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Children's oral health

posted 20 Jan 2013, 23:43 by Fiona Cram   [ updated 18 Feb 2016, 23:10 ]

A news article yesterday decried the poor oral health of many toddlers and children. A lot of responsibility (read: blame) for children's tooth decay is put at the feet of parents who are described as seemingly resistant to messages about the problems sugar, snacking, and poor oral hygiene. Māori and Pasifika children suffer more, and while the Ministry of Health endorses fluoridation as an effective public health intervention to reduce this disparity we continue to debate whether or not it should be in our water supply.

The article got me thinking about the work I've done in oral health and how much an understanding of history can inform our view of exactly what the problem is. It's easy to highlight the simplicity of an issue when newspaper space is limited. An easy problem will also require only an easy solution. It's more difficult, and lengthy, to provide a fuller, more complicated exploration of an issue. Such an exploration will undoubtedly reveal that many so-called simple problems (e.g., blame the parents) are in fact more 'wicked' and, as such, in need of complex, multilayered solutions. There may be no quick fixes.

While not wanting to go into all the detail about Māori child oral health disparities, I offer here a short history of the school dental service that may illuminate some more 'complicated' details of the 'problem'.

The school dental service began in 1921 after a survey of New Zealand children’s teeth showed that the majority required dental care. Under the supervision of Sir Thomas Hunter the responsibility for this care was handed over to school dental nurses who received two years, salaried training, and entered the workforce in 1923. Part of the explanation for this solution rested with the country’s geography and demography (with the majority of the population living in small, rural towns) (Welshman, 2000).

An initial move to enlist trained nurses into this scheme did not meet with the approval of the Nurses’ Association as all nurses were needed in nursing. McLean (1932, p.25) writes that

"The dental care, which could almost equally well be done by girls with two years’ training, would be a waste of economic value and a depreciation of their own qualifications if undertaken by trained nurses."

The scheme was not supported by the Dental Association as the women were not qualified as dentists (McLean, 1932). Puder (1970, p.1263) concluded that this opposition subsided as the scheme was implemented and "gradually there was growing approval" as children treated by the school dental service later became the ‘cooperative patients’ of private dentists.

"Dental nurses were more popular than dentists - women were seen as "temperamentally and psychologically" more suited to deal with children - and the nation's imagination had already been captured by the introduction of the Plunket Nurse" (Puke Ariki, nd).

School dental nurses were employed by the government and could not practice outside the school dental service. As well as performing "routine phases of children's dentistry" they were also responsible for oral health education. Practice supervision by the dental nurse inspector and the senior dental officer was ‘very rigid’ (Puder, 1970, p.1260). Children were enrolled in the school dental service from two-and-a-half to 13 1/2 years of age, and seen by the dental nurse every six months (Puder, 1970).

It could be argued that children received a lower standard of oral health care because of gender issues. Although the oral health care of children should have been the province of what was then a male dentist profession, it was instead decided to train and employ women because it was felt that they managed children better than men did. Rather than training these women as dentists, they were given a shorter training that would see them providing a far more limited service. And then they were called ‘nurses’ rather than, say, ‘dental assistants’ which some, such as Hester McLean (1932), would have preferred. According to key informants this initiative also resulted in a ‘silo-ing’ of oral health care delivery, and a focus on a restorative model of dentistry rather than on prevention.

The establishment of the School Dental Service (SDS) was based on a simple view that children just needed basic care. The social determinants of health, for example, were not considered when this model of care was designed; thus the service was set up to fail those at high risk of poor oral health, especially Māori communities. In addition, not much known at the time about child psychology or the development of the mouth; there was no such discipline as paediatric dentistry.

Based on his 1950 study of school children Fulton (cited in Welshman, 2000) argued that "New Zealand’s public dental programme has gained a large measure of success in controlling the effects of dental caries in schoolchildren'" Even so, at the same time Wynne (cited in Welshman, 2000) noted that in the United Kingdom dentists would have carried out the majority of the work of dental nurses.

In 1995 attendees at the AGM of the New Zealand Dental Nurses Institute voted for a name change for both the profession, to Dental Therapy, and the organisation, to the New Zealand Dental Therapists Association.[1] This came at a time when many of the dental nurse training institutes were being closed, working conditions were being undermined, and school dental clinics and equipment were not being adequately maintained (DTTAG, 2004).

The review of the School Dental Service, some 80 years after it was first initiated, found that barriers to Māori accessing this free service meant that this resource was unevenly distributed in the community, with the children of upper socioeconomic families having differential access (DHBNZ, 2006). The recommendations of the SDS review included the provision of information about the programme and increasing the Māori workforce.

References

Dental Therapy Technical Advisory Group (2004). Recruitmentand practice of dental therapists. Wellington: Ministry of Health.

DHBNZ (2006). DHBNZ National School DentalService review. Final report, December 2004. Wellington: Ministry of Health.

McLean, H. (1932). Nursing in New Zealand: History and reminiscences. Tolan Printing Company.

Puder, E.E. (1970). The New Zealand Dental Nurse. American Journal of Public Health, 60, 1259-1263.

Puke Ariki. (nd). Open wide – dental nursing history. 

Welshman, J. (2000). The dental auxiliary: A historical perspective. Paper given at Congrès IAHD 2000.


[1] This followed on from a name change to ‘dental therapist’ in 1988.


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