Were NZ's structural changes to the welfare state in the early 1990s associated with a measurable increase in oral health inequalities among children?

Can the sustainable development goal 9 support an untreated early childhood caries elimination agenda?

BACKGROUND

Early childhood caries (ECC) is a global public health challenge that requires innovation, infrastructure, and health system influences to bolster initiatives for its management and control. The aim of this scoping review was to investigate the published evidence on the association between ECC and the targets of the Sustainable Development Goal 9 (SDG9) concerned with industry, innovation, and infrastructure development.

METHODS

The scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A search was conducted in PubMed, Web of Science, and Scopus between July and August 2023 using a search strategy related to the promotion of resilient infrastructure, sustainable industries, scientific research and innovation, access to the internet and ECC. Only English language publications were included. Studies that solely examined ECC without reference to the SDG9 targets were excluded.

RESULTS

The search yielded 933 studies for review. After screening for the eligibility and removing duplicates, 916 unique articles remained for further screening. However, none of the identified studies provided data on the association between resilient infrastructure, sustainable industries, scientific research and innovation, access to the internet and ECC.

CONCLUSION

There were no primary studies that assessed the association between ECC and SDG9, even though the plausibility of a potential relationship exists. Future studies are needed to generate evidence on the link between ECC and SDG9 as this link may contribute to the reduction in the proportion of children with untreated ECC.

The Impact of Socio-Environmental, Individual, and Biological Factors on Oral Health-Related Quality of Life among Preschool Children: A Cohort Study with 3-Year Follow-Up

This study assessed impact of socio-environmental, individual, and biological factors on the worsening and severe worsening of oral health-related quality of life (OHRQoL) among preschoolers and their families. A cohort study was conducted in Diamantina, Brazil, with 151 children between 1 and 3 years of age and their mothers, who were evaluated at baseline (2014) and re-evaluated after 3 years (2017). The children were clinically examined to assess the presence of dental caries, malocclusion, dental trauma, and enamel defects. The mothers answered the Early Childhood Oral Health Impact Scale (B-ECOHIS) and a questionnaire addressing individual characteristics of the child and socio-environmental factors. Extensive caries found in the follow-up (relative risk [RR] = 1.91; 95% confidence interval [CI] = 1.26-2.91) and failure to undergo the dental treatment recommended at baseline (RR = 2.49; 95% CI = 1.62-3.81) were associated with worsening of OHRQoL over 3 years. An increase in the number of children in the household (RR = 2.95; 95% CI = 1.06-8.25), occurrence of extensive caries in the follow-up (RR = 2.06; 95% CI = 1.05-4.07), and failure to undergo the dental treatment recommended at baseline (RR = 3.68; 95% CI = 1.96-6.89) were associated with a severe worsening of OHRQoL. In conclusion, the risk of worsening and severe worsening of OHRQoL was higher in preschoolers with extensive caries at follow-up and among those who did not undergo dental treatment. Furthermore, severe worsening of OHRQoL was also impacted by an increase in the number of children in the household.

Inequalities in dental caries experience among 4-year-old New Zealand children

OBJECTIVES

To investigate ethnic-specific deprivation gradients in early childhood dental caries experience considering different domains of deprivation.

METHODS

We used cross-sectional near whole population-level data on 318 321 four-year-olds attending the "B4 School check," a national health and development check in New Zealand, across 6 fiscal years (2010/2011 to 2015/2016). The "lift the lip" screening tool was used to estimate experience of any caries and severe caries. We investigated deprivation gradients using the Index of Multiple Deprivation (IMD), which measures seven domains of deprivation across 5958 geographical areas ("data zones"). Ethnicity was categorized into five groups: (i) Māori, (ii) Pacific, (iii) Asian, (iv) Middle Eastern, Latin American and African (MELAA) and (v) European & Other (combined). We used a random intercepts model to estimate mutually adjusted associations between deprivation, ethnicity, age, fiscal year, and evidence of any dental caries experience.

RESULTS

Reports of any caries experience decreased from 15.8% (95% CI: 15.7; 15.9%) to 14.7% 95% CI: 14.4; 14.8%), while reports of severe caries experience increased from 3.0% (95% CI: 3.0; 3.1%) to 4.4% (95% CI: 4.3; 4.5%) from 2010/2011 to 2015/2016. This varied by ethnicity with larger increases in severe caries for Pacific children from 7.1% (95% CI: 6.8; 7.4%) to 14.1% (95% CI: 13.7; 14.5%). There were deprivation gradients in dental caries experience with considerable variation by ethnicity and by domain of deprivation. The association between deprivation and dental caries experience was weakest for Asian children and was most pronounced for Pacific and Māori children.

CONCLUSION

Socioeconomic gradients in dental caries experience are evident by age 4 years, and these gradients vary by ethnicity and domain of deprivation.

