In New Zealand, dentists, dental therapists (previously called dental nurses), dental hygienists, oral health therapists and dental technicians are the chief providers of dental care. Dental care is delivered by a mixed state and private dental service model; children and adolescents up to the age of 18 years have free dental care but adults must pay for their own care (although some funding is available for emergency treatment).
Dentists J. W. Tatton in Nelson, Herbert Rawson in Wellington and Benjamin Throp in Dunedin made their own nitrous oxide (laughing gas) for pain relief in the 1870s, long before it was commonly used by dentists internationally and in New Zealand.
The main oral-health problem faced by the early Polynesian arrivals in New Zealand was tooth decay around the age of 40. When New Zealand’s temperature dropped around 1500 AD, and competition for food resources increased amongst a growing Māori population, the early, softer diet of kūmara, yams, fish and birds changed. Fern root and shellfish were more frequently consumed. This increased the level of wear on teeth – which were usually flat by the time Māori were in their 20s – but tooth decay largely disappeared.
In the 19th century Māori often had better teeth than Pākehā, because they had less access to sugar and they ate less frequently during the day. Their oral health, however, appeared to deteriorate rapidly when they adopted more ‘westernised’ diets. By the mid-1930s the Dental Officer for the Native Schools observed that there was now very little difference between Māori and non-Māori children’s teeth: ‘Both were equally bad.’1
Pākehā New Zealanders in the late 19th century often had poor teeth and gums, and many people used mouthwashes to avoid bad breath. Ineffective dental powders and pastes were also marketed to settlers.
Toothache made people desperate for treatment, with some even resorting to treating themselves. Frank Throp, one of Dunedin’s early dentists, described asking an old Scotsman who had extracted his teeth. He was surprised to learn that the old man had taken them out himself ‘…wi’ a hammer and a chisel, same as we do for a hoss.’2 For others, necessity prompted trips to the dentist, doctor, chemist or even the blacksmith, where decayed teeth were usually extracted rather than repaired.
Margaret Caro, born of Scots parents near Nelson in 1848, worked for 16 years as a dentist in South Canterbury mining and farming communities with her husband, Dr Jacob Selig Caro. She was more than 1.8 metres tall, and rode long distances to provide medical and dental care, including extracting teeth, setting bones and stitching wounds. In 1881 she was the first woman listed on the Dentists’ Register in New Zealand. She did not appear to have any formal qualifications.
Early dentists were skilled practitioners, trained under an apprentice system. They sometimes combined dentistry with shopkeeping and dispensing medicines and remedies. An exception was John Davis, who established a dental practice in Auckland in 1841. He had partly completed a medical degree from Cambridge, England. Apart from a few pioneering women dentists such as Margaret Caro and Amy Johnston, dentists were almost exclusively men.
Initially dental equipment was primitive and limited. Only a hand-operated drill was available and there was no local anaesthetic for pain relief so dentists rarely filled teeth. However, six major technological advances revolutionised dentistry from the 1870s.
Dentists were now able to offer a variety of services and were no longer merely considered 'tooth-pullers'.
In the late 19th century the number of practising dentists steadily increased, as did the populations and areas they covered.
Two different types of dentistry developed in New Zealand. Those practising ‘mechanical dentistry’ mostly extracted teeth and fitted dentures, and became known as ‘advertising dentists’ because they advertised their services, usually at cheaper rates. As a result, their patient group often consisted of children, the poor, isolated groups and Māori.
‘Ethical dentists’, on the other hand, carried out ‘operative dentistry’ and restored teeth, which not only required some skill but knowledge of the biology and physiology of the human mouth. Demand for this type of treatment, however, was limited in New Zealand; extractions and the fitting of dentures were less expensive.
The Dentists Act 1880 introduced the registration of dentists and identified the training and qualifications required for registration. A Dental Board was formed to examine candidates for registration, with responsibility for the examination belonging to the University of New Zealand.
Non-registered dentists and ‘advertising dentists’ contested what they saw as restrictive registration and the need for further training, as well as constraints on the advertising of dental services. Public and political opposition to monopolies aided their cause and standards were lowered to allow registration of some previously excluded dentists and apprentices. The University of New Zealand no longer controlled the registration exam and the Dental Board was disestablished.
