Oral health in New Zealand children

Written by Harriet Scotland

  Introduction

This literature review is based on how the socioeconomic status of a child affects their oral health. In New Zealand, oral health is one of the most established chronic diseases (Ministry of Health, 2010), with dental carries being the most prevalent oral health issue in New Zealand children (Birse, 2004). Bach and Manton (2014) state that dental caries are one of the most common reasons that a child is admitted to hospital in New Zealand. Key themes that will be discussed based on literature researched are; disparities in oral health status and access to services, tooth brushing, fluoride, high sugar consumption, nutrition and attitudes to oral health. Following this literature search, it was discussed that oral health of children in New Zealand is majorly influenced by socioeconomic status. Mainly, this affects children in deprived areas, specifically Maori and Pacific children.

  Practice issue

The practice issue that will be discussed in this literature review is poor oral health within the children of New Zealand. Key findings from the oral health survey (Ministry of Health, 2010) states that children and adolescents coming from a low socioeconomic area have poorer oral health compared to children and adolescents coming from a wealthier socioeconomic area. The majority of these children and adolescents are Maori and Pacific ethnicities, and are more likely to have dental caries in their primary teeth. The main reason for this is not meeting teeth brushing recommendations, as well as the cost of accessing oral health care to treat tooth decay (Ministry of Health, 2010).

Nurses in New Zealand are a key link in preventing dental caries within the New Zealand population, especially among children. Primary health care providers are able to refer these children to receive appropriate medical or dental treatment for their teeth (Bach, Manton, 2014). In New Zealand, there is a health strategy aimed at improving oral health, based around nurse interactions with the family and the children. The nurse is able to provide support and education to the mother and child relating to oral health (Birse, 2004).
 
Dental caries is a chronic disease of the teeth due to dental decay (Birse, 2004). This is caused by bacteria in dental plaque, which demineralize the teeth. Dental caries can be prevented by reducing the amount of plaque buildup, decreasing sugar exposure, and using fluoride, which is a protective modifier (Ministry of Health, 2010). Oral health affects all aspects of a person’s wellbeing, including their mental, physical and social aspects of health. Oral health is not just tooth decay it consists of oral and throat cancers, chronic pain, gum disease, birth defects, tooth decay and other diseases related to oral mucosa, tongue, teeth and the surrounding cranio-facial structures (Ministry of Health, 2010).
 
Ministry of Health (2015b) states that most babies get their first teeth at around the age of six months. These are their baby teeth and for majority of babies, by the time they are three will have a full set of twenty baby teeth. Ministry of Health (2015a) states that the care for a child’s teeth from the ages of one, consists of brushing their teeth twice a day, regular teeth checkups, lifting their child’s lip up to ensure that they do not have any decay in their teeth, eating healthy especially snacks, and drinking water or milk.
  Literature review

A review of current literature was undertaken, with the aim of finding out why New Zealand has poor oral health. To do this, a preliminary search was used with article search engines CINAHL and PubMed being utilized. Following this preliminary search, it was discovered that children accounted for a big statistic in the population suffering from poor oral health in New Zealand. To refine the research further, there was a link between low socioeconomic backgrounds being an indicator of poor oral health in children. The research was then refined to socioeconomic status in children of New Zealand affecting poor oral health.

  Visiting a dentist in New Zealand

In New Zealand, visiting a dentist is free until a child turns 18 (Ministry of Health, 2010). However, literature states that the children of New Zealand still have poor oral health (Hamman, 2007). Hamman discusses key factors that are significant to the oral health of children such as, poor dietary habits, low socioeconomic status and fluoridation. Hamman  also outlines school dental services and their role and the primary prevention to reduce tooth decay. In New Zealand, there are major health inequities regarding oral health due to socioeconomic status for the preschool population (Bach, & Manton, 2014). This means that preschool dental decay is an issue with early caries being present. In the dental data of schools, 50% of five year olds have early dental caries. This data states that 58% of Maori children and 64% of Pacific children by the age five have early dental caries (Bach, & Manton, 2014). Collins, Fair, Dickinson, and Peacock (2009) states that due to the inequalities of ethnic groups such as the Maori and Pacific children they are more likely to have dental caries, as they are less inclined to access dental care and brush their teeth accordingly. Collins (2009) shows that children living in deprived socioeconomic areas are more likely to have a high prevalence of dental caries and oral health diseases. Hamman (2007) states that one of the main reasons for lower socioeconomic areas having higher rates of oral health issues is economic deprivation. This occurs due to not being able to assess varying health services, suggesting that the barriers stopping them from being able to do this is lack of knowledge, cost, and their availability to access services.

