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
- 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
- There may be a lack of co-ordinated after hours dental care, or this care may exist, but patients may not be aware
- 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.
How can GPs help improve oral health?
There are three easy actions to take which will improve the oral health of patients.
- Ask about oral health
- Examine the teeth and gums
- 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).
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
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:
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.
See here for management of common oral health conditions seen in general practice.
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 ( 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
- 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
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.
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
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
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
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 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.
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
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:
- 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.
- 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.
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.
- Mansour M, Cox S. Patients presenting to the general practitioner with pain of dental origin. Med J Aust 2006;185(2):64-7.
- 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.
- Bell G, Smith G, Rodgers J, et al. Patient choice of primary care practitioner for orofacial symptoms. Br Dent J
- 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.
- Ministry of Health. Oral health in New Zealand. Available from www.beehive.govt.nz (Accessed
- Craig E, Anderson P, Jackson C. The health status of children and young people in Canterbury. Report for the Canterbury
DHB. November 2008.
- DHBNZ. National School Dental Service Review: Final Report, December 2004. Ministry of Health. Wellington. 2006.
- Mauri Ora Associates. Review of Māori child oral health services. Report to the Ministry of Health. Mauri Ora
Associates. Auckland. 2004.
- 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
- 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.
He mate niho ka kitea e te Rata - Management of common oral health problems seen in general practice
Ka kata a Kae – Kae laughs.
This is from the story of Tinirau and Kae, where Kae eats Tinirau’s pet whale. Tinirau sends some women to
exact revenge. In order to identify Kae, they have to make him laugh to see his crooked teeth.
Patients may present to their GP with oral health problems. When necessary, treatment may need to be initiated followed
by appropriate referral to a dental service. Good oral health behaviours should be emphasised (see here).
Poor oral hygiene and gum disease
Halitosis or bad breath can indicate a number of oral health and general medical conditions. Check
the mouth (teeth, gums and tongue) for an obvious dental cause such as bacterial buildup on the tongue and consider other
factors such as diet. Some medical conditions associated with halitosis include sinus infection (post nasal drip), tonsillitis,
respiratory infection, diabetes and oral cancers.
|Figure 1: Gingivitis in a child. Note the redness around the gingival margin of the upper incisor teeth. (Source:
Gingivitis is localised inflammation of the gums (Figure 1). Symptoms include swollen bleeding gums
with brushing or flossing, erythema and halitosis but not usually pain.1 For treatment and prevention, good
oral hygiene should be followed. Appropriate use of an antiseptic mouth wash such as chlorhexidine gluconate 0.2% (Orion
brand fully subsidised) may also assist (see here for appropriate
use). If applicable, smoking cessation should be advised.
Periodontitis is the loss of supportive bone structure around the root of the teeth caused by chronic
gingivitis.1 Symptoms include receding gums that bleed easily on contact and subgingival dental plaque. Referral
for mechanical debridement and ongoing dental care is required. Periodontal disease is rarely a feature of systemic disease.
Pericoronitis is an acute localised infection under the gum flaps of a partially erupted tooth or impacted
tooth. This most commonly affects the wisdom teeth.1 Initial treatment is irrigation of the area to remove
debris (e.g. trapped food particles), chlorhexidine mouthwash and adequate analgesia. If the infection involves the wisdom
teeth bilaterally and the swelling is marked, there can be airway compromise, requiring urgent hospital referral. If there
is significant swelling or evidence of cellulitis or systemic disease, amoxycillin (500 mg three times per day, for five
days) or metronidazole (400 mg three times per day, for five days), may be prescribed.
Kawakawa for dental pain
Kawakawa (Macropiper excelsum, Māori Pepper Tree) is a traditional Rongoa Māori treatment used for toothache.
The leaves, which have a spicy taste, are chewed and retained in the mouth, while the saliva is swallowed.
Kawakawa is related to the black pepper tree and kava. The leaves contain the essential oil myristicin, which is
also the predominant psychoactive ingredient in nutmeg, although kawakawa is not used for psychotropic purposes.
There have been no scientific studies on the biological activity or toxicology of kawakawa, however no adverse effects
or interactions have been recorded.
Dental caries is a disease caused by bacteria which damage hard tooth structure (also known as tooth
decay or cavity). It is asymptomatic in the initial stages. If left untreated, the patient will usually start to notice
temperature sensitivity and mild pain. Preventative education and dental treatment is required.
