3. Promotion & Disease Prevention
3.1 Personal care and healthy environments
The New Zealand Dental Association position is:
That oral health is an integral part of general health and a basic human right.
That oral health and dental care must be considered as an integral part of Health Policy making.
The New Zealand Dental Association recommends healthy eating, regular and effective self-care and regular dental visits as the three essential steps to maintain healthy teeth and gums for all age groups.
It is important to limit the intake of sugary food and drinks, brush teeth and gums twice a day with fluoride toothpaste, and to regularly visit a dentist, and other oral health professionals when required.
While many oral conditions are preventable, oral health is strongly supported by healthy environments and by population level strategies to improve oral health.
The Association recommends regular and effective personal oral health care combined with policies that support healthy environments, and communities, and regular access to oral health care as the most effective ways to achieve good oral health in New Zealand.
3.2 Sugars and Sugary Drinks
The New Zealand Dental Association position is that is supports:
The introduction of a sugary drinks levy that aims to reduce the consumption of sugary drinks to reduce tooth decay and is consistent with the WHO guidelines.
The government and the beverage industry introducing a sugar icon on the packaging of all sugary drinks to indicate the amount of sugar, in teaspoons, in each product.
The regulation of the promotion, advertising and marketing of sugary drinks to children.
The development of policies by local government to introduce ‘water-only’ policies at council venues and events and to limit the sale and advertising of sugary drinks in and around schools.
Mandating schools and early learning services to adopt ‘water-only’ policies.
WHO guidelines that recommend free sugars should be less than 10% of daily energy intake.
The introduction of a daily allowance for the intake of free sugars for New Zealanders, in line with the recommendations from the WHO.
Encouraging the public to switch their sugary drinks to water by expansion of nationwide social marketing campaigns such as “Switch to Water” and “All Rizz no Fizz”.
Dental decay is a complex multifactorial disease with socio-economic and biological determinants.
Sugary drinks are one of the most significant risk factors for tooth decay, obesity, type 2 diabetes and other noncommunicable diseases. It is for this reason we urge governments to act and to address one of the main commercial determinants of tooth decay – the sugary drink industry.
As a nation we consume sugar at an alarming rate. The health effects of a diet high in sugar are well known, and our poor health statistics clearly reflect this. New Zealand is in the midst of an obesity and type 2 diabetes epidemic. We are the third most obese nation in the OECD. More than a third of all New Zealanders aged over 15yrs are obese, and one in ten children. The impacts of these health conditions place a massive drain on our already overburdened health system.
In 2023/2024, an estimated 321,000 (7.4%) New Zealand adults had one or more teeth removed due to decay, abscess, infection or gum disease. Approximately 31,000 (3.3%) of children had one or more teeth removed over the same period. Dental care is one of the most common reasons for children’s admission to hospitals, and for young children, dental disease is a leading cause of potentially avoidable hospitalisations. Admission rates to public hospitals for dental care have reached unsustainable rates, with approximately 9,000 young people aged under 18 years every year undergoing a general anaesthetic to have one or more teeth removed due to tooth decay.
The World Health Organization (WHO) guideline recommends that the daily intake of free sugars be limited to less than 10% (or 50gm) of total energy intake in both adults and children. The WHO defines ‘free sugars’ as monosaccharides (e.g. glucose, fructose) and disaccharides (e.g. sucrose) added to foods and drinks by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. It does not include naturally occurring sugars in fruits, vegetables, and dairy products.
The New Zealand Dental Association recommends water as the best drink of choice for oral health. The quality of reticulated water supplies in New Zealand is regulated and monitored. Water has no added sugar, no calories and is non-acidic, and for over half of the population reticulated tap-water provides the benefit of community water fluoridation.
3.3 Community Water Fluoridation
The New Zealand Dental Association position is:
That it strongly supports Community Water Fluoridation (CWF) as an effective, safe, and affordable public health measure.