Nash (2009) found that in New Zealand in the 1920’s, school based dental clinics existed in all elementary schools. Nash states that in 2009 there are 600 dental therapists based in schools. Because of this, 96% of children in New Zealand went to a dental therapist that was assigned to their school. Evidence shown in Nash, states that none of the children that were provided with this school service had dental decay left untreated. Birse (2004) states that there are fewer dental therapists within New Zealand as there were dental therapists based in schools since the 1920’s. Jiang, Page, McMilian, Lyons, Broadbent, & Morgaine (2014). states, disadvantaged people are less likely to visit a dentist and have unhealthier habits and a decreased knowledge in oral health compared to non-disadvantaged people. Piovesan, Antunes, Guedes, and Ardenghi (2010) state that a low level of education can affect the oral health of a person. As a parent they are the ones who provide the child with education on appropriate oral health behaviors, and in turn influencing the child’s perception of their oral health.  Therefore, this means it is important that the primary health nurse is aware of the implications of oral health in children (Birse, 2004). Bach and Manton (2014) found that when a child is under the age of six years they are not able to brush their teeth properly and need to be monitored and assisted by their caregivers with their teeth brushing routine. Parents who leave their children unassisted have a higher level of plaque buildup on their teeth. Therefore, this shows the importance of parental education regarding children oral health. Birse (2004) states that because nurses interact the most with the mother and child, they are in the best position to be able to educate the mother and child about oral hygiene and nutritional choices for their child. Jiang et al. (2014) states oral health should be a key target of any health programme and is the key to reducing inequalities.
  Early childhood dental caries

Bach and Manton (2014) state that there are significant inequalities regarding early childhood dental caries in preschool children in New Zealand due to economic status. Maori and Pacific children dental caries were poorer in the 1990’s. Non-Maori were more than three times likely not to have dental caries then Maori children with no further change in the trend. Bach, & Manton also found that Maori children start brushing their teeth at a later age and do not brush their teeth as frequently. They will also only seek dental help when they become symptomatic.  Following this Birse (2004) claims that Maori have a younger maternal age than non-Maori as well as a level of academic achievement that is lower than non-Maori. Stating that for oral health to relate to Maori the health message must relate to them in their communities. Therefore, implying that education based on oral health should be community based within the Maori support groups. This means that the nurse is to work with the family members of the Maori community to provide support and education based on oral health (Birse, 2004).

  Maori children

Broughton et al. (2013) state that indigenous Maori have different preferences in oral health methods than non-indigenous Maori. They stated that Maori children from the Manawatu/Wanganui region in New Zealand were three times more likely to have dental caries than children that were non-Maori, and three times more likely to not be enrolled in the school dental service. This research article stated that the dental decay epidemic strongly correlates with certain groups such as Maori and Pacific ethnicities impacting negatively on them, due to their lower socioeconomic status. Broughton et al. (2013) identified that there are four ways that early childhood dental carries can be prevented, including providing the mother who is pregnant with dental care; topical fluoride to the child’s teeth; counseling techniques for each stage of the child’s life called anticipatory guidance; and motivational interviewing techniques to provide the caregivers with strategies to come to solutions.

  Health strategies

The Ministry of Health identified oral health as one of the objectives of their health strategies. Starship Children’s Hospital in Auckland District Health Board (ADHB) started a health project for oral health in children. This was based on a nurse led project to increase oral health promotion as well as increasing general oral health. The project consisted of providing education to nursing staff and providing education to children and families. Therefore, the nurses addressed children and parents who accessed ADHB in healthcare education surrounding oral health (Collins et al, 2009).  Collins also states that the outcome of this was improvement of oral health care in children.