New Zealand's School Dental Service over the Decades: Its Response to Social, Political, and Economic Influences, and the Effect on Oral Health Inequalities

New Zealand’s School Dental Service (SDS) was founded in 1921, partly as a response to the “appalling” state of children’s teeth, but also at a time when social policy became centered on children’s health and welfare. Referring to the Commission on Social Determinants of Health (CSDH) conceptual framework, this review reflects upon how SDS policy evolved in response to contemporary constraints, challenges, and opportunities and, in turn, affected oral health. Although the SDS played a crucial role in improving oral health for New Zealanders overall and, in particular, children, challenges in addressing oral health inequalities remain to this day.

Supported by New Zealand’s Welfare State policies, the SDS expanded over several decades. Economic depression, war, and the “baby boom” affected its growth to some extent but, by 1976, all primary-aged children and most preschoolers were under its care. Despite SDS care, and the introduction of water fluoridation in the 1950s, oral health surveys in the 1970s observed that New Zealand children had heavily-filled teeth, and that adults lost their teeth early. Changes to SDS preventive and restorative practices reduced the average number of fillings per child by the early 1980s, but statistics then revealed substantial inequalities in child oral health, with Ma¯ ori and Pacific Island children faring worse than other children.

In the 1990s, New Zealand underwent a series of major structural “reforms,” including changes to the health system and a degree of withdrawal of the Welfare State. As a result, children’s oral health deteriorated and inequalities not only persisted but also widened. By the beginning of the new millennium, reviews of the SDS noted that, as well as worsening oral health, equipment and facilities were run-down and the workforce was aging. In 2006, the New Zealand Government invested in a “reorientation” of the SDS to a Community Oral Health Service (COHS), focusing on prevention. Ten years on, initial evaluations of the COHS appear to be mostly positive, but oral health inequalities persevere. Innovative strategies at COHS level may improve oral health but inequalities will only be overcome by the implementation of policies that address the wider social determinants of health.

Oral Health-related Beliefs, Behaviors, and Outcomes through the Life Course

Complex associations exist among socioeconomic status (SES) in early life, beliefs about oral health care (held by individuals and their parents), and oral health-related behaviors. The pathways to poor adult oral health are difficult to model and describe, especially due to a lack of longitudinal data. The study aim was to explore possible pathways of oral health from birth to adulthood (age 38 y). We hypothesized that higher socioeconomic position in childhood would predict favorable oral health beliefs in adolescence and early adulthood, which in turn would predict favorable self-care and dental attendance behaviors; those would lead to lower dental caries experience and better self-reported oral health by age 38 y. A generalized structural equation modeling approach was used to investigate the relationship among oral health-related beliefs, behaviors in early adulthood, and dental health outcomes and quality of life in adulthood (age, 38 y), based on longitudinal data from a population-based birth cohort. The current investigation utilized prospectively collected data on early (up to 15 y) and adult (26 and 32 y) SES, oral health-related beliefs (15, 26, and 32 y), self-care behaviors (15, 28, and 32 y), oral health outcomes (e.g., number of carious and missing tooth surfaces), and oral health-related quality of life (38 y). Early SES and parental oral health-related beliefs were associated with the study members' oral health-related beliefs, which in turn predicted toothbrushing and dental service use. Toothbrushing and dental service use were associated with the number of untreated carious and missing tooth surfaces in adulthood. The number of untreated carious and missing tooth surfaces were associated with oral health-related quality of life. Oral health toward the end of the fourth decade of life is associated with intergenerational factors and various aspects of people's beliefs, SES, dental attendance, and self-care operating since the childhood years.

Prevalence and risk factors of caregiver reported Severe Early Childhood Caries in Manitoba First Nations children: results from the RHS Phase 2 (2008-2010)

OBJECTIVES

The high prevalence and severity of caries among Canadian First Nations children is a growing concern. Dental surgery in hospital is often necessary to treat the signs of decay but does not address the underlying factors contributing to its development. The purpose of this study was to determine the prevalence and risk factors of caregiver-reported Baby Bottle Tooth Decay (BBTD), or Severe Early Childhood Caries (S-ECC), among preschool children recruited in Phase 2 of the First Nations Regional Longitudinal Health Survey (RHS).

STUDY DESIGN

Cross-sectional study including interviews with caregivers.

METHODS

This study was limited to data from Manitoba First Nations participating in the RHS Phase 2 (2008-10). Data were restricted to caregiver interviews for their child < 72 months of age. The main variable of interest was caregiver-reported BBTD, an antecedent term for S-ECC. Data analysis included descriptive statistics and bivariate analyses; p ≤ 0.05 was significant.