That New Zealanders should have access to optimally fluoridated water, wherever this is practical and affordable.
That the delivery of community water fluoridation is a core public health responsibility of public health authorities in conjunction with water suppliers.
That government must ensure the delivery of community water fluoridation is included in the considerations for the development of the organisation, funding and responsibilities for delivery of safe drinking water in New Zealand.
Fluoride is a naturally occurring element. It is found in the air, soil, water, seawater, plants and many foods. In New Zealand, fluoride occurs naturally in all water supplies, but at a level that is too low to protect against tooth decay. Community water fluoridation (CWF) which is the process of adjusting the fluoride level in reticulated water supplies to 0.7-1.0 parts per million helps protect against tooth decay.
The US Centres for Disease Control and Prevention named CWF as ‘one of the top 10 most effective public health tools of the 20th Century’.
A comprehensive 2014 New Zealand review of the scientific evidence for and against the efficacy and safety of community water fluoridation by the Prime Minister’s Chief Science Advisor and the Royal Society of New Zealand Te Apārangi concluded that:
“From a medical and public health perspective, water fluoridation at the levels used in New Zealand poses no significant health risks and is effective at reducing the prevalence and severity of tooth decay in communities where it is used.”
“Our assessment suggests that it is appropriate, from the scientific perspective, that fluoridation be expanded to assist those New Zealand communities that currently do not benefit from this public health measure – particularly those with a high prevalence of dental caries.”
Further updates were completed in 2021 by the Office of the Prime Minister’s Chief Science Advisor and in 2024 by the Ministry of Health. The 2024 review concluded that evidence published since 2021 indicates that there are clear benefits from CWF even when alternative forms of fluoride, such as fluoride toothpastes, are available. CWF promotes equity and there has been no high-quality evidence published since the reviews in 2014 and 2021 to suggest a causal link between fluoride at the levels used in New Zealand for CWF and significant harm to health.
Similarly, following a 2016 review of community water fluoridation the Australian NHMRC stated that existing evidence consistently shows that CWF reduces tooth decay, and is not associated with cancer, Down syndrome, cognitive dysfunction, lowered intelligence or hip fracture and there is no reliable evidence of an association between community water fluoridation at current Australian levels and other human health conditions.
A recent UK study in Cumbria, published in 2022, again concluded that children born at the commencement of fluoridation and children born after fluoridation had commenced, had lower rates of decay after adjustment for confounding effects. Both groups had reductions in dental service costs that exceeded the cost of fluoridation.
In New Zealand the Health (Fluoridation of Drinking Water) Amendment Act was passed in 2021 and allows the Director-General of Health to direct the addition of fluoride to a drinking-water supply after consideration of the scientific evidence on the effectiveness of fluoridation, the prevalence and severity of dental decay and whether the benefits outweigh the financial costs. The amendment to the Health Act aims to provide a nationally consistent approach to decisions regarding community water fluoridation.
Following passage of the Act, the Director-General issued 14 directives to local councils in July 2022 to fluoridate their water supplies. Implementation dates were between June 2023 and June 2026. A further 27 local authorities were advised by the Director-General of Health in November 2022 that the Director-General is now considering whether to issue directions to fluoridate in relation to one or more of their drinking-water supplies.
Introduction of CWF by the first tranche of Councils would increase population coverage from 51% to 60% and the second tranche could further increase coverage to 68%.
However, the Association is concerned that early signs indicate that water suppliers and the Ministry of Health are experiencing delays in implementing the directives. A recent High Court ruling questioned the process followed by the Director-General of Health when issuing the first directives in July 2022.
In late 2024, the Director-General reaffirmed the directives that had been issued, but the Association remains concerned that there may be ongoing delays to the implementation of directives under the Health (Fluoridation of Drinking Water) Amendment Act.
Community water fluoridation requires appropriate governance, community explanation and monitoring systems that are the responsibility of water suppliers and public health authorities.