Bach and Manton (2014) claims that primary prevention is one of the main strategies that promote oral health in children. The goal of primary prevention is to encourage and educate children to have a regular tooth-brushing regime using the correct techniques. It also suggests that children are to establish a nutritious well balanced diet and understand the importance of fluoride intake. It is important that the child undergoes regular checkups. Bach and Manton also outlines that if a child starts tooth brushing before the age of 12 months they are less likely to have dental caries compared to a child who starts brushing their teeth after 13 months of age. This is due to the education of parents and them being more aware of the implications of poor oral health on their children. Jiang et al. (2014) argues that however oral health education may increase inequalities in some circumstances in certain individuals. An evaluation was done on oral health education in Scotland that found that children from non-deprived areas had an increase in their oral health however children from low-deprived areas did not (Jiang et al. 2014). Jiang et al. also claims that literature based on dental health education has shown that there is no apparent effect of the interventions of education reducing the rates of teeth decay.

  Fluoride

Schluter and Lee (2016) outlines that areas without fluoride in their water impact largely on children who are Maori and Pacific ethnicity that reside in a lower socioeconomic group. They have an increased risk of poorer oral health then non-Maori and Pacific children. Fluoride is an important contributing factor to the oral health of a child. Fluoride inhibits demineralization and it enhances the demineralization. Fluoride can be found in fluoride toothpastes and for children in fluoride toothpastes with the correct formula. Fluoride is also found in some water supplies around New Zealand (Bach, and Manton, 2014). Bach and Manton states that fluoride in water has reduced the amount of dental caries by 30%. Children that live in areas with fluoridated water have improved oral health outcomes as well as increasing the oral health of children living in low socioeconomic areas. Hammam (2007) promotes fluoride as being an effective measure in the prevention of tooth decay in children. Stating that it helps to build the enamel and make the teeth strong. Hammam states that research has been shown that fluoride has up to a 50% reduction rate in tooth decay. Claiming that water fluoridation is the best form of fluoride in a diet.

  Sugars

Bach and Manton (2014) states that the timing of the intake of sugars is important as consuming foods high in sugar especially sucrose has a strong relationship with the prevalence of dental caries. It is recommended that children do not consume sugar in-between meals, as they are more likely to have dental caries. This is an issue in today’s society as sugar consumption has increased causing an increase in dental caries (Birse, 2004). Bach and Manton (2014) states that soft drinks are high in sucrose as well as fruit juice and is an increasing problem due to the increase in consumption of soft drinks. The increase in families buying soft drinks has lead to a decrease in the amount of milk and dairy products being consumed. Consumption of milk is an important dietary factor as calcium, casein and phosphate inhibit demineralization, which in turn promotes the remineralization of the child’s enamel (Bach & Manton, 2014).

  Implications in practice

Oral health in children is an important implication in practice as the nurse works closely with mothers and their children from a young age, especially in primary health care. Hammam (2007) states that district health boards are aiming to promote awareness for oral health. They are trying to increase the amount of patients enrolling in school dental services. In doing this they are encouraging nurses that range from well child nurses, public health nurses and practice nurses to promote them to enroll in these services and to create awareness for oral health. Bach and Manton (2014) provides information that children who attend school dental services can attend the clinic until they are 12-13 years of age when they finish primary school. Bach and Manton also states that because early childhood caries is a public health issue primary care providers should be able to identify the at risk children and provide them with early preventative programmes and services to do with oral care for children. Birse (2004) emphasizes the point that nurses should be able to identify if there is an abnormality within a child’s oral cavity depending on the complexity of it. Birse states that nurses lack knowledge surrounding how to assess oral hygiene and it is not a priority within a hospital setting.

Following this information, it is shown that low socioeconomic status effects oral health status. Low socioeconomic status can also lead to poor education or understanding around oral health within these families. This in turn means that as a nurse their role can be to educate the families around oral health hygiene providing information of when the child is to start brushing their teeth, how to brush their teeth, what toothpaste to use, providing information with adequate nutrition advice and when a child should have an intake of sugar if desired. They should be educated about fluoride within the water supply and have knowledge of services that are available for them (Bach & Manton, 2014).