In 1904, a private member’s bill introduced by Member of Parliament Thomas Sidey saw oversight of dental training assigned to the University of New Zealand under the Dentists Act 1904. Furthermore, matriculation was now a prerequisite and students had to study for at least two years.
The New Zealand Dental Association (NZDA) was set up in 1905 to represent registered dentists, and began publishing the New Zealand Dental Journal. Over half of practising dentists joined the new association. Because NZDA policy did not allow dentists to advertise, few ‘advertising dentists’ joined.
It was not until 1937 that the New Zealand Dental Council was set up to enforce standards of professional practice.
Debate over where to locate the nation’s only dental school was resolved in 1904, when Premier Richard Seddon was convinced by a deputation of Dunedin dentists that the city’s colder climate was more conducive to study. By 1923 a bigger school was needed. Auckland University and city politicians wanted it in Auckland, but it was decided to build a larger school in Dunedin. The new school was opened in Great King Street in 1926.
The Dentists Act 1904 assigned oversight of dental training to the University of New Zealand. A new dental school opened at Otago University in 1907 under Dr Henry Pickerill, who became an eminent plastic surgeon. After initial success, the dental school struggled to attract students. None entered training in 1917, prompting the introduction of bonded bursaries, which increased the number of students to 103 in 1923.
New Zealand children had very poor teeth and the NZDA lobbied the government for many years for action on children’s oral health, conducting inspections of schoolchildren’s teeth to provide evidence for their case. As early as 1905, F. W. Thompson, a well-known dentist, claimed that the teeth of 98% of New Zealand children did not receive the care they deserved. In 1912, medical inspections in schools, introduced by the government, revealed that 72% of Standard II children were suffering from ‘defective teeth’.
Adult teeth were no better. Pickerill, on arriving in Dunedin from England in 1907, was alarmed at the state of New Zealanders’ teeth and later noted: ‘Nine out of ten people appeared to have the most glaring dental defects, and sometimes as glaringly remedied’.1 On opening its doors to the public in 1907, the dental school was ‘besieged with patients’.
The NZDA, concerned about the population’s oral health status, as well as anxious to maintain autonomy and control and advance their professional status, continued to lobby for state funding for a dental service for children and dental departments in public hospitals in the main centres to treat those who could not afford to pay private dentists.
The inspection and repair of the teeth of New Zealand Territorial Force volunteers in 1914 highlighted the nation’s poor dental health. The New Zealand Dental Corps (NZDC) was formed in 1915 to provide dental treatment in camps to members of the New Zealand Expeditionary Force.
The involvement of dentists and dental mechanics in active war service, including Henry Pickerill, dean of the New Zealand Dental School, enhanced the prestige of dentistry and demonstrated the value of public dental health programmes. After further active service in the Second World War, the NZDC became the Royal New Zealand Dental Corps in 1947.
Captain Harold Dover was a dentist who served at Guadalcanal during the Second World War. He was also the president of the Wellington Society of Magicians, and was often called on to entertain the troops. His hardest audience was a surly detachment who were long overdue for home leave. He won them over by producing a cold can of beer from an empty roll of paper and ‘other impossible places’.1
The leader of the NZDC, Colonel Thomas Hunter, returned from war in 1918 determined to move the focus of dentistry from extraction to restoration and prevention of decay. As director of the new division of dental hygiene in the Department of Health, he successfully advocated the establishment of the School Dental Service (SDS) in 1921 to treat primary schoolchildren.
Social policy in this era focused on children’s health and welfare. The government considered it had a duty and right to intervene when it came to improving children’s health, to ensure healthy adults capable of contributing to society and continued success for the race, nation and Empire. The SDS was only one of several initiatives aimed at improving children’s health in the first part of the 20th century. Others included St Helens hospitals (1904), Plunket (1907), the School Medical Service (1912), and children's health camps (1919).
The election of a Labour government in 1935 and the passing of the Social Security Act 1938 led to general improvements in access to health care, including dental health care. From 1937 milk was provided free in schools, to supply calcium for teeth as well as improve children’s nutrition generally. By the mid-1940s free dental care had been extended to all students up to standard six (year 8) and many pre-schoolers were also under the care of the SDS.