RESULTS

Overall, caregivers of 431 preschool children responded. According to caregiver reports, 102/410 (24.9%) children had S-ECC. Further, 65.0% responded that their child had already undergone treatment for caries. Children with S-ECC were significantly older than those without. S-ECC was also associated with paternal education levels and employment status, and maternal smoking during pregnancy. Breastfed children were less likely to have S-ECC, while consuming drink crystal beverages in bottles, and daily intake of soft drinks, juice, sweets and fast food were associated with increased risk. Those who reported that healthcare services were not available and were not culturally appropriate were significantly more likely to have children with S-ECC.

CONCLUSIONS

Caregiver reports suggest that nearly 1 in every 4 children has been affected by S-ECC. Identified risk factors for Manitoba First Nations children included age, education and employment, dietary practices, access to care, and disruption to family and culture. This local evidence can be used to help inform future caries prevention activities in these Manitoba communities.

General Dental Practitioners’ Views on Early Childhood Caries and Timing of the First Dental Visit in Selangor, Malaysia

This survey evaluated the knowledge, attitudes, and practices of general dental practitioners (GDPs) in Selangor regarding early childhood caries (ECC) prevention and the recommended timing of a child’s first dental visit. A questionnaire was mailed to 521 licensed GDPs. Descriptive statistics were used, and bivariate and logistic regression analyses were performed. The response rate was 52.6%. Although 89.8% mentioned counseling parents and caregivers, only 44.2% were familiar with anticipatory guidance. Whereas 98.2% agreed that early examinations are important to prevent ECC, only 51.8% were aware of the recommendation for a first visit by 12 months of age. GDPs who recommended early dental visits were significantly more likely to be recent graduates, more familiar with professional guidelines, and less likely to be deterred by a child’s crying or behavior. In conclusion, GDPs in Selangor are aware about the importance of early dental visits in ECC prevention. However, a considerable number of them are still not aware of the recommendation that children must first visit the dentist by 12 months of age. Furthermore, some of their current practices in ECC management and prevention do not match professional recommendations.

Maternal self-report of oral health in six-year-old Pacific children from South Auckland, New Zealand

OBJECTIVE

To examine maternal and socio-demographic factors associated with oral health practices and experiences in six-year-old Pacific children.

METHODS

The longitudinal Pacific Islands Families (PIF) study is following a cohort of Pacific children born in Auckland, New Zealand in 2000. At approximately six years postpartum maternal reports (n = 1001) on child oral health practices and experiences of fillings and extractions were gathered.

RESULTS

Forty-five per cent of mothers reported that their child had experienced fillings or extractions. After adjusting for confounding factors, we found that Tongan children were almost twice as likely to have their teeth filled or extracted than Samoan children (OR, 1.93; 95%, 1.34-2.77). Differences between Samoan children and children of other ethnic groups were not significant. Children of mothers who had secondary qualifications were significantly less likely to have their teeth filled or extracted compared to children of mothers who had postsecondary qualifications (OR, 0.634; 95%, 0.44-0.90). Prolonged duration of breastfeeding was associated with an increased likelihood of filling or extraction experience. In terms of maternal oral hygiene, maternal tooth brushing frequency of less that once a day was significantly associated with increased odds of fillings and/or extractions in their children (OR, 1.35; 95% CI, 1.02-1.79). Children who were sometimes supervised for tooth brushing were significantly more likely to have fillings or extractions than children who were not provided supervision.

CONCLUSIONS

These findings highlight the role of cultural factors and maternal hygiene in child oral health outcomes and suggest that health promotion efforts should encompass the whole family and embrace a culturally appropriate approach.

The oral health of Indigenous children: a review of four nations

This review of the oral health of children in Australia, New Zealand, Canada and the USA demonstrates that significant oral health inequalities exist in each nation. Despite traditionally low levels of disease in Indigenous communities, dental caries is now highly prevalent and of increased severity among Indigenous children in comparison to their non-Indigenous counterparts. Early childhood caries is particularly prevalent. The high level of dental disease experience at an early age is associated with increased rates of general anaesthesia and greater risk of dental caries in later life. The rates and severity of dental caries experienced by young Indigenous children are even more alarming when we consider that dental caries is essentially a preventable disease. The success of specific preventive programmes is encouraging; these approaches should be further evaluated and implemented as part of broader health promotion programmes for Indigenous children and families in order to decrease current oral health disparities.

Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being

Dental caries in Indigenous children is a child health issue that is multifactorial in origin and strongly influenced by the determinants of health. The evidence suggests that extensive dental caries has an effect on health and well-being of the young child. This article focuses on early childhood caries as an overall proxy for Indigenous childhood oral health because decay during early life sets the foundation for oral health throughout childhood and adolescence. Strategies should begin with community engagement and always include primary care providers and other community health workers.