  Recommendations

The initial recommendations and rationale relating to nursing practice is that a parent should be provided with information regarding teeth brushing and oral cares for a baby, before the age of 1.  This is because as stated above by Bach and Manton (2014) children who have their teeth brushed before the age of 12 months are less likely to have dental caries then children who start brushing their teeth after the age of 13 months. I would also recommend that children’s families are educated about fluoride toothpaste as the New Zealand Ministry of health guidelines that children of all ages should be using fluoride toothpaste (Bach & Manton, 2014). I would recommend that it should be a health care priority that children receive an early examination as children with early detection of primary dental caries issues. With this intervention they will be able to undergo remineralization programmes to prevent them from progressing. Primary care providers should be educating the families to get their child’s teeth checked before the age of 12 months and after the eruption of their first tooth (Bach & Manton, 2014). I would recommend that when a child comes in for a checkup in the primary health setting. The nurse should also make it a priority to check the oral health of the child. The nurse should also make it a priority to check the level of education that the mother can retain and understand to do with oral health. The nurse could provide pamphlets and other sources to educate the mother. The nurse should also educate the mother about what the child should be drinking and how much sugar intake it should be having. The nurse could also teach the mother on brushing techniques and to check if they are providing their child with appropriate oral hygiene techniques. This is because child health nurses interact more regularly with the children and mother then many other health care workers (Birse, 2004).

  Conclusion

In conclusion, this literature review has been formed to discuss the clinical question of how does the socioeconomic background/lifestyle of a child effect their oral health. Following this literature search, it was discussed that oral health of children in New Zealand is majorly influenced by socioeconomic status. Mainly, this effects children in deprived areas, specifically Maori and Pacific children. Other influences the literature articles suggest that are causes of poor oral health are lack of fluoridation, poor nutrition, lack of education, and poor attitudes towards dental health.

  References

Bach, K., Manton, D. (2014). Early childhood caries: a New Zealand perspective. Journal of Primary Health Care, 6(2), 169-174.

Birse, S. (2004). Dental health is a key child health issue: New Zealand children’s dental health has declined since the early 1990’s. Nurses who work with children have a key role to play in reversing that trend. Kai Tiaki: Nursing New Zealand, 2(10), 20-22.

Broughton, J. R., Maipi, J. T. H., Person, M., Thompson, W. M., Morgaine, K.C., Tiakiwai, S. J., Kilgour, J., Berryman, K., Lawrence, H. P., & Jamieson, L. M. (2013). Reducing disease burden and health inequalities arising from chronic disease among indigenous children: an early childhood caries intervention in Aotearoa/New Zealand. BMC Public Health, 13(1177), 1-8.

Collins, E., Fair, N., Dickinson, A,. & Peacock, K. (2009). Collaboration between primary and secondary/tertiary services in oral health. Primary health care, 19(1), 35-39.

Hamman, R. (2007). The issue of poor oral health in children. Nursing Journal NorthTec, (11), 27-30.

Jiang, Y., Page, L. A. F., McMilian, J.,  Lyons, K., Broadbent, J., & Morgaine, K. C. (2014). Is New Zealand water fluoridation justified? New Zealand Medical Journal, 127(1406), 1175-8716.

Piovesan, C., Antunes, F. J. L., Guedes, R. S., & Ardenghi, T. M. (2010). Impact of socioeconomic and clinical factors on child oral health-related quality of life. Quality or Life Research,19(9), 1359-1366.

Ministry of Health. (2015a). Caring for your child’s teeth: 1-2 years. Wellington: Author.

Ministry of Health. (2010). Our Oral Health: Key findings of the 2009 New Zealand Oral Health Survey. Wellington: Author. 

Ministry of Health. (2015b). Teeth and teething. Wellington: Author.

Nash, D. A. (2009). Adding Dental Therapists to the Health Care Team to Improve Access to Oral Health Care for Children. Academic Pediatrics, 9(6), 446-451.

Schluter, P. J., & Lee, M. (2016). Water fluoridation and ethnic inequalities in dental caries profiles of New Zealand children aged 5 and 12-13 years: analysis of national cross-sectional registry databases for the decade 2004-2013. BMC Oral Health, 16(21), 1-10.