Oranga niho - Oral Health

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Key reviewers:
Dr Pauline Koopu, Te Whānāu-a-Apanui, Ngāti Konohi, Ngāti Kahu, Te Ao Marama (Māori Dental Association), Wellington
Dr Dorothy Boyd, Specialist in Paediatric Dentistry, Senior Dental Officer, Otago DHB
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Te wero - The Challenge

Ma te huruhuru te manu ka rere, ma te niho ora ka ora te tangata
With feathers the bird will fly, with good oral health, the person will thrive

Key concepts:
  • Major inequalities exist in the oral health of New Zealanders and urgent action is required
  • Rates of dental caries in children are increasing
  • Poor oral health is preventable but prevention must start early
  • Cost is one of the major barriers

Why do patients go to a GP rather than a dentist?

There are many reasons why a patient may present to general practice rather than a dentist. Some of these reasons are:1,2,3

  • A GP may be viewed as more accessible – patients can usually be seen on the same day
  • There may be financial considerations – a GP consultation is likely to be less expensive than a dentist
  • The patient may not have a regular dental provider and therefore views the GP as the first person to see when a problem arises
  • There may be a lack of co-ordinated after hours dental care, or this care may exist, but patients may not be aware of it
  • The patient may be seeking treatment that will give immediate relief of symptoms rather than definitive treatment of the underlying dental issue
  • A patients past experiences (e.g. fear, pain) and those of family and friends may influence the choice of practitioner
  • The patients may have limited knowledge of the specific roles of dental and medical practitioners
  • Oral health is a part of general health – people may not consider a dental origin for their health problem e.g. bacterial endocarditis

How can GPs help improve oral health?

There are three easy actions to take which will improve the oral health of patients.

  1. Ask about oral health
  2. Examine the teeth and gums
  3. Be aware of what services are available

1. Ask about oral health

It is good practice to ask patients about oral health. For example, when children present for immunisations (particularly at the 15 month immunisation visit), ask “Is your child enrolled with the School Dental Service?” Other opportunities may present during the “B4 School Check”, when new patients enrol in the practice, and during consultations where poor oral health is apparent (e.g. while examining a sore throat).

note

Best Practice tip: Make it a practice wide task to record enrolment status with the School Dental Service for all children aged under 18 years. Have enrolment forms for the School Dental Service in the practice and encourage parents to enrol their children. Place a recall to check when they next present that they have enrolled the child. If the child is already enrolled, check that they have attended appointments.

Most DHBs have information, downloadable enrolment forms and lists of local school dental clinics on their website.

2. Examine the teeth and gums

This applies not only when there are symptoms but also opportunistically when examining a patient’s throat or mouth. Encourage parents to look in their child’s mouth for signs of dental decay (e.g. obvious cavities or chalky white patches). If one whanau member has dental problems it is likely that others may have similar problems. Promoting good preventative behaviour needs to be targeted at the whole whanau.1

look

The “Lift the Lip” message, a joint venture from the Ministry of Health and the New Zealand Dental Association, is a nationally consistent phrase used to encourage parents to look in their child’s mouth. Instructional videos showing how to detect decay in young children can be viewed online. These videos are aimed at Well Child providers, B4 School Check providers and general practices. Available from:
www.healthysmiles.org.nz/default,120,lift-the-lip-.sm

3. Be aware of what services are available

Be aware of what services are available in the area such as Māori health providers, mobile units, contracted and private dentists. Be familiar with the options for dental care for all age groups and have information available on funding and resources. Contact your local DHB if you don't know where to start.

Establish good working relationships and referral processes with dental health teams. Dental care has tended to be relatively isolated from the rest of primary health care and often there may be limited communication between doctors and dentists.3

What action can GPs take when confronted by poor oral health?

Don’t ignore oral health
There are known links between periodontal (gum) disease and diabetes, smoking, oral cancers and poor maternal oral health and pre-term or low-birth weight babies.

Oral health encompasses both physical and psychosocial aspects which can have a major impact on the way an individual functions in their day to day life. Missing, damaged or diseased teeth and the pain and self-consciousness arising from this can have a marked effect on quality of life. Poor oral health can affect personal relationships, self esteem, general health and work.

“Promoting oral health is not simply a matter of reducing caries levels. It is also about promoting the overall health of society and its individuals.”– Ministry of Health4

Initiate treatment and refer
If a patient presents with an oral health problem, treatment may be initiated if appropriate, followed by referral for dental treatment.

look

See here for management of common oral health conditions seen in general practice.

How to enrol in the School Dental Service

Practices are encouraged to have enrollment forms available. Otherwise the parent or caregiver should contact the dental clinic at the school closest to their home address (listed in the phone book under school name) or ask their Plunket nurse. Primary school aged children who have not previously enrolled will receive an enrolment pack when they start school.