Sensitive teeth may be caused by periodontal disease, caries, trauma, toothbrush abrasion, erosion
or attrition, age, smoking and medical conditions (e.g. radiation therapy). Patients often experience acute localised
pain while eating and drinking cold foods/liquids. Toothpastes specially formulated for sensitive teeth can be used. Several
applications may be required before sensitivity is reduced. Dentists can also apply desensitising agents. It is also important
to eliminate any possible etiological disease.
Medical problems associated with oral health problems
- Dry mouth (xerostomia) – e.g. from Sjögren’s syndrome or from adverse effects of medication, head
and neck radiotherapy
- Gingival hyperplasia (hypertrophic gums) can be an adverse effect of calcium channel blockers or cyclosporin and
some antiepileptic medications.
Other causes of “dental” pain
- Trigeminal neuralgia
- Herpetic neuralgia
- Referred pain from tempo-mandibular joints
- Salivary gland disorders
- Jaw pain referred from mycocardial tissue or temporal arteritis
- Neoplasia e.g. breast secondaries in jaw
- Oral cancers
- Poor nutrition
- Mental health problems, visual impairment or lack of knowledge leading to poor oral hygiene and inadequate diet
- Parkinson’s disease leading to difficulties with chewing and dental hygiene
- Eating disorders e.g. Bulimia – associated with erosion of tooth enamel particularly of the palatal (roof
of mouth) surface of upper teeth
- Poorly controlled diabetes may result in oral health problems
- Osteonecrosis of the jaw related to bisphosphonate therapy
Dental infection or abscess
|Figure 2: Treatment for buccal abscess in a child, requiring general anaesthesia. Note the raised swelling buccal
to the lower right first primary molar. This child was four years old and had a total of ten teeth restored or extracted.
When small children have large amounts of work required, a general anaesthetic can be necessary. (Source: D. Boyd)
All people with dental abscess require referral for further dental care such as root canal treatment or extraction (Figure
2). Treatment of acute symptoms can be managed in general practice.
If pain is significant, prescribe adequate and regular analgesia – begin with paracetamol or ibuprofen which can
be taken together if pain relief, with either alone, is insufficient. If pain relief is still not adequate, add codeine.
Patients can be advised to consume cool, soft foods.
If there are signs of severe infection (cellulitis, diffuse, tense, painful swelling of the infected tissues) or the
patient is systemically unwell, prescribe amoxycillin (500 mg three times per day, for five days) or metronidazole (400
mg three times per day, for five days).2,3
If the patient has severe cellulitis, they may require hospital admission for intravenous antibiotics and fluids, or
emergency referral if swelling poses a serious risk to general health (e.g. a compromised airway). In rare cases, cavernous
sinus thrombosis may be a late complication of dental abscess or infection.
If there is marked swelling, the patient is in extreme discomfort or if dental care is not able to be accessed straight
away (e.g. over a weekend), the abscess may be lanced and drained, using topical anaesthesia (or freezing with ethyl chloride
spray). Incisions usually epithelialise rapidly, causing the abscess to fill with pus again, so it is important to follow-up
with a hot, salty mouthwash to encourage continued drainage.
Toothache without abscess
Pulpitis is inflammation of the dental pulp. This usually arises from caries but can be caused by dental erosion or
trauma. In the early stages pulpitis can be reversible after appropriate dental treatment (removal of carious tissue or
protection of the pulp and restoration). The pain is usually moderate and the episode that results in the patient presenting
for care may be preceded by other less acute episodes, pain on chewing and temperature sensitivity. If the inflammation
continues without appropriate dental treatment, the pulp can be irreversibly damaged and root canal therapy or extraction
may be required. The pain of irreversible pulpitis becomes severe, spontaneous, and persistent and often poorly localised.
Prescribe adequate analgesia (see previous) and refer for dental care. Antibiotics are not indicated in the absence of
Trauma to teeth
Trauma causing tooth loss is common, especially in children and can result in fracture of teeth (or jaw), tooth
loosening or tooth loss (avulsion). All patients with tooth trauma require dental referral and radiography.2 Tetanus
injection may be required in some circumstances. Prophylactic antibiotics (amoxycillin) are only required in some cases
of tooth avulsion.