While the proposed Social Security Act 1938 intended hospital treatment, medicines, and general practitioner visits to be free, dental services for adults were not mentioned. Although possibilities for further public dental schemes were discussed, nothing further eventuated until 1947 when the government extended free dental care to include adolescents. The Adolescent Dental Service (General Dental Benefits Scheme) was staffed by contracted private dentists and treated adolescents up to age 16 (later to age 18). Adults over this age were still responsible for funding their own dental care.
Dr Muriel Bell fought for the fluoridation of Auckland’s water supplies. She was opposed by the mayor, Dove-Myer Robinson – but succeeded in her campaign. As a result of her battles, she referred to herself as ‘Battle-axe Bell’.
Fluoride was introduced into the Hastings water supply in 1953 on a trial basis. This was considered a success, with children on fluoridated water supply requiring fewer fillings. Despite strong support from dentists and the Department of Health, the addition of fluoride to public water supplies to strengthen teeth was a contentious issue.
The 1957 Royal Commission of Inquiry into Fluoridation noted public concerns about the additive’s medical effects, a desire to maintain ‘pure’ food and drink, and the possible infringement of civil liberties and individual freedom. Fluoridation became an issue for local councils, to be decided by referendum.
Data collected by the SDS continued to demonstrate that children on fluoridated water supplies had fewer decayed, filled and extracted teeth. In the 2000s fluoridation continued to be a volatile political issue despite adverse health effects being unproven. Decisions by local councils on whether water would be fluoridated led to highly-charged debates between public health advocacy of fluoridation and opposition to introducing fluoride into the water supply by the anti-fluoridation lobby group, Fluoride Free New Zealand.
Anti-fluoridation activists claim that fluoride is a neurotoxin and that its presence in the water supply removes from individuals the right to make their own decisions about whether or not to consume fluoride.
In late 2016 the New Zealand government proposed legislation that will transfer responsibility for decision-making about the fluoridation of water from local councils to district health boards. If the Health (Fluoridation of Drinking Water) Amendment Bill is passed, local government will need to implement decisions about fluoridation made by district health boards. It is anticipated that this legislation will mean an increase in the fluoridation of drinking water in New Zealand.
In 2016 58% of New Zealanders lived in areas with fluoridated water supplies.
The introduction of the state-funded School Dental Service (SDS) in 1921 was a world first, prompted by concerns about poor dental health. Staffed entirely by female dental nurses, the service was available free to primary schoolchildren. The first 'draft' of dental nurses was recruited in 1921. They trained in a temporary school next to Government Buildings in Wellington, and graduated in mid-1923.
In the early years of the school dental service, rural dental nurses encountered children who had never had any dental care. One nurse described treating 60 children in a single day after they were driven to the clinic in the principal’s truck. She extracted four permanent teeth and 44 baby teeth.
The first school dental clinic was set up in Hawke’s Bay in July 1923. The Department of Health required school committees to provide clinics for their schools. While some were purpose-built, many were not, and the conditions the ‘pioneer dental nurses’ found themselves working in varied. By 1927 the government introduced a subsidy to help schools fund clinics and, by 1941, was solely funding clinics. The SDS was popular and efficient, and extended to native schools, private schools and country districts.
Dentists were divided on the need for dental nurses, despite the support of advocates for public provision of dental services, such as Norman Cox and John Saunders of the New Zealand Dental Association. Those opposed included Henry Pickerill, dean of the New Zealand Dental School, who saw dental nursing as lowering standards.
For primary schoolchildren, few sights provoked more fear than the appearance of a fellow student with a note summoning you to the dental clinic or ‘murder house’, as it became commonly known, due most likely to fillings being done without the use of local anaesthetic during the early days of dental care.
Many dentists doubted women’s strength and suitability for the work. They were opposed to state control of dentistry and the subsequent loss of professional independence it represented. Their prejudices were countered by the expectation that dental nurses would be cheaper to train, would be better at dealing with children and would leave the profession to marry (making them less of a threat to dentists). Dental nurses were also under the supervision and direction of a public health dentist.
For women, dental nursing provided a rare opportunity for a semi-autonomous career. It attracted many educated and mature students who soon proved their abilities on the job, often in isolated parts of the country. One of these nurses was Grace Rood, who was working in her clinic at the Waipawa sub-base when the 1931 Hawke’s Bay earthquake struck. She later set up a clinic at Pōrangahau, where she had no electricity, and used a primus stove to sterilise her instruments and boil water.