For information on adolescent dental care, call 0800 ITS FREE (0800 4873733)

Provide education to promote good oral health for all
In addition to education about immediate care, use the opportunity to provide ongoing education about preventative care. This may include advice on:

  • Good oral hygiene (look see here)
  • A healthy diet, in particular avoidance of sugary foods
  • Giving teeth a rest – encourage food and drink free periods between snacks and regular meals (ideally 1½ to 2 hours)
  • Regular dental examinations (annually if good oral health, three to six monthly if problems exist)
  • A smoke free environment
  • The use of mouth guards in sport

Oral healthcare funding in New Zealand

Publicly funded dental care in New Zealand is targeted at people under the age of 18. The aim is to promote good oral health from an early age so that the benefits flow on into adulthood. Dental care for adults is provided by private dental practitioners and in most cases the cost of treatment is the responsibility of the individual. However there are some publically funded targeted services.

Oral health care is funded for the following groups in New Zealand;

  • Children from birth to Year 8 (age ~ 12 years)
  • Adolescents from Year 9 (age ~ 13 years) to age 18 years
  • Low-income adults
  • Special needs and medically compromised patients

Children from birth to Year 8
All children need to be enrolled with the School Dental Service to receive free oral health care. The age of enrolment varies by region, but the majority are enrolled by age two and a half years. Dental care is provided by dental therapists in school, community or mobile dental clinics until the end of Year 8. Children can be referred to a dentist for further treatment, which is free if accessed under the Combined Dental Agreement.

Adolescents from Year 9 to 18th birthday
Adolescents can access free dental care under the Combined Dental Agreement. Year 8 students are provided with an enrolment form, usually from a dental therapist via the School Dental Service. They then select a contracted dentist for their care who will sign the form to access funding. Adolescents can be enrolled at any age up until their 18th birthday.

The treatment covered under this agreement includes regular examinations, preventive services (fissure sealants, fluoride treatments), fillings and extractions. A fee may apply for other services such as larger tooth coloured fillings in back teeth. Other specialised services such as orthodontic and cosmetic work (e.g. tooth whitening) are not covered.

Low-income adults
For people with a Community Services Card (CSC), funding for dental care up to $300 per annum is available through Work and Income New Zealand.

Some public hospitals provide limited services (pain relief and infection control) for people who are unable to access private care due to their financial circumstances. Patients accessing this service must have a CSC and are usually required to pay some of the cost of treatment.

In many areas hospital emergency departments only provide dental care if it is trauma related. Other after hours care is usually provided by private dentists working on an on-call roster. The cost of this care is the responsibility of the individual.

Special needs and medically compromised patients
Specialised dental care is available from hospital based services for people with medical conditions, intellectual or physical disabilities, mental illness or severe dental disease that prevents them from using private dental services. A part charge may often apply to these services. Criteria for referral varies by region, check with the local DHB.

Treatment secondary to trauma is covered by ACC
In circumstances where teeth are damaged in an accident, the cost of treatment for all age groups is usually covered in part by ACC.

The status of oral health in New Zealand

Oral health in New Zealand has improved in general over the last few decades, mainly attributed to the introduction of fluoride toothpaste and the fluoridation of the water supply in some areas.4 However, significant inequalities remain for some groups. The state of oral health varies widely with age, ethnicity, socio-economic status and access to fluoridated water.5

Child oral health statistics in New Zealand are worse than countries with similar oral health systems such as Australia and the United Kingdom.5 In New Zealand until the early 1990s, dental caries rates among children were declining. However in recent years these rates have become static or even slightly increased.6 Figure 1 shows the percentage of five year old children that are free of tooth decay, clearly demonstrating ethnic inequalities.

Primary health care has an important role in improving oral health.

“The vision is for an environment that promotes oral health, whether through fluoridated water, a healthy diet or publicly funded services staffed by a multidisciplinary workforce that actively addresses the needs of those at greatest risk of poor oral health. In this future, oral health is recognised as an important part of general good health. Links between oral health services and other health care ensure that oral health is promoted, improved, maintained and, where necessary, restored at the earliest opportunity.”

 – Ministry of Health5

Oral health inequalities in New Zealand

5 Year Old % Caries Free by Ethnicity, 2007
    64 59 35 22 29 27
  European/Other Māori Pacific Island
Fluridated  Living in an area with a fluoridated water
Non-fluridated  Living in an area with a non-fluoridated water
Figure 1: % five-year-old children in New Zealand caries free by ethnicity (School dental service data. Ministry of Health, 2009).9

Good oral health relies on success in four important areas – enrolment, attendance, good oral health behaviour and treatment. Significant inequalities have been identified amongst children in New Zealand. Higher rates of decayed, missing and filled teeth are found amongst Māori and Pacific children, those in low socio-economic groups and children living in rural areas.4,7,8 There are many reasons for these inequalities including;

  • Access to and delivery of dental care services
  • Availability of a fluoridated water scheme
  • Socio-economic status
  • Transient population
  • Cultural barriers

Access to and delivery of dental care services

Māori and Pacific children in particular have low rates of enrolment in the School Dental Service.4 If children can be enrolled early it provides a good opportunity, not only to detect early tooth decay but also to educate whanau about good practices and behaviours, that promote oral health. Once children are at primary school, the majority are enrolled but use of the service declines in adolescence.9