Ensure that ACC information is completed. In the case of non-accidental trauma, injuries need to be appropriately documented
and history recorded (see box below). Injuries to primary teeth may cause damage to permanent successor teeth.
|Figure 3: X-ray showing the relationship of the permanent teeth to the primary teeth. This demonstrates how trauma
to primary teeth can cause damage to permanent teeth. (Source: D. Boyd)
Treatment of an avulsed tooth2,4
The preferred emergency treatment of an avulsed permanent tooth is immediate re-implantation, ideally within
five minutes (and up to 15 minutes). If rinsing is needed, use normal saline and also flush out any clot from the socket
before the tooth is re-implanted. Touching, rubbing or cleaning of the root should be avoided as this reduces the likelihood
of successful re-implantation. Hold the tooth by the crown. Look at the adjacent teeth to gauge the line/angle of the
replaced tooth. The tooth can be held in place by gently biting on a piece of gauze. The patient should then be immediately
referred to a dentist. Primary (deciduous) teeth should not be re-implanted as doing so may damage the permanent tooth
above (Figure 3).
If the tooth is unable to be put back in, the patent should be referred immediately to a dentist and the tooth transported
in the patient’s mouth, under the top lip (but the risk of swallowing the tooth must be considered, especially in
children), or placed in a container with fresh, cold milk or saline (do not use water).
Oro-facial injuries occur commonly in cases of non-accidental injury. Reports of suspected child abuse can be made
to the Child Youth and Family Service – 0508 FAMILY (0508 326459). Alternatively, and for suspected abuse in
adults, contact the police.
The role of the doctor (or dentist) in this situation is to observe, document and report the injuries. Support should
be offered, but an in-depth interview of the victim to confirm whether or not abuse has occurred should not be attempted,
as this is the responsibility of the social worker or police officer.
Documentation should be specific and objective and should include:
- The time and date and who was present
- A verbatim account of the incident, including child/parent/caregiver statements
- A description of injuries, including diagrams if appropriate
- A note of any physical or behavioural anomalies
- An account of any advice sought on the matter e.g. from colleagues
- An account of subsequent action taken e.g. call to Child Youth and Family Services
- Planned follow-up and management of injuries
Post dental procedures
Teething in infants
|Figure 4: This is an eruption cyst, seen reasonably commonly in infants who are teething. It does not require treatment.
(Source: D. Boyd)
“Dry socket” – acute alveolar osteitis is seen in patients who have a history of
extraction in past 24 – 48 hours, and present with severe, persistent throbbing pain that is localised to the socket.
The socket is usually very tender to palpation and there is no blood clot visible. There may be associated halitosis.
A dry socket is more frequently seen in people who smoke, especially if they have not abstained since extraction. Initial
treatment is to examine the socket for debris and then irrigate with sterile saline. Antibiotics are not indicated but
analgesics may be required.4,5 The patient can be referred to a dentist for packing of the socket.
Post extraction haemorrhage is usually able to be stopped with a few minutes of local pressure on the
bleeding socket with a gauze swab or pack.4,6 This also applies to patients who may be taking aspirin or NSAIDs.4 If
the bleeding continues then refer for further dental care. Ideally this type of problem should be dealt with by the dentist
who performed the procedure, and the patient would normally be provided with written instructions on post extraction care.6 A
thorough review of the patient’s medical history should be taken to rule out a haematological disorder.
Lip bite post local anaesthetic is commonly seen in children. Significant trauma may be caused by a
child chewing on a numb lip.
Prophylactic antibiotics for prevention of bacterial endocarditis
New Zealand National Heart Foundation guidelines recommend antibiotic prophylaxis should
be given to those at highest risk of adverse outcomes, undergoing dental procedures that involve manipulation of either
gingival tissue or the periapical region of teeth or perforation of the oral mucosa. The recommended antibiotic is
amoxycillin 2 g (child: 50 mg/kg up to 2 g) as a single dose one hour before the procedure.7
Cardiac conditions for which endocarditis prophylaxis is recommended:
- Prosthetic heart valves (bio or mechanical)
- Rheumatic valvular heart disease
- Previous endocarditis
- Unrepaired cyanotic congenital heart disease (include palliative shunts and conduits)
- Surgical or catheter repair of congenital heart disease with six months of repair procedure
For people with cardiac conditions, an important goal is prevention of dental caries and periodontal disease. Education
and regular dental examination to detect disease, or risk of disease at an early stage, is ideal.
- Nguyen D, Martin J. Common dental infections in the primary care setting. Am Fam Physician. 2008;77(6):797-802.
- Douglass A, Douglass J. Common dental emergencies. Am Fam Physician. 2003;67:511-6.
- Clinical Knowledge Summaries (CKS). Dental abscess management. Available from www.cks.nhs.uk (Accessed
- Kingon A. Solving dental problems in general practice. Aust Fam Physician. 2009;38(4):211-6.
- Mansour M, Cox S. Patients presenting to the general practitioner with pain of dental origin. Med J Aust 2006;185(2):64-7.