It also requires adequate funding for the installation and maintenance of the capital infrastructure and modest operational investment for day-to-day operations.
New Zealanders should have access to optimally fluoridated water, wherever this is practical, to reduce and control levels of tooth decay.
Other common sources of fluoride in New Zealand are fluoridated toothpastes, fluoride mouth rinses and a range of professionally applied fluoride products.
3.4 Fluoridated Toothpastes
The New Zealand Dental Association recommends and endorses:
The availability of affordable fluoridated toothpaste with at least 1000ppm fluoride as a public health measure to reduce tooth decay.
Brushing twice a day with a toothpaste with at least 1000ppm fluoride for all ages.
Children up to 5 years of age should use a smear of toothpaste and from 6 years of age and older a pea sized amount should be used.
Children should be supervised when brushing their teeth with fluoride toothpaste.
Toothpaste should be labelled in ppm fluoride.
The use of toothpaste with a higher concentration of fluoride (5000ppm) for teenagers, adults and older adults who are at elevated risk of developing dental caries, after seeking the advice of a dentist or another appropriate oral health or health practitioner.
The New Zealand Dental Association does not recommend or endorse:
The use of non-fluoride toothpastes to control dental decay.
Fluoride toothpaste is the most widely known and available source of topical fluorides. Since the 1970s, fluoride toothpaste, independently or together with water fluoridation, has been responsible for the decrease in the incidence of dental caries.
Most fluoridated toothpastes on sale in New Zealand contain 1000-1500ppm fluoride. Toothpastes with fluoride in this range of concentrations have been shown to be effective in preventing, arresting and treating dental caries.
The 2009 New Zealand Ministry of Health Guidelines for the Use of Fluorides provide evidence-based support for the use of fluoride toothpastes as effective in preventing dental caries. The Guidelines agreed that fluoridated water and fluoride toothpastes provide ideal building blocks and that additional fluoride interventions can be considered for people at higher risk of dental caries.
The most recent (2019) Australian guidelines for the use of fluorides reported that evidence supports the use of 5000ppm toothpastes in populations at high risk of dental caries, including root caries. Their use was recommended on the advice of a dentist or other appropriately trained oral health or health practitioner.
The Association supports the fluoride toothpaste recommendations in the 2009 New Zealand guidelines and the more recent recommendation of the Australian guidelines for the use of high strength (5000ppm) toothpastes for people at high risk of dental caries.
3.5 Professionally Applied Fluorides
The New Zealand Dental Association position is:
The New Zealand Dental Association supports the use of professionally applied fluoride products as part of programmes to reduce or manage dental decay.
Topical fluorides can be used to prevent or control dental decay in a variety of formats, but commonly as fluoride varnishes, gels and foams, and as Silver Diamine Fluoride to arrest dental decay.
This paper does not explore the use of professionally applied fluorides as this in the realm of clinical guidelines which are beyond the scope of this Roadmap Towards Better Oral Health for New Zealand.
However, the New Zealand Dental Association does note that Silver Diamine Fluoride has recently been approved for use as a medicine by Medsafe in New Zealand. The Association supports the introduction of Silver Diamine Fluoride in New Zealand.
The Association has supported a multidisciplinary group to develop clinical guidelines appropriate to contemporary practice in New Zealand and will contribute to continuing clinical education for dentists and oral health professionals.
3.6 Tobacco
The New Zealand Dental Association position is:
That it supports smoking cessation programmes and initiatives in dental practices.
That it supports programmes and initiatives in the wider community focused on smoking cessation.
That it supports targeted measures to reduce smoking rates among at risk groups.
That it supports smoke-free environments and policies, and measures aimed at eliminating exposure to second-hand smoke.
That it supports New Zealand’s Smokefree 2025 goal that smoking rates for all population groups will be less than 5%.
That it supports the Smokefree Aotearoa 2025 Action Plan.