The SDS would be a much-studied template for similar services overseas. Under the Labour government of Michael Joseph Savage from 1935, the service was expanded and dental nurses given extra responsibilities. A new Dominion Training School opened in Wellington in 1940, with further schools opening in Auckland in 1952 and Christchurch in 1956.
Perle Hera Rakapa Taiaroa of Ngāi Tahu was one of the first fully qualified Māori dental nurses. She worked as a bonded dental nurse in New Plymouth from 1928 to 1931, before she married Ngāi Tahu leader and political activist Frank Winter. She later became vice-president of the Wellington section of the Pan-Pacific and South-East Asia Women’s Association, president of the Pōneke branch of the Māori Women’s Welfare League, and vice-president and treasurer of its Wellington district council.
By the fiftieth anniversary of the SDS in 1971, some 1,341 school dental nurses were working in 1,297 clinics, taking care of 582,964 preschool and school-age children. In 1923 the first group of dental nurses had completed 78.6 extractions for every 100 fillings; by 1970 this had reduced dramatically to 2.8 extractions per 100 fillings.
In spite of the efforts of the SDS, in the 1970s, a World Health Organization international oral health survey, and a further national survey, found that New Zealand children and adults had heavily-filled teeth and a high percentage of adults still lost all their teeth. As a result, the SDS implemented a new preventive and diagnostic regime designed to reduce the number of fillings.
During the 1980s dental nurse numbers dropped as school rolls fell, more women returned to work after having children, and women were drawn into a wider range of professions. Dental nurse training centres closed in Auckland and Christchurch.
In the early 1990s dental nurses became known as dental therapists and in 1994, they were joined by dental hygienists who began to train at Otago Polytechnic. In 2004 the Health Practitioners Competence Assurance Act brought registration for both dental hygienists and dental therapists. For dental therapists, this meant that they were no longer limited to working for the SDS but were able to work in private practice as well.
In the 1990s the SDS changed from a national service, run by the Department of Health, to a fragmented service administered by a succession of different governing and funding bodies. There was a greater focus on community health, integrated dental hospital-based services and Māori health providers. However, the rapid changes in social and economic policy and series of structural reforms during the 1990s had a negative impact on school dental services and children’s oral health worsened during this time.
Reviews of the SDS in the early 2000s noted that the service had deteriorated further. As well as worsening oral health statistics for children, facilities and equipment were run down, and the dental therapist workforce was ageing and experiencing shortages.
In 2006 the Labour government produced a new strategic vision with the aim to improve oral health for all New Zealanders (‘Good Oral Health for All, for Life’). This meant major changes for SDS, with the government investing millions into building and outfitting new clinics and mobile clinics, and building up the workforce (including employing dental assistants) to provide an effective Community Oral Health Service (COHS) focused on prevention of dental disease.
In recent years COHS data has shown that the oral health of children is improving once more but that there are still significant inequalities in oral health between groups of children, with Māori and Pasifika children having worse oral health than other children.
Having proven their worth in wartime, raised their professional status and income and maintained a private-sector monopoly on the treatment of adult teeth, dentists consolidated control of their industry in the 1950s.
During the 1960s dentists struggled with the ‘lack of control and direction’ in the dental technicians’ industry. Legislation eventually saw the establishment of a Dental Technicians’ Board and registration for dental technicians; however, dental technicians wanted to treat patients directly, to which the New Zealand Dental Association (NZDA) was strongly-opposed.
A Royal Commission of Inquiry into Social Security in 1969–72 considered the place dentistry should occupy with in the social security system. As a result, dentists were authorised to recommend people for sickness benefits, write prescriptions, and have dental laboratory work paid for by the state. The Commission rejected a request for a universal free dental service.
John Walsh was a vigorous and determined dean of the faculty of dentistry at the University of Otago from 1946 to 1971. He restructured the school, oversaw the building of a new Dunedin dental school in 1961, edited the New Zealand Dental Journal, designed an early (and never made) version of the high-speed dental drill, wrote three books on dentistry, and worked hard to raise awareness of dental health and make false teeth unfashionable. In August 2001 the university’s dental-school building was named the Walsh Building in his honour.