- Patel K, Driscoll P. Dental knowledge of accident and emergency senior house officers. Emerg Med J. 2002;19:539-41.
- National Heart Foundation of New Zealand (NHF). Guideline for the prevention of infective endocarditis associated
with dental and other medical interventions. NHF 2008. Available from www.nhf.org.nz (accessed
Oranga niho mo te iwi - Basic oral hygiene: what to tell your patients
Ma mahi ka ora – ‘By work one is sustained’ Mahi in this instance is referring to oral hygiene.
Fluoride supplements and fluoridated water
Fluoride is necessary for promoting repair of the teeth by aiding remineralisation of the surface. It works best when
used frequently and in low concentrations. Fluoride may be obtained topically from toothpaste and mouthwash or systemically
from the water supply or supplements. Both kinds of fluoride are important.
In New Zealand, fluoride occurs naturally in all water supplies, but usually the level is too low to protect against
tooth decay. Adjusting the water fluoride level to 0.7–1.0 ppm provides extra protection. Approximately half of
the New Zealand population receive fluoridated water. Communities vary on whether they have opted for fluoridation of
their water supply – 96% of Wellington residents receive fluoridated water compared with 4% of Canterbury residents.
Analysis of dental records in these regions showed that decay rates were 30% lower among five-year-old children receiving
fluoridated water and 40% lower among 12-year-olds.1
People drinking bottled or filtered water as their primary source of drinking water could be missing the decay preventative
effects of optimally fluoridated water that may be available from their community water supply. Boiling water does not
reduce the fluoride content.
Fluoride tablets are no longer recommended as a public health measure in New Zealand, as compliance with the daily regimen
is poor and the children who use them are normally from more health conscious families, and are therefore not at high
risk of tooth decay.2
Fluoride tablets can be considered for at-risk children and adolescents living in communities where the water supply
is not fully fluoridated. The effectiveness of this form of supplementation is not as clearly documented as water fluoridation.
Sodium fluoride tablets (1.1 mg) can be purchased at pharmacies or prescribed fully funded. Tablets should be sucked,
chewed or dissolved in drinking water (two 1.1 mg sodium fluoride tablets dissolved in 1 L drinking water).
Dose depends on age and the existing fluoride level in the drinking water supply (Table 1).2,3 This does
not mean that exactly this dose should be taken per day, but that important anti-cavity benefits may be gained with this
amount, without causing any adverse effects on health.
|Table 1: Dietary fluoride supplement schedule2,3
ion level in drinking water (ppm)*
= 1 sodium fluoride tablet
= ½ sodium fluoride tablet
= 2 sodium fluoride tablets
= 1 sodium fluoride tablet
| 1.0 ppm= 1 mg/L
| 1.1 mg sodium fluoride tablet contains 0.5 mg fluoride ion
Fluoride supplementation in pregnancy and children less than three years old is not recommended
Fluoride supplementation in pregnancy is not recommended because there is little evidence of benefit for the developing
foetus.4 Tooth enamel, the most caries-susceptible area of teeth, calcifies after birth making fluoride given
before birth ineffective in decay prevention.
Fluoride supplementation is not recommended for children younger than three years of age, regardless of the fluoride
level of the drinking water, because it is associated with dental fluorosis (white spots on the teeth).2
Consumption of fluoridated water (e.g. in formula) causes no adverse health effects for infants.5,6
Accidental fluoride poisoning in children
Fluoride can cause symptoms of toxicity at a level of 3 – 5 mg/kg, resulting in nausea, vomiting, diarrhoea and
hypersalivation, due to formation of hydrofluoric acid in the stomach. More serious toxicity (e.g. hypocalcaemia) can
occur with ingestions over 5 mg/kg.
“Regular strength” toothpaste contains 1 mg fluoride per gram of toothpaste, therefore, symptoms may occur
if a 10 kg child ingested 30 g toothpaste (~ ¼ tube) or more.
Poisoning is less common with ingestion of fluoride tablets. Sodium fluoride 1.1 mg tablets contain 0.5 mg fluoride,
therefore a 10 kg child would need to ingest around 60 tablets for toxicity to occur.
With small ingestions, milk may be given to relieve gastrointestinal symptoms (calcium binds with fluoride). More serious
toxicity requires immediate medical attention.
For further advice on managing fluoride poisoning, contact the National Poison Centre 0800 POISON (0800 764 766)
Brushing teeth, toothbrushes and toothpaste
Teeth should be brushed for two minutes, two times per day (in the morning and last thing at night). All the surfaces
of the teeth should be brushed as well as the top surface of the tongue.