Oral health professionals play a powerful role in supporting patients to enhance their overall wellbeing by providing brief interventions, clear guidance, and culturally responsive follow-up. These positive engagements can significantly contribute to reducing tobacco use and fostering healthier futures.
The Association upholds the importance of this work as a vital expression of ethical and professional responsibility, and strongly supports targeted, mana-enhancing interventions that uplift communities most affected by tobacco use. It is estimated that around 6.8% of adults are daily smokers. Māori and Pacific people, are significantly more likely to be smokers than other groups and smokers are more prevalent among people living in deprived neighbourhoods (10.7%) compared with adults in the least deprived neighbourhoods (3.1%).
Higher rates of smoking lead to significant health inequalities and are directly linked to cancers, respiratory diseases, heart disease, stroke and other disorders.
Tobacco is the main cause of premature death and disability in New Zealand and results in almost 5,000 deaths every year, killing more than half of those who use it. The health-related effects of smoking carry substantial costs in terms of health care support and lost productivity. Tobacco related costs to the health system were estimated to be $2.5 billion.
Good oral health and the use of tobacco in any form do not go together. The use of tobacco is harmful to health and oral health and is a common cause of addiction, preventable illness, disability and death. The use of most tobacco products leads to an increased risk of oral cancer, oral mucosal lesions, and periodontal disease. Tobacco use is also associated with reduced healing capacity of the oral and periodontal tissues, which increases the risk of poor healing with surgical procedures in the mouth and for oral tissues, including an increased risk of failure for dental implants.
Combined exposure to alcohol and tobacco creates a higher risk of oral and pharyngeal cancers that is the product of the increases in risk associated with exposure to either habit.
The Association supports programmes and initiatives in the wider community focused on smoking cessation.
3.7 Vaping
The New Zealand Dental Association position is:
That it supports vaping as a smoking cessation tool.
That it supports smoking cessation programmes and initiatives in dental practices.
That it supports programmes and initiatives in the wider community encouraging and supporting older people who smoke to switch to vaping.
That is supports targeted measures to reduce smoking and vaping rates among at risk groups.
That it supports New Zealand’s Smokefree 2025 goal that smoking rates for all population groups will be less than 5%.
That it supports strengthening the regulatory framework for vaping products in order to minimise youth vaping.
Emerging evidence suggests that vaping can be a safer alternative to smoking traditional tobacco products. A 2024 Cochrane Review provided the strongest evidence to date that e-cigarettes are more effective than traditional nicotine replacement therapies, such as patches and gum, in supporting people to quit smoking.
While vaping poses fewer risks than smoking, the ultimate goal remains supporting individuals to become free from all forms of nicotine dependence. Current daily vaping rates in New Zealand have increased significantly since being introduced into New Zealand in the mid-2000s. It is now estimated that 9.7% of adults aged 15 years and older vape on a daily basis. Daily vaping among 15–17-year-olds has also increased to 15.4%, and for those aged 18-24 years 25.2% are daily vapers.
Vaping was initially introduced as a tool to support smoking cessation, which may help explain the higher uptake seen among Māori and Pacific peoples. In 2022/23, nearly a quarter of Māori reported vaping daily. Māori were 2.5 times more likely to vape than non-Māori, and those living in the most socio-economically disadvantaged communities were 2.8 times more likely to vape than those in the most advantaged areas. These trends highlight the importance of ensuring that harm reduction tools are equitably designed, regulated, and supported to meet the needs of communities most impacted by smoking-related harm. There is no conclusive evidence at this time to prove adverse causal effects of e-cigarettes on oral health. However, systematic reviews have shown that mouth and throat irritation and periodontal damages are the most reported oral side effects.
3.8 Alcohol
The New Zealand Dental Association position is:
That it supports alcohol cessation programmes and initiatives in dental practices.
That it supports programmes and initiatives in the wider community focused on alcohol cessation.
That it supports targeted measures to reduce alcohol-related harm among at risk groups.
That it supports measures to limit alcohol advertising and sponsorship, particularly in sports.