After 1946, under the vigorous leadership of the new dean, Professor John Walsh, the Otago University dental school gained an international reputation. Walsh increased emphasis on ethics, patient service and graduate research into diet and dental health. He also promoted specialisation in orthodontics (correction of teeth), gum disease, prosthodontics (the restoration and replacement of teeth), dentistry for children and dental anaesthesia.
New technology, including high-speed drills, X-rays, improved pain relief and operating chairs that allowed the dentist to sit down, helped improve the effectiveness of chair-side dentistry.
Professional, academic and technological advancement was not matched by improvement in adult oral health. A national survey of adult oral health and attitudes to dentistry in 1976 documented the nation’s poor oral health.
During this decade, the concept of a dental team was frequently brought up by the NZDA. Adding an auxiliary to the team, in an operating (dental therapist) or preventive (dental hygienist) role, would decrease dentists’ workloads and add a preventive focus. No clear consensus on what form such an auxiliary would take led to further delays in introducing dental hygienists to New Zealand.
A second World Health Organization international oral health survey in 1988 found a much improved level of oral health in New Zealand with a low level of treatment need. Unfortunately, this and other research in the 1980s revealed another oral health issue, that of ethnic and socioeconomic inequalities in oral health between groups of New Zealanders.
In the 21st century, while most children access free dental care, the majority of adults must pay privately for dental services. A further national oral health survey in 2009 found that the main barrier to dental care for adults was cost, with more than half those surveyed reporting they did not see a dental professional often enough. The oral health of New Zealanders of all ages remains closely-related to their socio-economic status and ethnicity.
A positive outcome of the 1990s ‘health reforms’ was an increase in Māori health providers who were able to secure contracts to provide services for Māori, including oral health services. These providers are owned by Māori, are operated under kaupapa Māori (Māori ideology and practice), and offer a whānau ora (family health) approach to care.
Other Māori initiatives, such as Te Mahi Niho Hauora ki Rātana Pā, a dental health project at Rātana Pā using a Māori community health worker, School Dental Service (SDS) equipment and a contracted dental surgeon, succeeded in making oral health a community concern. Such initiatives have resulted in improved oral health, lessened distrust of dentists, and improved self-esteem and employment prospects among those receiving treatment.
In 1995 Te Aō Marama, the New Zealand Māori Dental Association, was founded in response to evidence that Māori children had more decayed and missing teeth than non-Māori children, and were less likely to be enrolled in the SDS as pre-schoolers. Māori adolescents were less likely than non-Māori adolescents to use the free dental benefit scheme. Māori adults had more decay and missing teeth, but often could not afford dentist visits.
While the New Zealand Army had trained dental hygienists from 1974, the first course for civilian dental hygienists only began in 1994. With the exception of a dental therapy course at the Auckland University of Technology (AUT), from 1999, education for dentists, dental therapists, dental hygienists and dental technicians, was centralised at the University of Otago in Dunedin.
In the 21st century Dunedin remained the home of New Zealand’s principal dental school, whose most recent premises were built in 1961, adjacent to the medical school. A new clinical services building will open in Dunedin in 2019 and the existing dental school building will be refurbished by 2020 to accommodate increased numbers of dental students and the addition of dental technology and oral health therapy students.
Further changes in 2006 saw the dental therapy and dental hygiene scopes of practice combined into oral health degrees, offered by AUT (2006) and the University of Otago (2007). Initially, oral health graduates had to register with the Dental Council of New Zealand in both the dental therapy and dental hygiene scopes of practice. From November 2017 they have been able to register in their own oral health therapy scope of practice. Clinical dental technicians are now able to care for patients directly by completing a postgraduate qualification at Otago.
Since the mid-1970s more women have become dentists and dental technicians, joining what had been overwhelmingly white middle-class male professions, and while dental therapy and dental hygiene were predominantly female professions, males now also choose to become oral health therapists. Those entering study in the dental and oral health professions are a more ethnically-diverse group than previously, and increasing the Māori and Pasifika workforce is a priority.
The services provided by dental professionals continue to change as more New Zealanders retain their natural teeth. There is now a greater emphasis on prevention of tooth decay and gum disease, and tooth preservation and enhancement.
Orthodontics, such as the use of braces, cosmetic dentistry, dental implants (implanting false teeth into the jawbone), tooth whitening (tooth bleaching), and crowning teeth have become more popular.
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