Powered toothbrushes with oscillating heads are more effective at removing plaque than standard toothbrushes. Otherwise
choose a toothbrush with a small head and soft bristles. Toothbrushes should be replaced every three to four months or
sooner if the bristles become frayed. This ensures the brush is producing an effective clean and avoids bacteria build-up.
Children should use a child-sized brush for ease of use. Children’s brushes often need replacing more frequently
than adult brushes.
Toothbrushes should not be shared. Brushes should be rinsed with tap water after use and stored upright in an open container
or holder to allow air-drying. Ensure that toothbrushes stored together do not touch to avoid cross-contamination. There
is no evidence that toothbrush cleaning solutions or storing brushes in mouthwashes has any additional benefit.
Toothpaste containing 1000 ppm fluoride (0.22% w/w sodium fluoride or 0.76% w/w monoflurophosphate) should be used.
Lower strength (400 – 450 ppm) fluoride toothpaste is marketed for children, however regular fluoride toothpaste
can be safely used as long as the amount is reduced. Adults and children over six years should use a pea-sized amount,
younger children need only a smear of toothpaste. After brushing, spit but do not rinse the mouth as fluoride is effective
when applied topically.
Tooth brushing in infants
Parents should start brushing their infant’s teeth as soon as the first tooth emerges from the gums. The tooth
may be wiped with a soft cloth (e.g. a clean handkerchief) with a small smear of fluoride toothpaste. When appropriate
change to a soft, small headed toothbrush with a smear of fluoride toothpaste. The child should spit out when they are
able to but not rinse their mouth. Try not to let the child swallow the toothpaste.
Other oral health tips for infants include:
- Do not put a baby to bed with a bottle
- Do not put fruit juices or sweetened drinks into the bottle
- Do not dip dummies (pacifiers) into sugar or honey
Dental floss should be used daily (or at least three times per week) to help to remove plaque and food particles between
teeth. Dentists may also recommend an interdental brush.
Transmission of Streptococcus mutans from parent to child8
The cariogenic bacteria, Streptococcus mutans has been shown to be a risk factor for early development of
dental caries. These bacteria can be transmitted via the saliva from parent to child in a variety of ways such as sharing
spoons, pre-tasting food, putting their infant’s dummy into their own mouth and kissing on the lips. There are
many other factors involved in the development of caries. These include whether the infant is fed by bottle or breast.
If bottle fed, the content and timing of feeds, the overall sugar content of the diet and the frequency and type of
snack foods are all factors. An important message for caregivers is that their own oral health impacts on their children.
Fluoride mouthwash helps to reduce and prevent tooth decay, providing slightly more protection than using fluoride toothpaste
alone.7 However for people with healthy teeth and gums, fluoride toothpaste is usually adequate. Fluoride mouthwash
should not be used by children aged less than six years, due to the risk of swallowing the product, unless under professional
Antimicrobial mouthwash (e.g. containing chlorhexidine or triclosan) reduces the bacteria count and inhibits bacterial
activity in dental plaque. It can be effective in reducing plaque and gingivitis (an early form of gum disease) but it
is usually not necessary for people with healthy gums. Chlorhexidine mouthwash should be used intermittently only as it
can stain the teeth and tongue. It should not be used straight before or after tooth brushing as the detergents in toothpaste
interact with chlorhexidine.
- Ministry Of Health. Fluoridation in New Zealand. Available from: www.moh.govt.nz/fluoride (accessed
- Ministry Of Health. Oral health services agreement. 2001. Available from: www.moh.govt.nz/moh.nsf/pagesmh/7648/$File/contract-operational-guidelines.doc (accessed
- American Dental Association. Facts on fluoride. 2005. Available from: www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf (accessed
- Leverett D, Adair S, Vaughan B, et al. Randomised clinical trial of the effect of prenatal fluoride supplements in
preventing dental caries. Caries Res. 1997;31(3):174-9.
- National Health and Medical Research Council Australia. NHMRC statement : the efficacy and safety of fluoridation
2007. Available from: www.nhmrc.gov.au/media/media/rel07/_files/Fluoride_Flyer.pdf (accessed
- De Liefde B, Herbison G. The prevalence of developmental defects of enamel and dental caries in New Zealand children
receiving differing fluoride supplementation, in 1982 and 1985. NZ Dent J 1989;85:2-8.
- Marinho V, Higgins J, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes)
versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database Syst Rev
- Weintraub J. Family matters: Influence of biology and behaviour on oral health. N Y State Dent J 2007;73(2):14-9.