That it supports measures to address deficiencies in the Sale and Supply of Alcohol Act.
The Association supports programmes and initiatives in the wider community that are focused on curbing alcohol-related harm.
Alcohol is the most widely used drug in New Zealand. Every year more than 800 deaths are caused by alcohol consumption. Alcohol is a psychoactive substance with addictive properties and is classified as a Group 1 carcinogen by the International Agency for Research on Cancer.
Harmful alcohol use is a significant burden to society. In 2024, the NZIER estimated a $9.1 billion cost of alcohol-related harm based on disability-adjusted life years. By comparison, alcohol excise revenue was $1.2 billion in 2020. Alcohol also puts considerable pressure on the health sector, particularly emergency services, as well as on our police and justice systems.
Alcohol is associated with a risk of developing malignancies such as breast cancer, colorectal cancer and cancer associated with the oral cavity, oropharynx, larynx and oesophagus. Alcohol is also a major risk factor for other non-communicable conditions such as cardiovascular disease and liver cirrhosis. There is no safe amount of alcohol consumption.
The impacts of alcohol consumption on oral health may include an increased likelihood of the occurrence of dental caries, periodontal disease, tooth wear, staining, halitosis and trauma. Alcohol consumption increases the risk of facial and oral injuries from falls, traffic accidents and violent confrontations.
Brief interventions from healthcare practitioners can reduce alcohol consumption among hazardous and harmful drinkers, indicating an important role for oral health practitioners in delivering these educational interventions.
Alcohol has a synergistic effect when combined with smoking, increasing the risk of oral cancers. Smokers have a 10 times higher risk of developing oral cancers than non-smokers, but when combined with alcohol, the risk multiplies up to 300 times more compared to people who neither smoke nor drink.
3.9 Injury Reduction
The New Zealand Dental Association position is:
That it supports the development of safer environments that minimise the risk of dental or maxillofacial injuries, particularly from falls and road traffic accidents.
That it supports measures to reduce interpersonal violence and alcohol-related harm.
That it supports the use of mouthguards in contact sports and in recreational activities with a high risk of dental or maxillofacial injury.
That it supports the use of custom-made mouthguards as they can offer greater comfort and a higher level of protection.
That it supports the use of full-face helmets for mountain bikers as they greatly reduce the incidence of dental injuries in case of accidents.
That it supports greater focus on prevention and the importance of initial care for dental injuries.
Dental and maxillofacial injuries constitute an important public health issue. They are often irreversible, frequently complex, difficult and costly to treat. Young children and teenagers have been identified as high-risk groups, particularly when learning to walk and when new and/or high-risk activities are involved.
Data from the 2009 New Zealand Oral Health Survey identified that 40% of the adults surveyed reported a history of dental trauma, and in 2008 32,110 people registered an orofacial injury with ACC. A retrospective audit of maxillofacial surgery department data at Dunedin and Southland Hospital between 2009 and 2020 reported 1,561 patients with 2,480 maxillofacial fractures.
Dental injuries occur from predominantly sport and recreational activities, falls, interpersonal violence, road traffic accidents and work environments.
Prevention of dental and maxillofacial injuries should be of high priority. Developing and promoting policies and protocols that focus on minimising the risk of oral injuries is a key to prevention. Appropriate health and safety requirements should be observed in workplaces. Recreational equipment and environments should be designed to minimise oral injury.
Public education programmes should promote awareness of potential oral injuries and emphasise the importance of parental supervision and protective equipment. Appropriate protection should be normalised and expected in the community.
Following an oral injury, prompt assessment by a dentist, including proper diagnosis, treatment planning, treatment and follow up, are important to improve the chances of a favourable outcome. Traumatic injuries to teeth require early assessment and appropriate management to enable optimum recovery.
In New Zealand awareness of ACC funded cover for oral injuries is needed, and continued focus is required to ensure ACC funding supports affordable, equitable, timely and appropriate access to care for oral injuries.