Social Inequality: Social inequality in perceived oral health among adults in Australia

OBJECTIVE

To establish population estimates of self-assessed tooth loss and subjective oral health and describe the social distribution of these measures among dentate adults in Australia.

METHODS

Self-report data were obtained from a nationally representative sample of 3,678 adults aged 18-91 years who participated in the 1999 National Dental Telephone Interview Survey and completed a subsequent mail survey. Oral health was evaluated using (1) self-assessed tooth loss, (2) the 14-item Oral Health Impact Profile, and (3) a global six-point rating of oral health.

RESULTS

While the absolute difference in tooth loss across household income levels increased at each successive age group (18-44 years, 45-64 years, 65+ years) from 0.7 teeth to 6.1 teeth, the magnitude of the difference was approximately twofold at each age group. For subjective oral health measures, the magnitude of difference across income groups was most pronounced in the 18-44 years age group. In multivariate analysis, low household income, blue-collar occupation, and high residential area disadvantage were positively associated with social impact from oral conditions and pathological tooth loss. Speaking other than English at home (relative to English), low household income (relative to high income), and vocational relative to tertiary education were each associated with more than twice the odds of poor self-rated oral health.

CONCLUSIONS

Significant social differentials in perceived oral health exist among dentate adults. Inequalities span the socio-economic hierarchy.

IMPLICATIONS

In addition to improving overall levels of oral health in the adult community, goals and targets should aim to reduce social inequalities in the distribution of outcomes.

Maternal self-report of oral health in 4-year-old Pacific children from South Auckland, New Zealand: findings from the Pacific Islands Families Study

OBJECTIVES

To report on the oral health risk in a disadvantaged group of 4-year-old Pacific children and their mothers living in South Auckland, New Zealand.

METHODS

The Pacific Islands Families study follows a cohort of Pacific infants born in 2000. Maternal self-report of mother and child's oral health practices and child's filling and extraction experience was undertaken at interview approximately 4 years postpartum.

RESULTS

Overall, 1,048 mothers of children were interviewed. Children's reported oral health practices were generally poor, with 47 percent brushing < or =1/day, 47 percent having no adult assistance with brushing, 57 percent routinely snacking or drinking immediately prior to bed, and 26 percent yet to receive their first dental checkup. Maternal practices were also poor, with 34 percent brushing < or =1/day and 50 percent having never seen or last visiting a dentist over 5 years ago. Significant differences were seen in many practices between the major ethnic subgroups. Of children attending the school dental service, 22 percent were reported having at least one filling and/or extraction. In multivariable analyses, variables corresponding to mother's toothbrushing frequency, child snacking or drinking prior to bed, and duration of breastfeeding were significantly associated with reported filling and/or extraction experience; but no difference was seen between the three major maternal ethnic subgroups.

CONCLUSIONS

Many mothers and their Pacific children have poor basic oral hygiene and dietary practices that increase the oral health risk in these children. Culturally appropriate and targeted strategies aimed at these modifiable practices need to be widely promoted so that the oral health burden carried by Pacific children can be reduced.

Adult Oral Health Inequalities Described Using Area-based and Household-based Socioeconomic Status Measures

OBJECTIVES

To describe adult oral health inequalities using an area-based and household-based measure of socioeconomic status (SES).

METHODS

Self-report questionnaires (seeking information on sociodemographic, oral health and oral self-care) were sent to a random sample of adults from the Dunedin South Electorate, New Zealand. Household- and area-based SES measures were collected. The main outcome measures were edentulism prevalence, average-poor self-rated oral health and not having visited a dentist for 2+ years. Data were weighted to produce population-based estimates.

RESULTS

The response rate was 78.2%; the sample mean age was 47 years (sd, 17; range 18-92 years) and females comprised 54.0%. Edentulism was most prevalent among those from low-SES households who were resident in high-deprivation areas (P<0.0001). Poor self-rated oral health (P<0.0001) and 2+ years since the last dental visit (P<0.0001) were also most prevalent among these same individuals. In contrast, respondents from high-SES households located in the least deprived areas had the lowest prevalence of edentulism, poor self-reported oral health or 2+ years since their last dental visit. Those from the other household/area SES combinations occupied intermediate positions.

CONCLUSIONS

There may be added value to dental public health in using a dual socio-economic measurement approach to population research, with greater oral health gains perhaps being possible by concentrating resources and clinical effort on people living in low-SES households in highly-deprived areas, rather than those living in low-SES households in areas that are not deprived.

The burden of oral ill health for children

This paper aims to draw attention to the common oral and dental diseases and conditions in childhood in the context of aetiological factors and to highlight how many of the risk factors for oral and dental ill health are common to other areas of chronic diseases among this age group: diet, hygiene, trauma, stress, and in older children and adolescents, smoking, alcohol use, and use of illegal substances. Suggestions as to how to address these common risk factors are proposed.