Dental therapists are no longer permanently based at every school, therefore access is reliant on ability to contact the service, transport and parental responsibility. In many areas community based clinics or mobile services have been developed to overcome these barriers. These clinics may operate from a non-traditional setting e.g. marae, work place or recreational venue.1

Availability of a fluoridated water scheme

More than half New Zealand’s population lives in areas that have fluoridated community water supplies, a factor known to improve dental health. The remainder live either in areas with non-fluoridated water supplies or areas reliant on rainwater. Water fluoridation has been shown to reduce dental caries by up to 50%. It is also effective in reducing socio-economic and ethnic disparities in dental caries.10

Socio-economic status

Socio-economic factors can have a major impact on oral health. Costs can limit access to services. Families on tight budgets with competing priorities may struggle to provide a good healthy diet (e.g. cost of soft drink vs. milk). They may also have limited resources to cover other costs such as toothbrushes, fluoridated toothpaste and dental floss.

Transient population

Māori and Pacific families are more likely to be transient and therefore are more likely to miss appointments for ongoing dental care and less likely to re-enrol in each new area.7

Cultural barriers

As the majority of oral health workers are non-Māori and non-Pacific, this may contribute to cultural barriers. There are a number of Māori oral health services operating in New Zealand (see below). Māori providers have adopted a whanau ora approach and have been very effective in improving Māori oral health where they operate.8 Barriers such as language, negative attitudes from whanau towards dental treatment and differing beliefs about dental care itself, can also contribute to poor oral health.

Māori health providers

Māori health providers currently operate successful community based oral health care services throughout New Zealand. An example is Te Manu Toroa.

Te Manu Toroa provides a Kaupapa Māori model of health care for Māori in the Tauranga and Te Puke areas. Te Manu Toroa provides dental health services for Māori children and also Māori mothers (under 18) who attend the Bay of Plenty Polytechnic. The most recent addition to the dental service, was the acquisition of a fully equipped mobile dental facility, which allows Te Manu Toroa to have onsite access to the majority of its patients.

For provision of services the following two significant barriers needed to be addressed:

  1. Changing Māori attitudes and beliefs about dental health services

Māori views on dental health services were traditionally reactionary: “If you had a bad enough tooth ache, pull it out. If you pull one out, pull them all out so you don’t have to come back again”. The cost of accessing a dentist was also an issue, hence the simple rationale that no teeth meant no ongoing costs.

Te Manu Toroa provides a proactive whanau ora approach. A caregiver is required to accompany their tamariki (children) and rangatahi (teenagers) to the dental service. This approach has not diminished the levels of access. The message is stressed to whanau that the service is free until a child turns 18. Simple interventions will, save money in the future.

There is a significant difference in attendance at the clinic between primary school (99%) and secondary school (55%) students. Lack of motivation of rangatahi to attend the dental service appears to stem from teenage culture rather than Māori culture. The goal of Te Manu Toroa is to increase attendance amongst rangatahi.

  1. Developing a good working relationship between the providers of primary health care and dental health services

Te Manu Toroa have worked to develop a collaborative professional approach to the provision of health services with local primary care. Patients have benefited through improved access to oral health care.

To find out who the Māori health providers are in your area, contact your local DHB.

Acknowledgement:
Thank you to Associate Professor John Broughton, Ngai Tahu, Ngati Kahungunu, Director Ngai Tahu Māori Health Research Unit, Dunedin School of Medicine, University of Otago, for guidance in this article.

References:

  1. Mansour M, Cox S. Patients presenting to the general practitioner with pain of dental origin. Med J Aust 2006;185(2):64-7.
  2. Lockhart P, Mason D, Konen J, et al. Prevalence and nature of orofacial and dental problems in family medicine. Arch Fam Med 2000;9:1109-12.
  3. Bell G, Smith G, Rodgers J, et al. Patient choice of primary care practitioner for orofacial symptoms. Br Dent J 2008;204:669-73.
  4. Ministry of Health. Good oral health for all, for life: The strategic vision for oral health in New Zealand. Wellington: Ministry of Health. August 2006.
  5. Ministry of Health. Oral health in New Zealand. Available from www.beehive.govt.nz (Accessed May 2009).
  6. Craig E, Anderson P, Jackson C. The health status of children and young people in Canterbury. Report for the Canterbury DHB. November 2008.
  7. DHBNZ. National School Dental Service Review: Final Report, December 2004. Ministry of Health. Wellington. 2006.
  8. Mauri Ora Associates. Review of Māori child oral health services. Report to the Ministry of Health. Mauri Ora Associates. Auckland. 2004.
  9. Ministry of Health. Age 5 and Year 8 oral health data from the School Dental Service 1990 – 2007. Ministry of Health, Wellington. Available from www.moh.govt.nz/oralhealth (Accessed June 2009).
  10. Thomson W, Ayers K, Broughton J. Child health inequalities in New Zealand: A background paper to the Public Health Advisory Committee. National Health Committee. Wellington. 2003.
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