Northland children have the worst teeth in the country as smaller towns continue to go without dental services and become "bombsites", according to dentists.
Northland District Health Board's 2021 annual report highlighted the poor dental health of Northland children in particular.
The report states that Northland's Year 8 students have a higher number of decayed, missing or filled teeth: 1.15 compared with 0.73 nationally.
Our 5-year-olds also have one of the lowest percentages of teeth without tooth decay: 42 per cent compared with 55.1 per cent nationally.
Children in Northland DHB had the worst oral health overall in New Zealand, according to Ministry of Health data.
Data from the Ministry of Health shows dental issues are the leading cause of avoidable hospitalisations in children under age 5 in Tai Tokerau.
The data repeatedly shows Northland children having double or even triple the amount of decayed, missing or filled teeth compared to other regions.
Health adviser Doug Healey has seen first-hand the dire state of dental care in Northland and was involved in providing a free dental service in Kaikohe in 2020 after the area went without a dentist for almost 18 months.
"Kaikohe had been abandoned from New Zealand oral healthcare and the little that had been done was unnoticeable."
Healey said a dentist described the state of Northland dental health as "like a bombsite."
"A town without a dental practice created a war zone."
Healey discovered that most parents were unaware that standard dental care is free for children and teenagers up to the age of 18.
On average each day in Northland, there are 111 oral health visits in primary schools from Community Oral Health Services run by DHBs.
More specialist dental care has to be procured from private dentists, who are costly - and non-existent in some areas of Northland.
"[For] some it means travelling over 80km, it's two months' worth of petrol and food to most families.
"The cost to take time off work, to drive into Kerikeri and then to pay for the [dentist] visit was almost a dead conversation as whānau had no surplus funds in an already social-economically challenged area," Healey said.
Northland DHB specialist public health dentist Ellen Clark said equity of access was a big problem in dental care and highlighted that Māori tamariki were significantly more likely to suffer from poor dental health.
"With so many remote areas that only have one or very few dental practices, it makes physical access an issue."
Some 470 Northland children went under general anaesthetic for tooth extractions in 2021; of those, 74 per cent were of Māori ethnicity, Clark said.
"At age 7, four out of five Māori children in Northland have at least one decayed tooth."
Clark pointed to a combination of low-socioeconomic factors: sugar-filled foods are easier to access and oral healthcare items such as toothbrushes and toothpaste may not be a priority for a family struggling to get food on the table.
"The less access to sugary drinks, the less decay we will see in our tamariki."
This month the Government began public consultation on a proposal to ban fizzy and sugary drinks in primary schools in a bid to reduce the amount of acidic sugar washing over children's teeth.
Minister of Education Chris Hipkins said dental decay was now the most common disease reported among New Zealand children.
Sugar-sweetened beverages accounted for more than a quarter of New Zealand children's sugar intake, Hipkins said.
Clark also noted that Northland has one of the lowest adolescent utilisation rates of dental services in the country.
Before he retired, dentist Paul Reeves said when he worked in Kaitaia he was shocked by the low number of children signing up for free dental care.
"We worked out that there were about 1300 children in the area eligible for free treatment, and the most I ever got up to was about 550 in a year."
As the only dental clinic in the area, Reeves said if he wasn't giving a child dental care, it's likely no one was at all.
"More than 50 per cent of children just never engaged."
Reeves said the issues with children's dental care in Northland were a burden to dentists, emotionally and financially, despite the subsidies.
"The Government intention was that everyone would be dentally fit by the time they hit 18."
Reeves felt that because the appointments were free they weren't perceived as valuable and that he saw a high failure rate with adolescent appointments.
"People would make appointments and then not turn up and eventually that's why I made the decision that I couldn't keep going, because it was too costly.
"If you only see the [child] once, it's financially disastrous to the dentist ... you weren't making an income on it, you're actually losing money."
Reeves said "for 100 years" we have known that children's teeth are more vulnerable than adults because they are not as well mineralised and strong.
Public engagement and understanding of the importance of oral health in children are still poor in Northland, and Reeves elected to no longer be involved in the treatment of children 15 years ago.
"I'm aware that children's dentistry doesn't really seem to have changed that much."