common, chronic childhood disease worldwide. Oral disease encompasses malocclusion, abscesses around the teeth, disturbances in tooth formation and eruption, and embedded and impacted teeth, among others. However, tooth decay (dental caries) is the single largest contributor to poor oral health, including among children living in Aotearoa. This report draws together data from 3 sources – 1) the NZ Health Survey, 2) the Community Oral Health Service (COHS), and 3) the National Minimum Dataset (NMDS) – to provide a picture of dental health of children and youth in Aotearoa.
Oral health conditions can have far-reaching effects on child health and well-being, including pain, eating and sleeping problems, speech disorders, physical growth, school performance, and quality of life. Dental caries in early childhood (before the age of 6 years) predict tooth decay experience into adulthood meaning that poor oral health becomes a lifelong problem.
As part of the 2022/23 NZ Health Survey, parents of children aged 14 years or younger were asked to rate their child’s oral health. Overall, 92% of parents responded that their child had good (or better) oral health and 2/3 reported brushing at least twice per day. However, other data suggest that the oral health of children and young people is far from optimal and that some of the worst outcomes are seen in the country’s most vulnerable populations
In Aotearoa, the COHS provides free dental care from birth until the end of year 8 (end of primary/ intermediate school) but coverage by the service has been declining since 2000. Conversely, over the same time period, hospitalisation rates for children with dental caries more than doubled for 5–9-year-olds and nearly tripled for 10–14-year-olds. Between 2018 and 2022, there were over 48,000 hospitalisations for dental issues in child and young adults, of which nearly three-quarters were due to dental caries. A chronic shortage of oral health providers working within the COHS, delayed presentation, and more severe disease may all be factors contributing to the rise in hospitalisations.
When compared with older children in Year 8 (aged 12–13 years), 5-year-olds are not only less likely to have seen a community provider (COHS coverage for 5-year-olds is only around 50%) but more likely to have dental decay when they do present, suggesting that oral health issues start early in life. This is supported by hospitalisation data; hospitalisation rates and procedures increase steeply from the age of two and peak at age five. This is especially important as early childhood caries predicts future caries in permanent teeth. The other age cohort at increased risk appears to be those aged 15–24 years, around half of whom report “never visiting” a dental health worker or “only visiting for problems.” Costs associated with treatment appear to be a major barrier for this group of young people.
Poor dental health is associated with disability, neighbourhood deprivation, and ethnicity. Children living with a disability are less likely to have good oral health (as rated by parents) and there is also a trend for poorer outcomes among this group although numbers available for analysis are small. There are strong deprivation gradients for oral health conditions in Aotearoa; hospitalisation rates among children living in the most deprived circumstances are twice that of those living in the least deprived circumstances. Even after accounting for ethnicity, the likelihood of dental caries increases steadily with each step in deprivation. In terms of ethnicity, the system appears to be failing Māori and Pacific children disproportionately. Compared with European/Other children, Māori and Pacific children are more likely to experience dental caries and to undergo an in-hospital dental procedure. These inequities exist even after controlling for neighbourhood deprivation.
Examination of children’s teeth by the COHS varies by geographic region, as does their dental health. Over the last five years, coverage of 5-year-olds by the COHS has decreased across the nation but the most marked reductions are in the northernmost regions of Te Tai Tokerau, Waitematā, Auckland, and Counties Manukau where coverage is as low as 40%. Correspondingly, children and young people living in some of these areas have poorer oral health status than do children in other regions in the country; approximately one in every two 5-year-olds seen by the COHS in some of these areas presents with dental decay. However, an unexpected finding was that poor oral health did not appear to translate to an increased hospitalisation rate for most of this group. In fact, hospitalisations for dental issues and dental procedures in these regions are among the lowest in the country, with the notable exception of Te Tai Tokerau. The reasons for this warrant further investigation.
Dental caries is preventable and there is very strong evidence for measures to prevent caries from developing in the first place (primary prevention). Reducing exposure to sugary drinks and food (especially at a young age), regular brushing with a fluoride toothpaste, and community water fluoridation (CWF) are all effective for primary prevention. Recommendations reflect the very young age at which oral health conditions can begin; parents are recommended not to give juice and to begin regular toothbrushing ideally before the child reaches one year of age. The cost of toothbrushes and appropriate toothpaste have been shown to be barriers to regular brushing. CWF is a cost-effective tool for improving oral health, particularly for those children living in the most socioeconomically deprived areas of Aotearoa. Currently, around 60% of the population have access to fluoridated water but this could be expected to rise to 80% following a direction to fluoridate drinking water supplies by the Director General of Health in 2021.
There are a range of secondary prevention (preventing the progression of caries from developing into cavities) and surgical treatment (stopping cavitation and preserving teeth) measures. These include the use of fluoride gels and sealants as well as crowns and other restorative treatments. However, restorative treatments are more likely to fail in children and cost is likely to be a major barrier. In Aotearoa, dental treatment under anaesthetic costs the country around $17 million annually.
Overall, there has been minimal improvement in the oral health of children in this country over recent years and large inequities persist. Recommendations include the adequate resourcing of oral health care services, greater representation of Māori and Pacific peoples in the oral health workforce, and improved engagement with communities. Addressing the drivers of socio-economic deprivation is critical to improving the oral health of children and young people living in Aotearoa.